China’s desert steppe is the transition zone between the grasslands in central China and the arid desert. Ecological security in this region has long been a subject of debate, both in the local and academic communities. Heavy metals and other pollutants are readily released during industrial production, combustion, and transportation, aggravating the vulnerability of the desert steppes. To understand the impact of industrial activiteis on the heavy metal content of dust fall in the desert steppe, a total of 37 dust fall samples were collected over 90 days. An inductively-coupled plasma mass spectrometer (NexION 350X) was used to measure the concentration of heavy metals Cu, Cd, Cr, Pb, Mn, Co, and Zn in the dust. Using comprehensive pollution index and multivariate statistical analysis methods, we explored the characteristics and sources of heavy metal pollution. We also quantitatively assessed the carcinogenic risks of heavy metals resulting from dust reduction with the help of health risk assessment models. The heavy metals’ comprehensive pollution index values in the study area’s dust fall were ranked as follows: Zn > Cd > Pb > Mn > Cu > Co > Cr. Among these, Zn, Cd, and Pb were significant pollution factors in the study area, and were affected by industrial production and transportation. The high pollution index was concentrated in the north of the research industrial park and on both sides of a highway. The seven heavy metals’ total non-carcinogenic risk index (HI) values were ranked as follows: Mn > Co > Pb > Zn > Cr > Cu > Cd (only the HI of Mn was greater than one). Excluding Mn, the non-carcinogenic and carcinogenic risk index values of the other six heavy metals were within acceptable ranges. Previous studies have also shown that industrial transportation and production have had a significant impact on the heavy metal content of dust fall in the desert steppe. This study also aimed to explore the comprehensive characteristics of heavy metal elements in dust affected by industrial activities, identify the sources of pollution, and determine the health risk index values in order to provide references for the atmospheric environmental protection of desert grasslands.We selected China’s desert steppe as the object of this study and used dust suppression tanks to collect samples indirectly. The Cd, Cu, Pb, Zn, Cr, Co, and Mn contents in the dust suppression samples were then determined, and the pollution level, spatial distribution characteristics, and health effects of heavy metals were evaluated. The purpose of this research was to: (1) analyse the heavy metal pollution status of dust fall in the study area using the Nemeiro pollution, potential ecological risk, geo-accumulation pollution, and heavy metal comprehensive pollution indices; (2) determine the sources of heavy metals in dust fall Stipa breviflora Griseb., Agropyron cristatum (L.) Gaertn., Pennisetum centrasiaticum Tzvel., Lespedeza potaninii Vass., Potentilla chinensis Ser., and Artemisia scoparia Waldst. et Kit.The study area was located in west Gaoshawo Town, Yanchi County, Wuzhong City, Ningxia, China . The terrain is high in the south and low in the north, and is dominated by hills with minor fluctuations in elevation. It is adjacent to Dingbian County in Shaanxi Province to the east, the Mu Us Desert (part of the Ordos Platform) to the north, and the Loess Plateau to the south. It is the transition zone between the grassland area of central China and the arid desert. The Industrial Park, comprised of the Thorning Dong Energy and Chemical Base, focuses on the development of coal, oil, gas, and new energy technologies. This region is situated along the Qingyin Expressway, 307 State Road, and the Taizhongyin railway and plays an important role in transport. Typically, this area has a continental monsoon climate with droughts, an annual average temperature of 7.8 °C, and an average temperature difference between summer and winter of approximately 28 °C. The soil types in this region are sandy and sierozem-based soils (Chinese soil taxonomy). The major vegetation types in the area include Using the grassland resource field survey method, we comprehensively considered the regional topography, climatic characteristics, and road traffic. We set up 50 sampling points in the study area with three dust reduction tanks at each sampling point to ensure that the collected materials could reach the test measurement amount. The sampling period was from 10 October 2019 to 10 January 2020. Continuous sampling was carried out for 90 days, and 37 effective sampling points were collected . AtmosphHeavy metal detection requires a microwave digestion/extraction system  for digestion and an inductively coupled plasma mass spectrometer  to determine Cu, Cd, Cr, Pb, Zn, Mn, and Co content. Three sets of parallel tests were performed, and the average value was used to determine the concentration of heavy metals. The Chinese National Standard Soil Standard Value (GSS-8) was used for quality control and the recovery rate was calculated to improve the accuracy and precision of the analysis. Concurrently, 10% of the samples were reserved for repeatability testing. The test precision of each heavy metal element was within approximately 5%, the relative double difference was approximately 10%, and the analytical pass rate was 100%. Through random inspection and abnormal point inspection, the results were found to meet the quality control requirements.Data were collected as previously described by ment}PN) , potentiment}RI) , geo-accnt}Igeo) , and intnt}Igeo) :i in the soil, −1), and −1). The Ningxia environmental soil background value was taken as the soil background concentration of heavy metal i China National Environmental Monitoring Center . Based on the soil background value in Ningxia, six elements  exceeded limits by the following rates: Cu, 62.16%; Cd, 94.59%; Pb, 100%; Zn, 91.89%; Mn, 24.32% and Co, 2.71 %. Among these, Cd, Pb, and Zn exceeded the thresholds by the highest amounts and accumulated to varying degrees in the study area. These findings are consistent with our previous researching indicating that there are over-standard heavy metal rates in the study area’s soil . These three heavy metal elements were affected by the combination of social and economic activities and other human factors, which all significantly influence dust fall in the study area. After referencing previous research and our calculations, we choose Mn as the reference factor . The ordP < 0.01). According to the correlation coefficient, we speculate that Cu–Cd–Pb–Co has a composite source and Cr–Mn has a similar source. As the correlation coefficient between Zn and the other six elements was low, we determined that it had a separate source of pollution.Correlation analysis is useful for identifying the sources of heavy metals . A signiOur findings were determined using the EPA PMF5.0 software with the number of words set to three. The model was iterated at least 77 times and the residual was between −3 and 3. The determination coefficients of the seven elements were as follows: Cu (0.95), Cd (0.68), Cr (0.80), Pb (0.93), Zn (0.99), Mn (0.99), and Co (0.88). The determination coefficients of all heavy metals were higher than 0.6, indicating that the PMF model had a good fitting effect . AccordiFactor 2 accounted for 20.60% of the total source. The contribution rates of Cr and Mn in factor 2 were 46.99% and 42.47%, respectively. Studies have shown that Cr is the main source of industrial pollution , and Mn mosphere . Figure Factor 3 accounted for 35.32% of the total source. Cu, Pb, and Co had higher concentrations in factor 3, and their contribution rates were 61.05%, 53.07%, and 38.92%, respectively. It is generally believed that Cu and Pb are related to human transportation . High coAs shown in The individual non-carcinogenic risk quotient (HQ) and total non-carcinogenic risk index (HI) of the seven atmospheric dust heavy metals in the study area across evaluated exposure routes were calculated using formulas −6, indicating no carcinogenic health risk for Cd and Pb in the evaluated pathways. For both non-carcinogenic and carcinogenic risks, the exposure routes were ranked as follows: inhalation > hand-to-mouth > skin contact.The non-carcinogenic risk of dust fall heavy metal elements to the human body across the three exposure routes had HQ rankings of inhalation > hand-to-mouth > skin contact. The heavy metal HQ through hand-to-mouth and skin contact exposure route was less than one, and there was no non-carcinogenic risk. Mn ingested through the respiratory route had a non-carcinogenic risk (HQ: 5.27–11). There are great differences between different heavy metal elements. The individual non-carcinogenic health risk indices of heavy metal elements, except for Mn, through the three exposure routes were all less than one, which was within the safe range and indicated that they would not cause harm to human health. However, the HI is relatively high in the area where Mn accumulated. This phenomenon warrants greater attention. The average value of the total HI was 11.6, indicating a risk to non-carcinogenic health. We concluded that heavy metals in the study area pose a certain threat to human health. The total HI values of the seven heavy metal elements ranked Mn > Co > Pb > Zn > Cr > Cu > Cd, and only Mn had an HI greater than one. Mn was the most important element that created non-carcinogenic hazards in dust reduction. The TCR values of the two carcinogenic heavy metals showed that Cd > Pb, and the carcinogenic index of dust fall heavy metals exposed by the three methods to the human body was less than 10Health risk assessment is very important for quantifying human health when exposed to heavy metals. Although some elements are required by the human body, long-term inhalation exposure can affect the respiratory system and increase the risk of lung and nasal cancers . CurrentThis study comprehensively analysed the pollution characteristics of heavy metals in the dust fall of the desert steppe, an industrial area, using the Nemeiro pollution, geo-accumulation, and potential ecological risk indices. To further determine the source of pollution, the correlation and PMF model were combined with geostatistical evaluation methods to identify the distribution of heavy metal elements in the area’s dust fall. Considering the carcinogenic risk for residents near the study area, a quantitative assessment was made using the exposure risk and risk characterisation of the health risk model. The main conclusions were as follows:(1) Using Ningxia’s soil background value as the standard, the study area’s Melo pollution index of 4.04 indicated heavy pollution, and 48.65% of the samples showed strong ecological risks. The over-standard rates of Cu, Cd, Pb, Zn, Mn, and Co were 62.16%, 94.59%, 100%, 91.89%, 24.32%, and 2.71%, respectively (Cr was excluded). The ranking of the comprehensive pollution index (IPI.dhm) was Zn > Cd > Pb > Mn > Cu > Co > Cr. The excess rates of Zn, Cd, and Pb in the study area were above 90%. These three elements were affected by the synergistic influence of social and economic activities and human factors. Zn is the element with the highest contribution rate of pollution in dust fall, and the degree of pollution was very high.(2) In the correlation and PMF models, Zn and Cd were considered to have traffic pollution sources, and the higher pollution index was concentrated in the northern area of the industrial park and on both sides of the highway. Cr and Mn had influence of natural factors, and high values were concentrated in the southeast region as non-point source pollution. Cu, Pb, and Co were composite pollution sources that were affected by the dominant wind direction and adjacent areas. High values were concentrated in the northwest region of the industrial park, and the southeast region was a low-value area. Based on the multivariate analysis results, Zn, Cd, and Pb were significant pollution factors in the study area. These three elements were all related to the wear of automobile brakes and tires. Although there are many types of industrial activities, the analysis results confirmed that the study area was deserted. Heavy metals in the grassland dust were severely affected by transportation, and their accumulation characteristics were observable around the industrial park and on both sides of the transportation route.(3) Across different exposure routes, the average daily exposure doses of heavy metals in the study area ranked hand-to-mouth > inhalation > skin contact, and accounted for 65.57%, 34.03%, and 0.399% of the total daily average exposure, respectively. The hand-to-mouth route was the main way to reduce the average daily exposure risk of heavy metals in the study area. The total non-carcinogenic risk HI of the seven heavy metal elements ranked Mn > Co > Pb > Zn > Cr > Cu > Cd, and only Mn’s HI was greater than one. In this study, Zn, Cd, and Pb were comprehensively significant pollution factors, but they had a low health risk index that indicated a low significant health risk for adults. The non-carcinogenic and carcinogenic risk indices of all heavy metal elements, excluding Mn, were within acceptable limits. Because the study area experienced heavy winds and sand with scarce rainfall throughout the year, we recommend that areas with frequent industrial activities take protective measures such as controlling the speed of vehicles, especially large ones that transport production materials and heavy loads. Vehicles should be equipped with dust suppression devices to effectively prevent the spread of pollutants from the root causes.This study used a different perspective and combined a variety of evaluation methods to explore the pollution characteristics and health risks of heavy metals in the dust fall of the desert steppe. Our results provide a scientific basis for the atmospheric, ecological, and environmental protection of this region.10.7717/peerj.12430/supp-1Supplemental Information 1*Corresponding author e-mail: 705484905@qq.com (Nan Mi).Click here for additional data file.


Research on reading comprehension in immigrant students is heterogeneous and conflicting. Differences in socioeconomic status and cultural origins are very likely confounds in determining whether differences to native pupils can be attributed to immigrant status. We collected data on 312 Spanish students of Native, of Hispanic origin–therefore with the same family language as native students- and Non-Hispanic origin, while controlling for socioeconomic status, non-verbal reasoning and school membership. We measured reading comprehension, knowledge of syntax, sentence comprehension monitoring, and vocabulary. Differences among groups appeared only in vocabulary and syntax (with poorer performance in the non-Hispanic group), with no differences in reading comprehension. However, regression analyses showed that most of the variability in reading comprehension was predicted by age, socioeconomic status, non-verbal reasoning, and comprehension monitoring. Group membership did not significantly contribute to explain reading comprehension variability. The present study supports the idea that socioeconomically disadvantaged students, both native and immigrants from diverse cultural backgrounds, irrespective of the language of origin, are probably equally at risk of poor reading comprehension. An estimated 11% of children in schools worldwide are born to immigrant parents and can be considered to have an immigrant background (IB). This figure hides a great deal of variability among countries: Numbers range from under 1% for some  to nearly 30% for others , and in Organisation for Economic Co-operation and Development (OECD) and European countries around 25% 15-year-old students was foreign-born or had at least one immigrant parent. In all of them it is common for IB children to underachieve academically, especially first-generation immigrant students , 2018. IThis underperformance could be related to poor reading abilities, among other core academic abilities such as mathematics and science . The SimInterestingly, decoding does not appear to be problematic. Most studies find similar levels of word reading between these children and their native peers e.g., . Only a There are many potential reasons for this variability in the literature. One is IB students’ primary language. Structural similarities between L1 and L2 may affect the extent to which their performance differs. Some IB children may share the L1 of their native peers. For example, children from the Commonwealth emigrating or born to immigrant parents in the United States or the United Kingdom do not have to overcome a language barrier as great as the one facing non-English-speaking children. A similar situation can be found in Spain with IB children coming from Spanish-speaking countries. The L1 most spoken among IB children of Spain is Spanish , mainly coming from Central and South America. Although the biggest groups of IB children in Spain are those coming from Europe (30.9%) and Africa (30.7%), they have a wide range of L1s, different from native students . AdditioSD = 1) indicate that the communities of Madrid (−0.10) and the Basque Country (−0.25) would be the only ones that would show values close to the OECD average, while the Canary Islands (−0.80), the Region of Murcia (−0.82) and Andalusia (−0.87) would be the furthest from this average  is a potential confound. On occasions, researchers have not taken this variable into consideration e.g., . Other s average .Reading comprehension can be affected by limited decoding skills or oral language comprehension . Since iIt has been argued that certain cognitive factors other than oral language and decoding skill need to be added to the SVR model to adequately capture individual differences in reading . ExecutiThe influence of all these cognitive and linguistic components on the reading of immigrant children, and their relative importance in explaining individual differences are of interest. Various studies have analyzed the similarity of L1 and L2 models of reading . It seemThe aim of this study was to analyze the development of reading comprehension and related abilities in Spanish-immigrant Primary and Secondary school children of different cultural backgrounds, specifically controlling for language and SES, and with Spanish as a common L2. By comparing native Spanish children with those having a Hispanic background, and to others with non-Spanish speaking families, we could analyze separately the impact of language and immigrant status on reading.The specific aims of our study were: (1) to assess the level of reading comprehension in immigrant students (Hispanic and Non-Hispanic) in comparison to their native peers, when controlling for SES; (2) to compare reading comprehension and related linguistic processes  in these immigrant and native populations at different ages; (3) to analyze the relative contribution of these components, together with age and SES, in explaining individual differences in reading comprehension in immigrant and native reader groups.We hypothesized that (1) reading comprehension of students with equivalent SES would be similar despite their cultural origin and language, (2) reading comprehension and the related cognitive and linguistic components would grow with age in all groups, but differences should appear in non-Hispanic group with respect to native and Hispanic children in oral language skills, (3) despite similar performance and development, distinctive weights of linguistic and sociocultural aspects in each reading model would show different predictors of reading comprehension in native and immigrant children, with Hispanic and native-Spanish children showing the same predictors of individual differences.We selected 314 participants from 37 different schools of the Southern, Eastern and Northern regions of Spain. There was a total of 157 immigrant-background children  who had both parents born outside Spain, and 157 native children , all of whom were from Spanish-speaking families and participated in a larger nationwide study on reading development. This nationwide study was carried out in 43 public and private schools from several regions of Spain: Basque Country, Murcia, Andalusia, and Canary Islands. It included a total of 4292 children and adolescents aged from 7 to 15 years, enrolled in courses from 2° grade of primary education to 2° grade of secondary education. Within this bigger sample, we took all IB children that participated in the nationwide study and selected a native participant of the same grade and school. Whenever possible, IB children were paired with native participants of the same sex and from the same classroom. Additional inclusion criteria for both groups were a non-verbal IQ higher than 70 or below 130, and no clinical diagnosis or special educational needs.Hispanic children  who were monolingual-Spanish speakers , mainly with families from Ecuador (38%), Colombia, and Argentina (18% each); and 61 Non-Hispanic children , bilingual speakers who had Spanish as a second language, mainly with families from Morocco (49%) and Romania (21%)—proportions for other European and African nationalities were below 5%. The place of birth for IB participants was Spain for 26.6% of HI and 27.8% of NH . No significant differences were found between the HI and NH groups in the number of years living in Spain , the age of arrival in Spain , t = −0.48, p = 0.63, or the number of children that had learned to read in Spain , χ2 = 0.22, p = 0.64.Within the immigrant sample two groups could be differentiated: 94 SD = 2.0), while the mean age of the Hispanic children was 10.03 years (SD = 2.1) and the mean age of the Non-Hispanic group was 10.19 years (SD = 2.3). There were no significant differences between the native and the immigrant groups in age, gender or non-verbal IQ, F = 0.21, p = 0.81, η2 = 0.001, χ2 = 3.58, p = 0.17, and F = 1.75, p = 0.18, η2 = 0.01, respectively. Additionally, a SES index was created following N = 4292). After standardizing the data, a principal components analysis was carried out initially on all the participants with complete data on these three variables (n = 3017) and the FactoMineR package of R Language  = 21.82, p < 0.01, η2 = 0.12. This disparity was due to native families having higher income and occupational level than immigrant families, all ps < 0.001, despite less years of schooling than HI parents (p < 0.01) and a trend to higher than NH (p = 0.055). Regarding IB families, HI had higher incomes (p < 0.001), years of schooling (p < 0.01), and a trend to higher occupational level than NH parents (p = 0.06). The group of native children could be considered middle/low-SES, while both immigrant groups could be considered low-SES according to the SES index and compared to the national dataset.Although matched groups of IB and native children of the same schools and grades were selected, there were significant differences in this SES index, 2 = 1.01, p = 0.91, and there were no significant differences between groups in non-verbal IQ  under 9 years old, (2) between 9 and 11 years old, and (3) over 11 years old. The proportion of NA, HI and NH students in each age set was equivalent, χBackground measures included Kaufman’s Brief Intelligence Test (K-BIT) , a socioVocabulary, and Matrices . We used the raw scores for both scales. Raw scores range from 0 to 48 for Matrices and from 0 to 82 for the Vocabulary subscale (from 0 to 45 for participants under age 8).We administered the Spanish version of the test that provides two main scores: home stimulation measure was the mean score on the 8 items of the scale.Specifically designed for this study, it was a parental survey on socioeconomic status , languages spoken at home, and a 5-point Likert scale (0–4) of 8 items exploring reading-related practices including reading and writing habits, access to books at home, and the frequency of cultural activities, such as going to exhibitions or bookshops. The Attention ratings and academic support measures were the mean of the correspondent responses.It was used to record specific diagnoses, academic support , and performance in attention skills in class as rated by participants’ teachers in a 6-point Likert scale (1–6). Several experimental tasks were used to evaluate reading comprehension and related abilities. All of them were programmed using E-Prime v2.0 software .In this task participants read aloud 96 words  and 96 non-words  shown in random order in the centre of the computer screen. Data regarding accuracy on reading words and non-words, as well as the response times in both reading options, were obtained. Total scores were calculated as total word and non-word reading accuracy. Internal consistency  of these tasks was 0.89 in both cases.This task consisted of eight texts that differed in difficulty (four easy and four difficult) and text type (two narrative and two expository within each level of difficulty). Participants read in a self-paced fashion a minimum of two texts and a maximum of four, in a random presentation . Each text was followed by four true-or-false literal and inferential questions to evaluate comprehension. The number of texts that participants had to read was determined automatically by their accuracy on the reading comprehension questions. Children in 5th grade or under read two easier texts at the beginning and, if they achieved less than 50% of accuracy, then stopped. If they achieved a higher score, they went on to complete the other two harder texts. Children in 6th grade or above read the two harder texts initially and, if they achieved less than 50% of accuracy, they had to complete the two easier texts. Total score on this task was the total percentage of correct responses to all comprehension answers presented . Internal consistency of this task was 0.90 .The structure of this task was the same as the reading comprehension task, but with orally presented stories. Total scores were calculated as the total accuracy of all comprehension answers. Internal consistency  was 0.79.In this task of comprehension monitoring, participants were asked to read silently sentences with suitable vocabulary and easy syntactic structure. Four versions of each sentence were created: (a) semantically incongruent sentences—sentences that contained an adjective semantically incoherent with a noun—, (b) grammatical-gender incongruent sentences—sentences that contained gender disagreement between a noun and an adjective—, (c) grammatical-number disagreement sentences —sentences that contained number disagreement between a noun and an adjective—, and (d) correct sentences—sentences that did not include semantic or grammatical errors. The adjective that made the sentence correct or incorrect varied its position in the sentence, so it was not predictable. The sentences were presented in the middle of the screen and participants had to decide whether the sentence was correct, or it contained an error . Each participant read 40 sentences randomly presented . Sentences were counterbalanced across participants. Total scores were calculated as the total accuracy of children’s responses. The internal consistency  was 0.57.This task was adapted from the syntax scale of the PROLEC-R test battery for reading in Spanish . Thirty Parental informed consent for inclusion in the study was obtained for all participants. This study was conducted in accordance with the Declaration of Helsinki, and its protocol was approved by the Universidad de La Laguna Research Ethics Committee. All tasks were administered individually in quiet and comfortable areas provided by the schools. Psychology graduates properly trained in these tasks carried out data collection.The evaluation process began with the administration of the K-BIT, followed by the computerized tasks. To carry out the computerized tasks a desktop PC was used accompanied by a keyboard with two response buttons highlighted in color , a mouse, and two sets of headphones with integrated microphones (one for the participant and one for the examiner) to listen to the instructions of each test and record the verbal responses of participants when needed. The order of administration of the computerized tasks and the presentation of the assessment items of each task were randomized. All tests had a verbal explanation presented through the headphones and written instructions shown on screen. Each task also included different practice items, in which the examiner could provide help to participants if needed. On average, a 1-h session per participant was needed to complete these computerized tasks. The period between the administration of the K-BIT and the computerized tasks was used to provide the families and teachers with the questionnaires and collect them.Aims 1 and 2  were achieved by using a series of ANCOVAs on group membership—Native, Hispanic Immigrants, and non-Hispanic Immigrants—, and age and SES as covariates. Also, accuracy of reading comprehension was compared for these three groups to the results from a large sample of native schoolchildren from different areas of Spain.For Aim 3 (models of reading comprehension in the different groups), we carried out a regression analysis with age, non-verbal reasoning, SES, group membership, and the different components, as predictors of reading comprehension.Twenty-nine participants had some missing data, compromising 1.2% of the total data set. Missing data appeared in reading and listening comprehension , sentence monitoring (0.6%), sentence-picture matching (1.0%), academic support (0.6%), and attention ratings (5.4%). We ran a multiple imputation analysis to estimate missing data using the SPSS v.20 Multiple Imputation procedure with five iterations, based on linear regression for the test measures and logistic regression for teacher ratings and support measures.SD = 21.2), 62.3 (SD = 18.9), and 58.1 (SD = 19.4) for Native, Hispanic and non-Hispanic children, respectively (see SD = 20.9). The Native group had a total of 36.9% of participants in the lowest quartile of the larger population sample. In the case of the Hispanic and non-Hispanic immigrants these proportions were of 26.3 and 34.6%, respectively. The proportions of children in the highest quartile were 17.0, 12.5, and 10.9% for the NA, HI, and NH groups, respectively. In the native population of the larger study, the proportions of children in the lowest and highest quartile were 27.0 and 21.0%, respectively. Taking reading comprehension scores of the native population of the larger study as a standard, we can determine that our native and immigrant background groups showed a lower performance . NA and NH groups performed similarly low, while HI participants showed no mean differences compared with the larger study group, but where underrepresented in the highest quartile , except for reading comprehension (p = 0.07) and word/non-word reading (ps > 0.946).A series of ANCOVAs exploring the impact of age, SES, and origin were carried out on all main variables see . All varp = 0.12) or listening comprehension (p = 0.29). There were also no significant interactions between age and origin . We found the same for the word/non-word reading measures, which showed no significant differences for origin (ps > 0.23) and no significant interactions between age and origin (ps > 0.68).A non-significant relationship of origin was found for reading comprehension (ps < 0.027). No significant interaction between age and origin was found in these variables (ps > 0.06). In sentence-picture matching, Non-Hispanic children performed more poorly than native, p = 0.002, and Hispanic children, p = 0.040. Similarly, in vocabulary, the NH group performed below the HI and the NA groups (ps < 0.0001). Surprisingly, the HI group also performed marginally below the native children (p = 0.045). In sentence monitoring, the NH group had poorer results than the HI group (p = 0.03) and marginally than the native group (p = 0.06).Analyses of sentence-picture matching, sentence monitoring, and vocabulary did show significant differences for origin (ps < 0.0001), but there were no significant B parameters for origin (ps > 0.23).Two additional ANCOVAs were carried out across groups on word and non-word reading accuracy, with SES as a covariate. Again, age turned out to be a significant predictor of decoding . Thus, a series of ANCOVA with age as a covariate were performed in HI students. Age was a significant predictor in all analyses (ps < 0.008), but there were no significant differences between first/second generation HI children on any of the measures (ps > 0.348).Our sample included both children born in Spain and abroad. We compared performance in the HI and NH groups between children with different birthplace with a series of relaimpo R statistical package  = 4.91, p < 0.0001, and R2 = 0.21. Of the predictors, the only individual variables with a coefficient significantly different from zero were sentence monitoring (p = 0.03), and non-verbal reasoning (p = 0.009). Group of origin coefficients were not significantly different from zero, and neither were the coefficients of any interactions involving group.Dominance analysis showed that age, non-verbal reasoning, and SES, jointly explained 16.9% of the variance. The relative importance metric LMG  confirmePrevious studies on reading comprehension in immigrant students have pointed to the importance of contextual and socioeconomic factors for explaining differences in their performance with respect to native students e.g., . In our With this procedure, the differences between immigrant and native groups in reading comprehension were non-significant, as we had predicted. We had hypothesized that there would be differences on oral language skills only between the native and the non-Hispanic group. This hypothesis was mostly confirmed. Between-group analyses showed differences in vocabulary, comprehension monitoring, and specific syntactic processes: non-Spanish-speaking immigrants performed more poorly than native and Spanish-speaking immigrant children. The results obtained in this study are consistent with previous research which mostly shows significant differences in vocabulary and syntax between immigrant students who learn to read in a L2 e.g.,  and natiThere were no differences on syntax between Hispanic immigrants and native children as predicted. We did find differences in the vocabulary task, in which Hispanic children performed better than non-Hispanics, but not as well as native-Spanish children. Both groups speak different varieties of Spanish, with different degrees of differentiation in vocabulary, morphology, syntax, and prosody that could explain this finding, as shown in normalization studies of vocabulary tests carried out in Spanish-speaking pediatric population .Apparently, these differences are not sufficient to grossly affect reading comprehension. Whichever mechanisms immigrant children are using to compensate for differences in syntax and/or vocabulary seem appropriate to overcome potential limitations in reading. This compensation could also be present in listening comprehension, which would explain the lack of differences also on that task. The amount and quality of input might not be sufficient to achieve native levels of oral competence, but enough to attain adequate levels of oral and written text comprehension. An alternative explanation is of course a lack of sensitivity of our listening and reading comprehension tasks to subtle differences, or that they were not demanding enough. However, the lack of floor or ceiling effects on either task does not support this explanation.The differences between non-Hispanic and native-Spanish children in comprehension monitoring are somewhat surprising. However, this error-detection task requires a great deal of linguistic knowledge. The kind of errors included are mostly related to syntactic and lexical anomalies and could thus be greatly influenced by L1 differences, as was found by The analysis of differences in reading comprehension among groups adds some data to conflicting results in the literature. Although many previous studies did use control children from the same classes, they did not measure individual SES data as we did. An exception of studies that controlled for individual SES and did find differences is One of the more relevant contributions of our study is the dissociation of language and immigrant status by including a group of children of immigrant background with the same L1 as the majority-native population. Our data suggest that language differences are the greatest contributor to differences in immigrant groups. Of course, additional cultural variables should not be ruled out when considering overall academic performance. Even in our case, Hispanic and non-Hispanic (mostly Moroccan and Romanian) immigrant families differ in many ways other than language, since they come from different cultural backgrounds.Based on the SES Index obtained from the nationwide sample, all our participants, natives, and especially IB children, can be considered to be in the low-SES range of our Spanish sample. In A main predictive effect of age, with a complete lack of interaction with immigrant status, was found for all measures, as expected. Improved performance with age supports the validity of the tasks and is consistent with our predictions.Our results are in accordance with studies that find no increase in differences between native and immigrant pupils across ages. A joint regression analysis on all the groups was computed to test for predictors of differences in reading comprehension. Most of the variability was explained by age, SES, and non-verbal reasoning. Of the remaining variables, only comprehension monitoring was an individual significant predictor, explaining a small proportion of variance, but clearly more than any other variable. Group of origin did not significantly contribute to explain reading comprehension variability, and no interaction involving this variable was significant. Our hypothesis that different groups would have different developmental pathways or predictors was not supported by the data. On the contrary, this regression analysis adds to the conclusion that, in reading comprehension, these groups are more similar than different.It could also be the case that factors other than language status should be considered. Home literacy-related experiences have been pointed out as relevant in reading development of Latino children in the United States see . As we hAmong the limitations of this study, we should consider the possible influence of the use of experimental tests. True-or-false and multiple-choice tests—like those used here—tend to show smaller differences between immigrant and non-immigrant groups . In addiThe lack of information about proficiency in oral Spanish of the immigrant and even the native children is also a restriction in our data set. In this sense, The results might also have been different if higher-SES students and schools had been included. Nevertheless, we suggest that the lack of differences in our study could be related to a generally low performance of a generally low-SES sample. In any case, these results, with a low-SES group of participants that teases apart the influence of language and immigrant status, contribute to a somewhat contradictory literature about reading comprehension of immigrant pupils. New studies following this procedure are needed. Future research should focus not only on the different languages that immigrant children speak and their proficiency in the language used at school, but also in the relationship that their economic, social and cultural status may have with their reading comprehension performance. Random sampling and a bigger sample, including high-SES students and bilingual natives, would be also desirable to improve the representativeness of the findings. Finally, in order to better track developmental changes in reading comprehension and related cognitive and linguistic processes across native and immigrant children and adolescents, longitudinal studies would be highly recommended.The main finding of this study emphasizes that, once SES is controlled for, reading comprehension achievement of immigrant students (both Hispanic and Non-Hispanic) is equivalent to their native Spanish classmates. The study also partially separates linguistic differences from cultural factors. Even if similar levels of reading comprehension are attained, children with different L1s show lower performance on oral language tasks. These skills are important and could impact overall academic achievement in other ways. Also, even when language is apparently very close, as in the case of Hispanic and native students, subtle differences could remain in areas such as vocabulary. Without excluding the influence of cultural factors, this study highlights the importance of adequate L2 oral language skills. It emphasizes current measures undertaken in the Spanish educational system, where children with poor Spanish are offered inclusion in special support units and transferred to mainstream classes when they reach adequate levels of oral language. Although most immigrant children have a sufficient level of Spanish to be in a regular classroom, when they had language difficulties it is crucial for their academic development to receive regular support provided for children with learning difficulties, which includes support teachers, pull-out lessons, and curricular adaptations.In this sense, our results should not be seen as an argument against providing additional academic support to immigrant students that perform similarly to their native peers. Quite to the contrary, the results obtained in the present study converge with the perspectives which claim that socioeconomically disadvantaged students are a major risk group, no matter if they are native or from an immigrant background.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 Universidad de La Laguna Research Ethics Committee. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.JI-A and DS: conceptualization, writing—original draft preparation, and investigation. JI-A, JH-C, JD, AE, PM, MB, LF, and DS: methodology, writing—review, and editing. JI-A, JH-C, AE, and DS: formal analysis. JD, PM, MB, LF, and DS: resources. JI-A and JH-C: data curation. MB, LF, and DS: supervision, project administration, and funding acquisition. All authors have read and agreed to the published version of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


There were important inverse correlations of heart rate and indices of sinus arrhythmia (r = −0.52 for pvRSA and r = −0.58 for RMSSD), but not the anthropometry. Conclusion: Lower prevalence of respiratory sinus arrhythmia among children with overweight and obesity is a result of higher resting heart rate observed in this population.Background: The study was conducted to investigate the implications of anthropometry in school-aged children on the degree of respiratory sinus arrhythmia observed in clinical settings. Methods: In a cohort study, 626 healthy children  aged 10.8 ± 0.5 years attending primary school in a single town underwent a 12-lead electrocardiogram coupled with measurements of height, weight and blood pressure. Indices of respiratory sinus arrhythmia  were derived from semi-automatic measurements of RR intervals. Height, weight, BMI, blood pressure as well as waist and hip circumferences were compared between subjects with rhythmic heart rate and respiratory sinus arrhythmia, and correlations between indices of sinus arrhythmia and anthropometry were investigated. Results: Respiratory sinus arrhythmia was recognized in 43% of the participants. Subjects with sinus arrhythmia had lower heart rate ( Respiratory sinus arrhythmia is a physiological phenomenon, which can be recognized on an electrocardiogram (ECG) or during chest auscultation. This automatic mechanism causes heart rate (HR) to increase during inspiration, enhancing effective gas exchange in the lungs, and to decrease during expiration, limiting energy expenditure on unnecessary heartbeats and preventing ineffective ventilation. The effector pathway of RSA is mediated by parasympathetic neurons of vagus nerve; thus, higher vagal tone enhances the RSA. In children and young adults, in whom the change of HR according to the respiratory phase is more pronounced, RSA can resemble heart rhythm disturbances; thus, auscultation on breath-holding helps in differentiating RSA from other arrhythmias. To date, the connection between RSA and parasympathetic activity is rarely used in clinical practice; however, the laboratory settings enable analysis of more complex patterns of heart rate variability (HRV). According to current studies, higher HRV is associated with good exercise capacity ,2,3 and n = 13), school absence (n = 39) and heart rhythm disturbances registered on the recording (n = 3). Health status of the participants was verified by written questionnaires addressed to their parents. Two patients with serious comorbidities  were already excluded for the previously mentioned reasons. Intake of medications: oral supplementation of thyroid hormones , antihistamines, leukotriene receptor antagonists, methylphenidate, as well as inhaled beta2-adrenergic agonists and steroids were not a reason for exclusion. In the case of an acute infection on the day of screening, the visit was postponed. A transthoracic echocardiography performed with GE Vivid E95 ultrasound machine comprised basic pediatric projections: subcostal view, four- and five-chamber views, long axis view and short axis at the level of aortic valve, atrioventricular valves and papillary muscles, as well as suprasternal view of the aortic arch. The protocol included measurements of left ventricular dimensions, left atrium and aortic root diameters along with the assessment of flow pattern through atrioventricular, aortic and pulmonary valves. Patent foramen ovale, small atrial septal defects without signs of hemodynamic importance, first degree mitral, tricuspid or pulmonary regurgitations, as well as a bicuspid aortic valve without dysfunction were not considered to be remarkable pathologies. None of the subjects examined according to the aforementioned protocol had signs of cardiomyopathy or substantial heart defects. Anthropometric measurements were performed according to the previously described protocol [The study was conducted as part of a yearly program aimed at early prevention of non-communicable diseases. The program was addressed to all fifth grade students from the town of Sopot  in the years 2015–2018, provided that written consent was given by their legal guardians. Out of 681 children who took part in the screening, 626 children aged 9.67 to 11.67 were included in the study. The reasons for disqualification were: improper age  and systolic blood pressure (p = 0.037) were greater in boys as compared to girls, in contrast to HR that was significantly higher in girls (p < 0.001). Among the electrocardiographic variables, QRS length was greater in boys (p < 0.001), while QTc was greater in girls (p < 0.001).We examined 626 students, 326 (52.1%) of which were male. The statistical analysis of anthropometry revealed no significant difference between boys and girls in age, height, weight or BMI. Waist circumference (p < 0.001), lower weight (p = 0.009), BMI (p = 0.005) and systolic (p = 0.018) and diastolic (p = 0.004) blood pressure as well as shorter QTc (p < 0.001). No differences in terms of height and electrocardiographic variables were observed. Descriptive statistics of the study population are presented in In 43% of the recordings, heart rate was rhythmic, whereas in the remaining 57% we recognized respiratory sinus arrhythmia. Adolescents with RSA were characterized by a significantly lower HR , 5.4% were underweight, 13.1% were overweight and 4.0% had developed obesity. The indices of RSA in distinct groups are summarized in p = 0.046). In the comparison of subjects with BMI above 85th percentile to the normal-weight group (p < 0.001), whereas the RSA indices were significantly higher in the normal-weight population  .The study showed that children with respiratory sinus arrhythmia were thinner and had lower blood pressure compared to their peers with rhythmic HR. However, considering the inverse correlation between HR and RSA, together with the tendency to higher HR among overweight children, it should be assumed that anthropometric parameters have no direct influence on RSA in 11-year-olds. Noticeably, despite considerable dispersion of RSA among the students, none of them suffered from a structural heart disease.The close relationship between HR and the grade of RSA is understandable from both a physiological and mathematical approach. Firstly, it is the vagus nerve that is responsible for slowing down the HR and increasing its variability as well. Secondly, lower HR is directly associated with longer interbeat intervals, which permits greater absolute differences between them. This connection has been reported previously ,13 and lInterestingly, RMSSDc differed substantially between boys and girls, whereas no other indices of RSA did. This finding is a result of higher heart rate in girls which masked differences in RSA. Since prevalence of RSA in relation to sex was not a subject of the present study, we leave it for further investigation.The association of elevated HR with overweight and obesity in children has been described by previous authors ,17,18,19It should be emphasized that 10 s ECG recording is not a reference method for the measurement of HRV. Considering the multitude of factors that have an effect on HR and its variability as well as numerous components of the overall HRV (from short to ultra-long term variability), a study on HRV requires optimal conditions and quality equipment. The aim of our study was to analyze only one component of HRV: RSA, in a very short recording, so the methodology did not meet the standards for HRV analysis. Nevertheless, the data on RSA in children and adolescents in the literature are mainly extracted from 5 min HRV analysis, with only a few studies on short recordings ,22. To oIn terms of study limitations, it should be mentioned that the parasympathetic activity is a result of multiple factors that were not considered in the present research. HRV is not stable across time: not only is it age-dependent, but it also displays a certain circadian rhythm. In general, greater values of HRV parameters are observed in the morning than in the evening . In our Using the 10 s recordings for the sake of the present study can be considered its limitation and a strength as well. Admittedly, the smaller number of RR intervals in the analyzed dataset is more prone to bias and has lower reproducibility in comparison with larger ones. However, in reference to the aim of the study, which was analysis of RSA in clinical settings, we assume that the method was adequate, since it corresponds better with RSA assessment during an outpatient medical visit.The choice of RSA indices was adjusted to the applied methodology as well. Even though multiple parameters, based on either RR interval duration or frequency, are used to describe HRV, only a few are possible to derive from a small dataset. RMSSD not only was proven to correspond with the parasympathetic activity , but alsThe presence and magnitude of RSA in children assessed during medical screening has no clear implications regarding their anthropometry. Considering an inverse correlation between indices of RSA with HR together with noticeable diversification of resting HR among pediatric patients, the analysis of RSA should include correction for HR.


To investigate the differences in ocular surface characteristics, tear film quality, and the incidence of dry eye disease (DED) between Systemic Lupus Erythematosus (SLE) patients and healthy populations.This age and gender-matched cross-sectional study included 96 SLE patients without secondary Sjögren's syndrome (SS) and 72 healthy subjects. The Ocular Surface Disease Index (OSDI), tear meniscus height (TMH), non-invasive tear film breakup time (NIKBUT), meibography, and tear film lipid layer grade were assessed. A receiver operative characteristic (ROC) curve was constructed to evaluate the predictive value of risk factors.P = 0.019). SLE patients without SS had higher OSDI scores , and shorter NIKBUT . Furthermore, TMH, Tear film lipid layer grade, and Meibomian gland (MG) dropout in SLE patients were worse than those in control subjects . For ROC analysis, the area under curve (AUC), sensitivity and specificity of prediction were 0.915, 75.8 and 92.1% for the combination of SLE disease activity index (SLEDAI), age and NIKBUT.Compared with the control subjects, a significantly greater proportion of SLE patients met the TFOS DEWS II DED diagnostic criteria (34.3 vs. 18.1%, SLE patients without SS exhibited a higher risk for DED than healthy subjects, and the poorer Meibomian gland function in SLE patients may potentially contribute to the development of DED. The combined parameters of SLEDAI, age and NIKBUT showed a high efficiency for the diagnosis of DED in SLE patients, with practical clinical applications. Dry eye disease (DED) is a multifactorial disease of the ocular surface, which is characterized by the loss of tear film homeostasis accompanied by ocular surface symptoms , 2. The SS can be classified in two types: primary SS (pSS) and secondary SS (sSS), in which SS can occur concomitantly with other autoimmune diseases, the most common being rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) or scleroderma. Many studies have confirmed that patients with SS are prone to DED –8. The pThe TFOS DEWS II Diagnostic Methodology Report proposed a more appropriate examination sequence and technique to guide the clinical diagnosis of DED, and recommends non-invasive examination . The KerThe purpose of this cross-sectional study was to investigate the differences in ocular surface characteristics, tear film quality, and the incidence of DED between SLE patients and healthy populations according to the diagnostic criteria and methodology recommended by the TFOS DEWS II Diagnostic Methodology Report. Furthermore, the potential predictors of DED among SLE patients were explored.This age and gender-matched cross-sectional study recruited 96 SLE patients without SS (96 eyes) and 72 healthy subjects (72 eyes) from the First Affiliated Hospital of Anhui Medical University. Right eye of each participant was selected for statistical purposes. If only one eye was diagnosed as DED, that eye was selected for statistical analysis. The study followed the tenets of the Declaration of Helsinki and was approved by the institutional Research Ethics Board. Informed consent was obtained from all subjects prior to any procedure.Inclusion criteria: the initial diagnosis was consistent with the criteria for SLE established by the American Rheumatology Association (ACR) . ExclusiThe DED evaluation was carried out in accordance with the diagnostic criteria and methodology recommended by the TFOS DEWS II Diagnostic Methodology Report . The symSubjective symptoms of DED were assessed using the Ocular Surface Disease Index (OSDI) questionnaire which is the most widely used questionnaire for DED clinical trials . The 12-The Keratograph 5M instrument  was used to noninvasively assess the ocular surface and tear film parameters, including Tear meniscus height (TMH), non-invasive tear film breakup time (NIKBUT), tear film lipid layer grade and meibography. The structure of Keratograph 5M is based on the principle of a placido ring to provide high-definition video with multi-wavelength light source for data analysis.The infrared tear meniscus image was photographed with a Keratograph 5M instrument, and the TMH directly below the center of the pupil was measured with the inbuilt digital calipers. The average of the three measurements near the center of the meniscus was taken. Through the built-in software on Keratograph 5M, NIKBUT was automatically recorded as the time for the first distortion in the grid reflection to be detected. The average of three consecutive NIKBUT values was calculated in each case.The tear film lipid layer was graded according to the Guillon-Keeler grading system: grade 0, non-continuous layer; grade 1, open meshwork; grade 2, closed meshwork; grade 3, wave/flow; grade 4, amorphous; and grade 5, colored fringes .http://imagej.nih.gov/ij) (The meibomian gland (MG) dropout area was quantitatively measured using Image J software (.gov/ij) , and gra.gov/ij) . Eyelid .gov/ij) .The diagnostic criteria for DED and subtypes of DED were adapted from the rapid non-invasive dry eye evaluation algorithm, which has been previously validated and proven to have high diagnostic consistency with diagnostic criteria and methodology recommended by the TFOS DEWS II Diagnostic Methodology Report , 21. PatThe SLE disease activity index (SLEDAI) was used to evaluate the SLE activity: inactivity: 0–4 points; mild activity: 5–9 points; moderate activity: 10–14 points; severe activity: ≥15 points .t test was used to assess group differences. No-normally distributed data was described by median  and the Mann–Whitney U test was used to assess group differences. The chi-square test was used to assess group differences for categorical variables. Analysis of variance was used to compare the normally distributed data between the three groups, and the Kruskal–Wallis test was used to compare the no-normally distributed data between the three groups. The receiver operative characteristic (ROC) curves were plotted to evaluate the predictive value of risk factors. When P < 0.05 , the difference was considered statistically significant.SPSS 26.0 software was used for data analysis. Continuous and normally distributed variables were presented as means and standard deviation (SD), and an independent sample In this age and gender-matched cross-sectional study, a total of 168 participants were included . The demographic and ocular surface characteristics of the participants are presented in P = 0.019). OSDI scores were higher in SLE patients than in healthy subjects [10.0  versus 5.0 , P < 0.001, P = 0.035, P = 0.049, Compared with the healthy subjects, a significantly greater proportion of SLE patients met the TFOS DEWS II DED diagnostic criteria .According to the five-point Meiboscale, greater levels of MG dropout were observed in SLE patients than in healthy subjects [2 vs. 1, P = 0.071) , 9 cases of evaporative dry eye (EDE), and 14 cases of mixed DED. In healthy subjects, there were 1 case of ADDE, 8 cases of DED, and 4 cases of mixed DED . There w= 0.071) . In addiP < 0.05, SLE patients were stratified according to published cut-off values for DED diagnostic tools and compared their OSDI. The results showed that patients diagnosed with DED using NIKBUT < 10 S or tear film lipid layer grade ≤3 had a statistically higher OSDI than patients who did not meet the criteria (p < 0.05) and had higher SLEDAI (P < 0.05). However, there were no significant differences between two groups in smoking, alcohol use, corticosteroids use, hydroxychloroquine use, hypertension, diabetes, CRP, C3, and ESR .Next, we sought to identify the possibility that confounding factors leading to the high risk of DED, particularly tobacco use, immunosuppressive drug use, and other immune-related clinical factors. According to the diagnostic criteria of DED, patients with SLE were divided into DED group and non-DED group. ROC curves were drawed to evaluate predicted value of each risk factor. As shown in The aim of this study was to investigate the differences in ocular surface characteristics, tear film quality, and the incidence of DED between SLE patients without SS and healthy populations. Autoimmune-related DED is not a new topic, and DED in pSS and sSS patients has been widely studied and reported , 11. HowThe results showed that the proportion of SLE patients who met the TFOS DEWS II DED diagnostic criteria was significantly higher than that of the control group. The current study showed that TMH was lower in SLE patients, which is consistent with the trend of previous studies of DED in patients with autoimmune diseases , 24. In One of the purposes of this study was to investigate the classification of DED in SLE patients. According to TFOS DEWS II criteria, DED can be divided into three subtypes: ADDE, EDE, and mixed DED. ADDE is related to lacrimal gland dysfunction, which is more common in SS patients. EDE is mainly associated with abnormal eyelid function (e.g. MGD) . ConsideIn the past, due to the limitations of recognition and detection equipment, the diagnosis of autoimmune-related DED often focused on the destruction of the lacrimal gland and the change in tear volume, resulting in incomplete evaluation and ignoring the change in the meibomian gland and lipid layer of tear film. The meibography techniques of Keratograph 5M provide us with favorable conditions for quantifying MG dropout, which is one of the characteristic clinical manifestations of MGD . The resMeanwhile, there was discordance between symptoms and signs of DED in SLE patients, which has been reported in pSS . The resThis study demonstrated that compared to SLE patients without DED, DED patients were older and had higher SLEDAI. This suggested that ophthalmologists and rheumatologists should pay attention to DED in SLE patients, especially those with older age and severe disease activity. However, there were no significant differences between two groups in smoking, alcohol use, corticosteroids use, hydroxychloroquine use, hypertension, diabetes, CRP, C3, and ESR. This result suggested that immunosuppressive drugs did not increase the incidence of DED in SLE patients, which was consistent with the results of Yoon et al. .Through the ROC analysis, it can be found that the AUC of SLEDAI, age, and BUT are 0.752, 0.748, and 0.896, respectively. Each of them can be used as a reference indicator for early prediction of DED in SLE patients. However, AUC of each single indicator was between 0.7 and 0.9, and the diagnostic accuracy of them for DED was moderate. When the combination of the three was selected, the AUC was the largest (>0.9), indicating that the diagnostic accuracy of DED is the highest. Therefore, the combined detection can improve the accuracy of prediction.There were some shortcomings in this study. (1) The participants were only recruited from the First Affiliated Hospital of Anhui Medical University, so there may be restrictions due to regional restrictions. (2) Due to patient compliance, we did not include the very severe SLE, which might affect the analysis of the correlation between ocular surface parameters and SLEDAI. (3) In the future research, we need to add other DED diagnostic tools  to improve the accuracy of DED diagnosis.In conclusion, the results showed that SLE patients without SS had a higher risk of developing DED than healthy populations, and tended to present with mixed DED. The poorer meibomian gland function in SLE patients may potentially contribute to the development of DED. The combined indicators of SLEDAI, age and NIKBUT showed a high accuracy for the diagonosis of DED in SLE patients.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.The present study was approved by the Ethics Committee of the First Affiliated Hospital of Anhui Medical University. Informed consent was obtained from all participants. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.ZG and RL: study concept and design. ZG, AZ, and QL: collecting and analyzing the data. QL and AZ: statistical expertise. ZG: writing the manuscript. RL and ZS: technical or material support, supervision, and critical revision of the manuscript. All authors contributed to the article and approved the submitted version.This research was supported by the National Natural Science Foundation of China (81871296), Clinical Science Foundation of Anhui Medical University (2021xkj158), and Natural Science Foundation of Universities in Anhui Province (KJ2021A0298).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Early detection of developmental delays relies on the accuracy of the caregivers' concerns of children's developmental problems. The aim of this study was to investigate the agreement between the caregivers' awareness of children's developmental problems and professional identification.Caregivers of 1,963 children  younger than 6 years old who were at risk of developmental delays and referred to the center for a comprehensive evaluation were enrolled in this study. Children were identified by a transdisciplinary team including a pediatric neurologist, a pediatric psychiatrist, two psychologists, two occupational therapists, two physical therapists, two speech therapists, a social worker, and a special instructor. A series of standardized developmental assessments were used to identify children with developmental delay. Retrospective chart reviews were conducted on all children to confirm specific developmental disorders.The caregivers' initial concerns of cognitive, speech/language, emotional/behavioral, and motor and global development showed low agreement with the results of professional identification. The major disagreement was observed in the cognitive domain. Speech/language developmental concern was an important red-flag indicator of cognitive and emotional/behavioral developmental delays. The presence of intellectual disability, autism spectrum disorder, and attention deficit hyperactivity disorder was high in this study. When having caregivers' concerns about speech/language and emotional/behavioral development, the odds of children with autism spectrum disorder was 2.37 and 2.17 times greater than those without autism spectrum disorder, respectively. The presence of attention deficit hyperactivity disorder was significantly associated with concerns about cognitive and emotional/behavioral developmental delays. Child's age and mothers' level of education were significant indicators for detecting the child's developmental problems.It is recommended that assessing the cognitive developmental status is essential for all children in the identification process. Practitioners should not overlook caregivers' concern about speech/language and emotional/behavioral development. Transdisciplinary practitioners provide educational guidance to caregivers, especially in the domains of cognitive, speech/language, and emotional/behavioral development. Early detection of developmental delays allows the timely provision of appropriate early intervention services , 2. PrevCaregiver awareness is one of the various factors that determine the prognosis or eventual outcome of children with developmental delay . While tFor over a decade, a significant decline in the prevalence of developmental delays was observed in US children aged 3–17 years from 2009 to 2011 and 2015 to 2017  . The assp < 0.01), ASD , and ID  from 2009 to 2017  Do caregivers' concerns of children's developmental problems agree with the professional identification? (2) To what extent do the relationships between caregivers' concerns and specific developmental disorders exist? (3) Do demographic characteristics account for the variability in caregivers' concerns of children's developmental problems? Having a better understanding of the agreement between caregivers' concerns of children's developmental problems and the results of professional identification will help pediatric practitioners provide parenting education and early intervention services.The design of the study was a retrospective cohort study.n = 57), Vietnam (n = 33), Philippines (n = 5), Indonesia (n = 4), Korea (n = 3), Thailand (n = 2), Malaysia (n = 1), India (n = 1), Japan (n = 1), Egypt (n = 1), Croatia (n = 1), Australia (n = 1), Sweden (n = 1), Netherlands (n = 1), and United States (n = 1).Data were drawn from 1,963 children at risk for/with developmental delay and their caregivers through the Center of Team Evaluation for Children's Development in southern Taiwan from January 2017 to December 2019. Children under 6 years old at risk of developmental delays who were referred to the center for a comprehensive evaluation were enrolled in the study. Many parents had concerns about their child's condition due to developmental disorders and health. They would ask pediatricians for a referral to the center for a comprehensive evaluation. Some children were referred by preschool teachers when they failed screening. Certain children were referred by pediatricians while at the clinic visit. Initially, the case manager interviewed caregivers and obtained written informed consent. The case manager used a standard set of checklist items to categorize caregiver concerns. Next, children were evaluated by a transdisciplinary team including a pediatric neurologist, a pediatric psychiatrist, two psychologists, two occupational therapists, two physical therapists, two speech therapists, a social worker, and a special instructor. After the evaluation by the transdisciplinary team, the pediatric neurologist and pediatric psychiatrist would give the diagnosis to children based on the International Classification of Diseases, 10th revision (ICD-10) codes and documented on the medical chart. Caregivers were interviewed by a case manager about their concerns and the demographic characteristics of the children and family. When interviewing, one parent was present and mainly was the mother of the child. The caregivers' concerns were categorized into five developmental domains: cognition, speech/language, emotion/behavior, motor, and global. Global developmental problems were coded when caregivers reported at least two or more developmental domains of problems. A series of developmental assessments including the Bayley Scales of Infant Development-Third edition (Bayley-III), Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R), Peabody Developmental Motor Scale-Second edition (PDMS-2), Chinese Children Developmental Inventory (CCDI), the Screening Tool for Autism in Toddlers and Young Children (STAT), and Child Behavior Checklist (CBCL) were used to identify children with developmental delay. The registered psychologists used the Bayley-III, WPPSI-R, and STAT. Occupational therapists and physical therapists used the PDMS-2. Main caregivers filled out the CCDI and CBCL. All of the tests listed were done on all the included children in a standardized manner. Retrospective chart reviews were conducted on all children to confirm a diagnosis on ID, ASD, and ADHD based on the ICD-10 codes.t-tests were used to examine group differences in other variables.The demographic data, independent variables, and outcome measures for study variables were examined using descriptive statistics. A percentage of caregivers' concerns and final diagnosis were correctly identified. Agreement was assessed using kappa coefficient values. The degree of the association between caregivers' concerns and specific developmental disorders was estimated by simple logistic regression. Chi-square tests were used to determine differences in categorical variables, and independent sample 2 = 10.84, p = 0.013). Of 1,086 children identified at risk for/with a single domain concern, low agreements corresponding to professional identification in each domain were observed ranging from −0.013 to 0.009. The agreement percentages for children identified at risk for/with a multiple domain concern were 72.4% , indicating very poor agreement.N = 102; 5.2%), ASD , and ADHD  was recognized in 1,963 children. Then we analyzed the relationship between caregivers' single and multiple concerns and ID, ASD, or ADHD. For children identified at risk for/with a single domain concern, simple logistic regression revealed that children who were concerned to have speech/language developmental problems were 3.64 times more likely to be diagnosed with ID compared to children without speech/language concerns . Compared to children in the agreement group, the number of children in the family was lower, mothers had lower levels of education, and more children belonged to an immigrant family in the discrepancy group. For the other 877 children at risk for/with a multiple domain concern, the caregivers' initial concerns were the same as the professional diagnosis for 635 children (72.4%), with a discrepancy in 242 children (27.6%). The age at which developmental problems were first noticed was significantly different between the agreement and discrepancy groups . More children over the age of 3 years, older mother's age, and higher levels of mother's education were observed in the discrepancy group compared to children in the agreement group.The early identification of children younger than 6 years of age at risk of developmental delays is essential for the appropriate early intervention services in Taiwan. This study revealed four main findings. First, the major children's developmental problem identified by caregivers and professionals was global developmental delay. The caregivers' initial concerns were the same as the professional diagnosis for 759 children (38.7%), with a discrepancy in 1,204 children (61.3%). The results showed low agreement between the caregivers and the professionals in all developmental domains. Second, the major disagreement between caregivers' concerns and professional identification was observed in the cognitive developmental domain. Cognitive developmental delay was the major involved non-concern domain across any other caregivers' concerns, indicating a comprehensive evaluation for cognitive development should be conducted in the identification process. Speech/language developmental concern was a common red-flag indicator of cognitive and emotional/behavioral developmental delays. Third, the high rate of presence of ID, ASD, and ADHD was observed. The significant relationships between caregivers' concerns and presence of ID were apparent in speech/language and cognitive development. The presence of ASD was significantly associated with caregivers' concerns about speech/language and emotional/behavioral developmental delay. The presence of ADHD was significantly associated with caregivers' concerns about cognitive and emotional/behavioral developmental delay. Fourth, child's age, the number of children in the family, mothers' level of education, and belonged to an immigrant family were significant indicators for detecting the child's developmental problems among children identified at risk for/with a single domain concern. For caregivers of children identified at risk for/with a multiple domain concern, those with older child, older mother's age, and higher levels of mother's education reported different concerns from professional identification.The most common developmental delay among the children in our study was a global developmental delay. Consistent with the findings of a previous study, some caregivers usually report their worry about language problems rather than global developmental delay . In thisIn this study, cognitive developmental domain was observed as the major disagreement between caregivers' concerns and professional identification. Notably, we found that cognitive development was the major involved domain associated with global developmental delay. This was due to the fact that the definitive diagnoses for cognitive and global developmental delays overlapped . AdditioCaregivers' concerns about speech/language developmental delay were significantly associated with the comorbid presence of ID. This is in line with research by Chen et al.  showing Recently, the population of individuals with ASD has increased rapidly. According to the Centers for Disease Control and Prevention (CDC) in the United States, this population has increased to twice the size in the previous decade. In our study, the children of caregivers concerned about a developmental delay in various domains had the presence of ASD, with most children with ASD diagnosed at a young age. As expected, language and emotional/behavioral developmental delays were associated with co-occurring ASD , 32, 33.The high rate of comorbid presence of ADHD was also observed among children with global developmental delay. As expected, children with cognitive or emotional/behavioral developmental concerns were more likely to have ADHD , 36. CarThe findings regarding mother's education levels were in line with previous reports of mother's educational level being critical in the identification of a child's developmental problems , 27, 29.This study has a few limitations. The caregivers and families were recruited from southern cities in Taiwan; hence, geographical differences in socioeconomic status in Taiwan were not considered, and therefore, the findings of this study may not be generalized to families in other areas of Taiwan. Second, the caregivers' concerns about their children's developmental problems and demographic characteristics were collected by caregivers' reports, so caregiver's awareness about their child's development may be overshadowed by their concerns about multiple conditions such as feeding problems, sleeping problems, allergies, subsequent underweight, and activity participation. The caregivers' concerns may be misinterpreted or affected by poor communication.The findings of this study provide some indication of the caregivers' concerns about cognitive, speech/language, emotional/behavioral, and motor development that should be questioned in terms of their association with the real problem. We suggest that assessing the cognitive developmental status is essential for all children in the identification process. Speech/language concerns served as a significant red-flag indicator of identifying multiple domains of developmental delay, especially cognitive and emotional/behavioral developmental delays. Furthermore, our findings indicated that practitioners should pay significant attention to educational guidance on increasing the agreement of caregivers' concerns of children's developmental problems with the results of professional identification, especially in the domains of cognitive, speech/language, and emotional/behavioral development. By being aware of caregivers' educational status, the risk of low-level developmental knowledge and utilization of medical support may be reduced. This information may be useful in understanding the discrepancy between caregivers' initial concerns and professional identification in developmental delays.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 Review Board of National Cheng Kung University Hospital. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.L-YL and Y-FT conceptualized and designed the study. L-YL performed the statistical analyses, drafted the initial manuscript, and takes responsibility for the paper as a whole. W-HY, W-PL, and C-CC coordinated and supervised the data collection. Y-FT coordinated funding acquisition, methodology, project administration, and supervision. All authors contributed to the article and approved the submitted version.This study was supported by grants from the National Cheng Kung University Hospital (NCKUH-10802015) and the Ministry of Science and Technology (MOST 106-2314-B-006-075 and 108-2314-B-006-066) of Taiwan.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Aim: To provide insight in the primary health care (PHC) case management of febrile children under-five in Dar es Salaam, and to identify areas for improving quality of care.Methods: We used data from the routine care arm of the ePOCT trial, including children aged 2–59 months who presented with an acute febrile illness to two health centers in Dar es Salaam (2014–2016). The presenting complaint, anthropometrics, vital signs, test results, final diagnosis, and treatment were prospectively collected in all children. We used descriptive statistics to analyze the frequencies of diagnoses, adherence to diagnostics, and prescribed treatments.Results: We included 547 children . Most diagnoses were viral: upper respiratory tract infection (60%) and/or gastro-enteritis (18%). Vital signs and anthropometric measurements taken by research staff and urinary testing failed to influence treatment decisions. In total, 518/547 (95%) children received antibiotics, while 119/547 (22%) had an indication for antibiotics based on local guidelines. Antibiotic dosing was frequently out of range. Non-recommended treatments were common (29%), most often cough syrup and vitamins.Conclusion: Our study points to challenges in using diagnostic test results, concerns regarding quality of antibiotic prescriptions, and frequent use of non-evidence-based complementary medicines in PHC in Tanzania. Larger studies on diagnostic and treatments processes in PHC in Tanzania are needed to inform effective solutions to support PHC workers in case management of children. Child health has improved over the last 20 years in the United Republic of Tanzania. In 2013, the country attained the 4th Millennium Development Goal target—to reduce the under-5 mortality rate by two-thirds from 1990 levels  on the management of febrile children, compared to using an electronic version of IMCI . It alsoThis is a prospective cohort study of febrile children in primary care in Dar es Salaam, Tanzania, collected as a routine care cohort in parallel to the ePOCT randomized controlled trial. The main outcome measures were the frequencies of and coherence between presenting complaints, diagnostic tests, provider diagnoses and treatment. In addition, we studied the adherence to treatment recommendations of the IMCI chart booklet and national guidelines.Data were collected in a convenience sample of two neighboring public health centers of the study facilities in the Kindondoni District, Dar es Salaam, Tanzania (Facility A and B). Routine clinicians managing febrile children in the participating health centers were asked to take part in the study. In facility A care was provided by two clinicians (clinician 1 and 2) and in facility B by one clinician (clinician 3). All clinicians were certified clinical officers. Clinical officers undergo a 3 year training in basic and applied medicine, and are responsible for the health care of large dispersed rural populations . They trThis study included children aged 2 to 59 months who presented consecutively with an acute febrile illness to the included health centers. The same inclusion and exclusion criteria as the ePOCT trial were used  . WrittenData collection took place from December 2014 to February 2016. A trained research assistant saw the patients first, collected data in a predefined case report form on presenting complaints of the child (as reported by the caregiver) and measured basic anthropometrics and vital signs: weight, mid-upper-arm-circumference (MUAC), axillary temperature (T), and respiratory rate (RR). In addition, the research assistant inquired systematically about the presence of cough or difficulty breathing. The research assistant also performed an mRDT in all included children. Other diagnostic tests were ordered at the discretion of the treating clinicians. Test results were recorded on a study form by the research assistant. Clinicians were asked to record their diagnoses and prescribed treatments with dosing. Before discharge of the patient, the research assistant checked whether these diagnoses and treatments corresponded to those noted by the clinician in the patient's chart, and clarified all discrepancies with the clinician. Research staff did not interfere with the provider diagnoses, nor with treatments. Health worker consultations were not observed by study staff. It was ensured that all essential medicines were available during the conduct of the study . AdditioFor the purpose of this analysis, “recommended treatments per clinical diagnosis” were based on the 2008 IMCI and the Standard Treatment Guidelines of Tanzania from 2013 , 26. TheWe used the following descriptive statistics: frequencies of presenting complaints, clinical diagnoses, diagnostic tests, treatments and dosages were calculated. We tested for differences in provider diagnoses and treatments between clinicians using chi-square tests. We also populated 95% confidence intervals (CI) for proportions to allow comparison between providers. Analyses were performed in Stata version 15.1 and SPSS version 25.There was no patient or public involvement in the design or conduct of this study, nor in the writing of this manuscript.The original ePOCT study protocol and related documents were approved by the institutional review boards of the Ifakara Health Institute and the National Institute for Medical Research in Tanzania , by the Ethikkommission Beider Basel in Switzerland (EKNZ UBE 15/03), and the Boston Children's Hospital ethical review board. Written informed consent was obtained from all parents or guardians.In total 547 children were included , each ofn = 38), “URTI” and “malaria” (n = 31), “URTI” and “UTI” (n = 17) and “malaria” and “UTI” (n = 16), but also many other combinations were present , were cough, or symptoms suggestive of an upper respiratory infection , see  present . There w present .p = 0.20). A urine dipstick was ordered for a variety of complaints , diagnostic tests were ordered for 54/547 (10%) of children . Urine dmplaints , 8/54 (1Besides axillary temperature (which was an inclusion criterion for the study), weight, MUAC, and RR were measured in all children by trained study staff and made available to the treating clinician. Study staff also specifically inquired about the presence of cough or difficulty breathing. Based on the combination of fever, cough, and elevated respiratory rate (as per IMCI cutoffs), 146/363 (40%) of children with respiratory complaints met the IMCI pneumonia classification; 16/146 (11%) of those received a diagnosis “pneumonia” by the clinician; 120/146 (82%) were diagnosed as “URTI” . Fifteenp = 0.40).Ninety-five percent of the children received an antibiotic treatment 518/547, . Amoxicin = 51) were prescribed antibiotics in 92% of cases, although these infections are mostly viral. Details of prescribed antibiotics for the most frequent infections can be found in A first-line recommended antibiotic treatment was prescribed in 11/31 (36%) of children with a “pneumonia” diagnosis. 82/146 (56%) of children with an IMCI pneumonia classification based on the research staff measurements were prescribed a first-line antibiotic treatment . Among tp = 0.78 for dosing within WHO 2008 range, data not shown). All six recorded azithromycin prescriptions were too high (range 17–71 mg/kg/day). For cephalexin all prescriptions except one were within the range of 25–100 mg/kg/day of the WHO Model Prescribing Information , vitamins, and zinc . RecommeIn this descriptive analysis of primary diagnostic and treatment practices for febrile children in Dar es Salaam, Tanzania, we found a very high prevalence of antibiotic prescription. Several issues around antibiotic prescription were identified, including a mismatch between diagnoses and antibiotic treatment, and inaccurate dosing. Misdiagnoses and incorrect treatment prescriptions were common despite provision of respiratory rates, weight and MUAC to clinicians. Adherence to mRDT test results was highly variable. Urine dipstick testing did not appear to change the diagnostic or treatment process in this cohort. Prescription of complementary, non-indicated treatments was frequent.Our study has obvious limitations. The cohort was small and included only three clinicians in two health centers. The generalizability of the findings is hence very limited. However, we did not note relevant provider variability across most domains observed, besides in the treatment of malaria. Dar es Salaam presents a very specific, urban care setting in Tanzania and our findings cannot be generalized to other parts of the country. Our study did not collect data on the consultation process, but rather only on the “inputs” and “outputs” of the consultation. We were hence limited in our ability to explain our findings. At the same time, the lack of observation of the consultation process is also a strength of our study: previous studies in Tanzania often used observations of consultations , 14, 22,Overall, our findings point to several challenges faced by clinicians in managing febrile children, which warrant further investigation.The distribution of the infectious diagnoses  reflects recent epidemiological evidence of the study area , 37. TheInterestingly, clinicians hardly used IMCI classifications for their diagnoses, but rather used diagnoses such as “upper respiratory tract infection” and “gastroenteritis” found in national guidelines and standard pediatric textbooks. Especially as Tanzania is moving toward a national electronic medical record system, it will be important to understand how diagnoses are used by primary care clinicians.Two diagnoses, malaria, and UTI, should have been based on diagnostic testing. For malaria, many studies have raised concerns about the lack of testing and adherence to test results –41. We aPrevious studies pointed to the lack of diagnostic tests as a main challenge in fever management. Our findings underline the need for clear guidance and training in the use and interpretation of diagnostic tests. In addition, a variety of “know-do” gaps have been described to explain non-adherence to IMCI guidelines and diagnostic tests, these include a preference on relying on personal experience, provider priorities, goodness of fit in routine practices as well as intrinsic and extrinsic motivation , 14, 42.Our findings confirm the concern about high-volume antibiotic prescription in primary care in Tanzania , 43–45. Our study raises additional concerns about the quality of antibiotic prescription. Only a small minority of diagnosis-antibiotic prescription pairs aligned with guidance from IMCI or national guidelines. Similarly, a study from Zanzibar reported that only 22% of antibiotic prescriptions were appropriate for the diagnosis . Broad-sAnother consequence of prescribing non-essential medicines is the additional cost-incurred by parents. One-third of patients were prescribed additional non-evidence-based treatments such as vitamins and cough syrup, putting additional financial burden on families and incurring potential safety risks in children .The observations from this descriptive study and its limitations again point to the complexity of quality of care in pediatric primary care in Africa. Current evidence in Tanzania is largely limited to small-scale, fragmented reports or focusing on hospital settings or malaria case-management specifically , 53. In 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 review boards of the Ifakara Health Institute and the National Institute for Medical Research in Tanzania , the Ethikkommission Beider Basel in Switzerland (EKNZ UBE 15/03), and the Boston Children's Hospital ethical review board. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.JM was responsible for the design of the paper and the data analysis and was the main author of the draft and revised manuscript. OD contributed to data analysis and writing and revision of the manuscript. RT and LL contributed to the writing and revision of the manuscript. KK initiated the study, was responsible for funding, designed the trial and supervised the data collection and the writing of the paper. All authors substantially contributed to the writing  of the manuscript.John Masimba, Ifakara Health Institute, Dar es salaam, Tanzania.Josephine Samaka, Ifakara Health Institute, Dar es salaam, Tanzania.Zamzam Said, Ifakara Health Institute, Dar es salaam, Tanzania.Hosiana Temba, Ifakara Health Institute, Dar es salaam, Tanzania.Frank Kagoro, Ifakara Health Institute, Dar es salaam, Tanzania.Valérie D'Acremont, Unisanté – University Center for General Medicine and Public Health, Lausanne, Switzerland; Swiss Tropical and Public Health Institute, Basel, Switzerland.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.