Osteoarthritis is a common disease affecting the quality of life in the elderly population. Osteoarthritis is a painful condition commonly encountered in patients aged 65 years and older and it may cause muscle weakness. Sarcopenia is a condition that has an increasing prevalence in the elderly population. The present study evaluated the relationship between sarcopenia and osteoarthritis.The study included 100 patients aged 65 years and older who were diagnosed with diabetes mellitus. The patients were divided into two groups as Group 1 and Group 2. Group 1 was composed of 50 patients with diabetes and osteoarthritis and Group 2 was composed of 50 patients with diabetes but without osteoarthritis. A detailed medical history was obtained from all patients and all patients underwent physical examination. The get-up and go test was performed, handgrip strength was measured with a hand dynamometer, bioimpedance analysis was performed, and mid-upper arm circumference, calf circumference and waist circumference were measured, and laboratory tests including complete blood count, biochemical nutritional parameters, liver and kidney function tests, and erythrocyte sedimentation rate were ordered. The Kellgren and Lawrence grading system was used to evaluate the severity of osteoarthritis and the skeletal muscle mass index was used to evaluate the muscle mass. These parameters were compared between the two groups.Of the study participants, 1% had severe sarcopenia, 22% had moderate sarcopenia, and 77% did not have sarcopenia. Albumin (p=0.013), magnesium (p=0.038), total protein (0.004), erythrocyte sedimentation rate (p=0.047), hemoglobin level (p=0.018), muscle strength (p=0.046), height (p=0.033), and muscle mass (p<0.05) were significantly different in patients with osteoarthritis compared to patients without osteoarthritis. Patients with osteoarthritis achieved poorer results on the get-up and go test (p=0.014), and mid-upper arm circumference (p=0.028), and calf circumference (p=0.016) were lower in this group. There was a negative moderate correlation between the muscle mass and the Kellgren and Lawrence grade , whereas there was a positive moderate correlation between sarcopenia index and the Kellgren and Lawrence grade  in patients with osteoarthritis.The present study is the first to evaluate the relationship between sarcopenia and osteoarthritis in geriatric diabetic patients. The present study found a significant relationship between osteoarthritis and sarcopenia in geriatric patients with type II diabetes mellitus. The authors suggest that pain associated with osteoarthritis results in immobility, decrease in functional performance, and thus development of sarcopenia. Diabetes mellitus and impaired glucose intolerance are considered to be related with aging and their prevalence rates increase with increasing age. There are two main polygenic defects in type II diabetes mellitus. These include insulin resistance and impairment in beta-cell insulin secretion. Insulin resistance plays a role in the pathophysiology of hypertension, hyperlipidemia, and obesity, and it is also thought to be involved in the development of sarcopenia.,5 Sarcopenia, which is defined as the progressive generalized loss of muscle mass and muscle strength, is one of the most important causes of frailty, disability, and morbidity in the elderly population.,7 Sarcopenia and associated disorders pose a significant burden on the patients and their relatives as well as on the health-care systems and economies of the countries. Several mechanisms are implicated in the onset and progression of sarcopenia. These mechanisms may be related to protein synthesis, proteolysis, neuromuscular integrity, and muscle fat content. Various mechanisms can be involved in sarcopenic individuals and their relative contribution may vary over time. The pathophysiology of sarcopenia related with aging can be explained by a decrease in anabolic hormones , increase in apoptotic activity of myofibrils, increase in proinflammatory cytokines , increased oxidative stress associated with free radical accumulation, alterations in mitochondrial functions of myocytes, and decrease in the number of α-motor neurons. Chronic disorders as osteoarthritis are catabolic processes contributing to the progression of sarcopenia. Considering the fact that common factors could affect changes in the different components of the musculoskeletal system, it is possible that osteoarthritis could predict age-related sarcopenia.,12 Osteoarthritis is the most common joint disorder occurring in patients aged 65 years and older at a rate of 40% and affecting the knee joint.,14 It is difficult to suggest a clear relationship between osteoarthritis and diabetes; however, many studies have demonstrated a positive relationship between these two entities. Several authors have suggested that the prevalence of osteoarthritis is higher in young and middle-aged diabetic patients, and joint destruction starts at an earlier age and shows a more severe course than in the control group. It was demonstrated that insulin resistance and hyperinsulinemia stimulates bone growth in patients with type II diabetes mellitus.Diabetes mellitus is an important public health problem in Turkey as well as in the world.Multiple mechanisms are involved in the pathogenesis of sarcopenia and osteoarthritis both of which have an increasing prevalence among the middle-aged and elderly diabetic population and are associated with a decline in physical function and decrease in the quality of life. These two conditions also constitute an important public health concern due to treatment costs, associated complications and increasing prevalence in recent years in Turkey as well as in the world. The aim of the present study was to evaluate the relationship between sarcopenia and osteoarthritis, which is one of the musculoskeletal disorders responsible for severe disability that occurs with aging in diabetic patients.The study was designed as a cross-sectional study and has been approved by the local ethics committee.  The study included 100 consecutive patients aged 65 years and older who were admitted to the diabetes outpatient clinics at our hospital. The patients were divided into two groups. Group 1 was composed of diabetic patients who presented with joint pain and were diagnosed with osteoarthritis and who did not have any other conditions that would cause sarcopenia. Group 2 was composed of diabetic patients who did not have joint pain and in whom the diagnosis of osteoarthritis was ruled out. Patients with type I diabetes mellitus, patients with a history of major surgery, malignancy, severe cardiovascular disease, acute cerebrovascular conditions, acute or chronic infections, uncontrolled diabetes, major psychiatric condition, patients with abnormal kidney and liver function tests, patients with a pacemaker or any type of implant, severe edema, severe electrolyte disturbances, patients with any condition that would affect mobility , and patients with diabetic neuropathy or polyneuropathy and those with additional chronic conditions that would cause sarcopenia were excluded from the study. Weight, height, body mass index, waist circumference, and blood pressure of the patients were measured. The get-up and go test was performed, handgrip strength was measured with a hand dynamometer, bioimpedance analysis (BIA) was performed, and mid-upper arm circumference, calf circumference and waist circumference were measured. Laboratory tests including complete blood count, biochemical nutritional parameters, liver and kidney function tests, and erythrocyte sedimentation rate were ordered. Fasting blood samples were collected in the morning between 08:00 AM and 10:00 AM. Blood samples were collected into SST II, LH PST II, and EDTA tubes, and simultaneously analyzed. Handgrip strength was measured using a hand dynamometer. Anthropometric measurements including height, mid-upper arm circumference, and calf circumference were obtained. The Kellgren and Lawrence grade and skeletal muscle mass index (SMMI) were calculated and these values were compared between the two groups.Plasma glucose was measured with an enzymatic test, glycated hemoglobin was measured using high-performance liquid chromatography (HPLC) method. Total cholesterol, high-density lipoprotein, low-density lipoprotein, calcium, phosphor, alanine transaminase, aspartate transaminase, gamma-glutamyl transferase, alkaline phosphatase, amylase, and albumin, and triglyceride concentrations were measured using enzymatic colorimetric test. Creatinine level was measured with Jaffe reaction, Vitamin D level was measured using HPLC method, bilirubin levels were measured using the diazo reaction. C-reactive protein level was measured using enzyme immunoassay, iron, iron binding capacity, magnesium, total protein, uric acid, and blood urea nitrogen were measured using spectrophotometry, ferritin level was measured using immunochemiluminescence, and folat level was measured using radioimmunoassay. Potassium, sodium, and chloride levels were measured by ion-selective electrode, creatine kinase and lactic dehydrogenase activity were measured by kinetic analysis method. Lipase levels were measured by turbidimetric method, erythrocyte sedimentation rate was measured by the Westergren method. TSH, free T3, free T4 and Vitamin B12 levels were measured by electrochemiluminescence, and hemogram parameters were measured by flow cytometry.2) was calculated using these measurements. The mid-upper arm circumference and calf circumference were measured using a tape. A mid-upper arm circumference <22 cm was considered low and a value above 22 cm was considered normal; a calf circumference <31 cm was considered low; and a value above 31 cm was considered normal.Height was measured using a stadiometer , while the shoes, socks, and hats were removed. Weight was measured using a daily-calibrated electronic scale , while the shoes, socks, and heavy garments were removed. The body mass index  + 5.102. Height was measured in centimeters, resistance was measured in Ohm, 1 point was assigned to male gender and 0 points was assigned to female gender, and age was evaluated in years. The cutoff values for SMMI in males are as follows: ≥10.76 kg/m2, normal; 8.51–10.75 kg/m2, moderate sarcopenia: ≤8.50 kg/m2, and severe sarcopenia.,20The SMMI was calculated using weight, muscle mass (%), and BIA with the following formula: SMMI (kg) = . Handgrip strength in both sides was measured three times while the patient was in seated position with the arm positioned next to the trunk and the elbow flexed at 90°, and the average of three measurements was recorded.The physical performance was evaluated with the get-up and go test. The patients were instructed to stand up from a chair without holding the armrests, walk 3 m and turn around, walk back to the chair, and then sit down. The performance score was evaluated as follows: 1 = normal, 2 = subtly abnormal, 3 = mildly abnormal, 4 = moderately abnormal, and 5 = severely abnormal. The score of patients showing no evidence for the risk of falls during the test was considered to be normal and the score of patients showing any evidence for the risk of falls during the test was considered to be severely abnormal.Descriptive statistics  were used to define continuous variables. The Student’s t-test was used to compare two independent variables with normal distribution, and the Mann–Whitney U test was used to compare two variables without normal distribution. Pearson’s correlation coefficient was used to evaluate the relationship between two variables with normal distribution, and Spearman’s rho correlation coefficient was calculated to evaluate the relationship between two variables without normal distribution. Chi-square test was used  to evaluate the relationship between categorical variables. The level of statistical significance was set at 0.05. The statistical analysis was performed using MedCalc Statistical Software 12.7.7 .Of 100 patients included in the study, 35 were male and 65 were female. The mean age was 71.3 + 5.3 years. When patients were categorized according to the sarcopenia classification system proposed by the European Working Group on Sarcopenia in Older People (EWGSOP), 1% had severe sarcopenia, 22% had moderate sarcopenia, and 77% did not have sarcopenia. Demographic data, anthropometric measurements, and clinical and biochemical parameters are summarized in There were significant differences between patients with and without osteoarthritis in terms of albumin (p=0.013), magnesium (p=0.038), total protein (p=0.004), ESR (p=0.047), hemoglobin level (p=0.018), muscle strength (p=0.046), height (p=0.033), and muscle mass (p<0.05). Patients with osteoarthritis achieved significantly worse scores in the get-up and go test (p=0.014), and mid-upper arm circumference (p=0.028) and calf circumference (p=0.016) were lower. In patients with osteoarthritis, there was a moderate negative correlation between the muscle mass and the Kellgren and Lawrence grade , and there was a moderate positive correlation between the SMMI and the Kellgren and Lawrence grade  .There was significant difference between patients with moderate sarcopenia and non-sarcopenic patients in terms of amylase (p=0.013), iron (p=0.028), potassium (p=0.007), protein (p=0.043), ESR (p<0.05), hemoglobin (p<0.05), handgrip strength (p<0.05), height (p< 0.05), muscle mass (p<0.05), gender (p<0.05), the get-up and go test (p<0.05), Kellgren and Lawrence grade (p=0.020), and BMI (p<0.05) .,24 Sarcopenia, which is defined as a relatively new geriatric syndrome, has become a significant burden on the healthcare systems particularly in the developed countries due to increasing prevalence in the elderly population.,25,26 In the literature, the prevalence of sarcopenia in women aged 50 years or older was reported to be ranging between 1% and 30%. Sarcopenia has a complex pathophysiology in the elderly. Both intrinsic and extrinsic factors have been implicated in the development of sarcopenia. Intrinsic factors include decrease in anabolic hormones , increased apoptotic activity in the myofibrils, increased levels of proinflammatory cytokines (particularly TNF-α and IL-6), oxidative stress associated with the accumulation of free radicals, changes in mitochondrial functions in the myocytes, and decrease in the number of α-motor neurons, whereas extrinsic factors include energy deficiency, decreased protein intake, and immobility. On the other hand, the presence of acute and chronic diseases can also contribute to the development of sarcopenia in the elderly individuals. Osteoarthritis is an important and common disease resulting in morbidity and mortality. There are limited data regarding the prevalence of osteoarthritis in the population. It has long been known that there is a relationship between chronic diseases and impaired life quality and increased risk of mortality and morbidity.To the best of our knowledge, this is the first study to evaluate the association between sarcopenia and osteoarthritis in geriatric diabetic patients. The term sarcopenia  has been proposed to describe the loss of muscle strength associated with decreased muscle mass, decline in muscle functions and aging, and it is a complex syndrome resulting in disability and dependence with the progression of disease.,32 This relation can be explained by arthrogenic muscle inhibition, which is referred to as the decrease in the efferent motor neuron stimulation in the skeletal muscle, by the changes in the afferent component of the involved joint. Kemnitz et al. showed that knee and hip pain in patients with osteoarthritis causes a decrease in the muscle strength and quality in the lower extremities and therefore results in an increased risk of falls; they also reported that disability is not related to the degree of radiographic changes but strongly related to the severity of these changes. The present study showed that the presence of osteoarthritis results in a decrease in the muscle strength, mass, and performance and this was related to the degree of radiographic findings. Radiographic stage increased with increasing severity of sarcopenia and decreasing muscle mass. The study found a relationship between radiological severity and osteoarthritis. Skeletal muscle system develops as a whole. Thus, any problem in particular system may affect other systems. On the other hand, muscular system acts as an endocrine organ by producing bioactive molecules that may contribute to homeostatic regulation of both bone and muscle tissues. In a study conducted on German women, the prevalence of sarcopenia was found to be higher among participants with osteoarthritis in the hip joint and lower extremities. In same study, osteoarthritis was reported to cause the development of sarcopenia in elderly women.The present study found a significant association between osteoarthritis and sarcopenia. Recent studies have shown that osteoarthritis in the knee and hip joint in the elderly people results in a decrease in the muscle mass and muscle strength. Slemenda et al. evaluated the relationship between knee osteoarthritis and lower extremity weakness and found a relationship between quadriceps muscle weakness and osteoarthritis. The same study also found quadriceps muscle weakness in patients with osteoarthritis in the absence of knee pain or muscle atrophy and this was explained by the presence of muscle function. Quadriceps muscle weakness was defined as the primary risk factor for the progression of joint destruction in patients with knee osteoarthritis. A similar study conducted on in-patients reported a relationship between quadriceps muscle weakness and being confined to bed and a similar relationship has been proposed for other people in the community.The present study found a negative correlation between the muscle mass measured with BIA as recommended by EWGSOP and osteoarthritis. The muscle mass was lower in patients with osteoarthritis. Different results may have been obtained if the muscle mass of the individuals were measured with more sensitive dual-energy X-ray absorptiometry. However, SMMI was not significantly different between the two groups, because calculation of SMMI does not take into account the muscle mass of the patients. This finding can be explained in this manner. Although SMMI was not different in the patient group with osteoarthritis, muscle strength and muscle performance that are other indicators of sarcopenia were lower in this group. Quadriceps muscle weakness commonly associated with knee osteoarthritis is often thought to be caused by the inactivity and impairment in the muscle caused by the pain in the involved joint. The studies have shown that quadriceps weakness can also result in osteoarthritis among other risk factors such as obesity, occupation, and gender. Another study conducted on patients with and without knee pain showed a relationship between quadriceps muscle strength and activation and knee pain. The get-up and go test evaluated the muscle performance, which is a component of sarcopenia. Quadriceps muscle plays an important role in climbing up the stairs, walking and standing, and weakness in this muscle directly causes loss of function in the patients. In the present study, patients with osteoarthritis achieved poorer scores in the get-up and go test compared to those without osteoarthritis. Waters et al. found significantly lower walking speed in patients with osteoarthritis than in those without osteoarthritis. Another study showed limitation in the activities in subjects with knee pain. Same study also showed a relationship between quadriceps muscle weakness and disability in patients with knee pain.In the present study, patients with osteoarthritis had lower muscle strength. The study group in this study was composed of patients with knee osteoarthritis. Thus, we did not expect that handgrip strength measuring with hand dynamometer would be affected; however, handgrip strength showing the muscle strength was lower (19.5) in patients with osteoarthritis. This raises the possibility that there might a decrease in overall muscle strength and not only in the muscles around the involved joints. In a study reporting on males with hip osteoarthritis, muscle strength in the adductor, abductor and flexor muscles of the hip joint were found to be lower in patients with osteoarthritis.The rates of patients with a mid-upper arm circumference lower than 20 cm and a calf circumference lower than 31 cm were higher among patients with osteoarthritis. These anthropometric measurements can be regarded as indirect indications of sarcopenia.Total protein, albumin, complete blood count, and magnesium levels were lower in patients with osteoarthritis. This can be regarded as the reflection of inflammatory process related to osteoarthritis.There was a significant association between osteoarthritis and sarcopenia in geriatric patients with type 2 diabetes mellitus. The association between osteoarthritis and sarcopenia could be mediated by functional and cellular pathways. The authors consider that osteoarthritis results in sarcopenia by causing immobility and a decrease in functional performance. Clinical implication of these findings would be that physicians should be aware of increased risk of sarcopenia in patients with osteoarthritis. Detection of sarcopenia in such patients is particular importance for developing therapeutic and preventive strategies.It is currently difficult to answer the causality dilemma of which came first, osteoarthritis, or sarcopenia?Ethics Committee Approval: The Ethics Committee of University of Health Sciences Umraniye Education and Research Hospital, Date: 22.01,2016; Number: 1154.Peer-review: Externally peer-reviewed.Conflict of Interest: None declared.Authorship Contributions: Concept – S.B, R.S.; Design –S.B, R.S.; Supervision – S.B.; Materials –R.S., D.O., E.S.; Data collection &/or processing – R.S., D.O., E.S., A.B; Analysis and/or interpretation – S.B., A.B.; Literature search – R.S., D.O., E.S., S.A.; Writing – R.S., S.A.; Critical review –S.B.


There has been a recent interest in how architecture affects mental health and psychological well-being, motivated by the fact that we spend the majority of our waking time inside and interacting with built environments. Some studies have investigated the psychological responses to indoor design parameters; for instance, contours, and proposed that curved interiors, when compared to angular ones, were aesthetically preferred and induced higher positive emotions. The present study aimed to systematically examine this hypothesis and further explore the impact of contrasting contours on affect, behavior, and cognition. We exposed 42 participants to four well-matched indoor living rooms under a free-exploration photorealistic virtual reality paradigm. We included style as an explorative second-level variable. Out of the 33 outcome variables measured, and after correcting for false discoveries, only two eventually confirmed differences in the contours analysis, in favor of angular rooms. Analysis of style primarily validated the contrast of our stimulus set, and showed significance in one other dependent variable. Results of additional analysis using the Bayesian framework were in line with those of the frequentist approach. The present results provide evidence against the hypothesis that curvature is preferred, suggesting that the psychological response to contours in a close-to-reality architectural setting could be more complex. This study, therefore, helps to communicate a more complete scientific view on the experience of interior spaces and proposes directions for necessary future research. Built (man-made) environments have become fundamental components of human existence. For the majority of our waking time, we navigate and interact with architectural environments while we live, connect, learn, work, and recreate. The spaces encountered in daily life vary in their physical and aesthetic properties, and may have an influence on affect, behavior, and cognition, and eventually impact mental health and psychological well-being ,2. TheseWhen accounting for the considerable time spent inside buildings, two-thirds of which is in dwellings , the glaA domain in which first successful attempts have been made to link architectural features to psychological responses in human beings concerns contours. We refer to contours here to describe the “edge or line that defines or bounds a shape or an object” . The intAnother line of research exploring the response to built environments has investigated the restorative properties of indoor spaces. The attention restoration theory (ART) proposes that natural environments, filled with “soft fascinations”, could restore cognitive capacity, reduce mental fatigue, and increase focus and attention . Being iWithin the scope of the present study, we aimed to systematically examine the influence of contours (angular versus curved) in virtual indoor architectural settings on affect, behavior, and cognition. Given the significant time urban dwellers spend in the home environment, which has considerably increased since the COVID-19 outbreak in March 2020, we selected the residential space as the context of our present investigation. Interiors are considered a major part of architecture, more than ever in the revolutionary works of modernist architects who regarded interior spaces as the essence , highlighted the importance of furniture, and influenced modern furniture design . Furthermore, we wanted to account for the evidence that architectural style and layout influence the response to form , and to As we aimed to delve deeper beyond the mere investigation of pleasantness, beauty, and arousal, our behavioral measures covered a larger set of affective and psychological dimensions, for a better overview of spatial perception. To inspect the impact of contour on cognition and restorativeness, we included a measure of perceived restored attention, building on the attention restoration theory (ART) , and a mN = 36 individuals who provided usable complete sets of behavioral VR data. Eventually, 48 healthy adults were enrolled, aged between 18 and 40 years, with no severe visual impairments. Further inclusion criteria included fluency in German language and absence of diagnosed mental or neurodegenerative disorder or cognitive impairment. Subjects were recruited through the Castellum Database of the Max Planck Institute for Human Development in Berlin (MPIB) and an online platform (https://www.ebay-kleinanzeigen.de/) and were compensated with 10 euros/h. All participants signed the consent form before the experiment.A sample size estimation using G*Power—version 3.1.9.7 , resulted in the need for 36 participants to enable medium effect size. Due to the high potentiality of technical errors, and the increasing rate of cancelled sessions as a result of the COVID-19 pandemic, the recruitment process was kept open until reaching Two pairs of living rooms were created for the purpose of the study . Rooms oThe size of the virtual room was similar to the MPIB VR lab space dimensions and fixed accordingly to (L × W × H = 4.9 × 3.9 × 3 m) so that free movement was possible during participants’ exploration. Three-dimensional models of all the objects and details of the rooms were created using 3Ds Max—version Theseus, 2020 , and the paradigm with all the tasks was implemented using the gaming software Unity—version 2019.2.1f1, 64-bit . The rooms were rendered in real-time during the experiment, using Unity High Definition Render Pipeline  and were displayed with Steam VR —multiple updates during experiment, no standing version to report, through an HTC Vive Pro headset , connected to a wireless adapter to allow for unobstructed movement. In order to increase immersion, a real physical large couch was included in the set-up, positioned at the same location as in the virtual rooms. Participants could use it within their exploration time, and were asked to sit on it to perform the cognitive tasks .Additionally, a virtual training room was created, simulating the lab appearance  includinAs the study comprised a within-subject design, all participants were tested under all conditions in randomized order, always starting with the training room. Participants with odd ID numbers were first exposed to the training room with curved features, while those with even IDs were assigned to the one with angular ones. Using counterbalancing through a Latin square design, and after eliminating sequences where rooms of the same pair would have been shown successively, four groups were identified, to which participants were randomly assigned: Group A ; Group B ; Group C ; and Group D , where AM is “angular modern”, CM is “curved modern”, AC is “angular classic”, and CC is “curved classic”.The main part of the experimental paradigm consisted of the VR session. In each room, participants started exploring the virtual space for 3 min, followed by a 2-min cognitive task in a sitting position, and responded to a set of questions. Multiple questionnaires were administered before and after the VR session .The in-VR questionnaires included two sections assessing respectively the affective and spatial experience (ASE), and momentary affective state (MAS). ASE consisted of 20 items related to the subjective perception of emotional and spatial dimensions. Participants provided self-reports on 20 bipolar  dimensions using 11-point numeric scales, tagged by two opposite descriptive adjectives on each of the sides. Dimensions encompassed valence, arousal, and dominance, but also covered other spatial aspects , and were retrieved from previous studies ,8,56,74,As part of the post-VR PC-based questionnaire, subjects reported on more aspects of the virtual, spatial, and cognitive experience. Perceived restorativeness (PR) was measured using an adapted 12-item German version of the Perceived Restorativeness Scale (PRS) , under fCognitive performance was evaluated using the results of an in-VR two-minute skip counting task . After ewww.igroup.org, Accessed on 15 September 2020) administered post-VR. IPQ contains 14 items rated on a five-point Likert scale (1–5) tagged with different anchors, according to the four sub-scales that measure different components of presence: General Presence (GP), Spatial Presence (SP), Involvement (INV), and Experienced Realism (REAL). Both SSQ and IPQ were administered right after the VR session, as part of the post-VR questionnaire. Additionally, we collected information related to demographics and other individual differences that are beyond the scope of the present analyses.To evaluate the overall VR experience, and control for specific undesired effects, cyber-sickness was measured using an adapted German version of the Simulation Sickness Questionnaire (SSQ) , adminisAll experimental sessions were conducted in the VR lab at the MPIB (November to December 2020), in compliance with the institute’s COVID-19 regulations for lab hygiene. The experiment was composed of three parts: (1) pre-VR questionnaires and preparation; (2) immersive session; and, (3) post-VR questionnaires and tasks. Participants received the consent form via email before the day of the experiment. They were encouraged to read and sign the form, and to fill in the pre-VR questionnaire before coming to the lab, otherwise, those were completed on the day of the experiment. Upon arrival, participants were presented with an introduction to the study, filled a PC-based questionnaire to collect baseline measures for the affective state and simulation sickness symptoms, and performed a short training session on the cognitive task. Next, they were prepared for the VR session. Details were described thoroughly, the head-mounted display (HMD) was put on with the help of the research assistance staff, and subjects were guided to stand in the teleportation areas next to the room door. The VR session started with an empty teleportation room showing instructions for 20 s, followed by the training room, for familiarization with all in-VR tasks. Each room was simulated for 3 min of free exploration, and participants were encouraged to explore as they needed to, until they felt they could later recognize the room from a photo. At the end of the exploration time, a message was shown at eye level with a message to sit on the couch. Instructions for the cognitive task were displayed on a screen at the wall facing the couch, and when participants confirmed readiness, the starting number was shown. Answers were manually written down by the experimenter, who prompted the participant to “restart” after a wrong number was named, until a “stop” sign was shown at the end of the 2 min. Later, a screen appeared in the middle of the room with instructions on how to answer the questionnaire using the controller. Once all questions were answered, participants were asked to leave the controller on the couch and go to the teleportation spot at the door. The sequence of events and tasks is displayed in https://aspredicted.org/vp93z.pdf, Accessed on 23 February 2021). During data preprocessing, sessions with technical software/hardware errors, and those where participants requested breaks or showed severe symptoms of simulation sickness were excluded. Out of the 48 participants enrolled, a range of 36–40  were included in the analyses  and style (modern vs. classic). When the normality assumption was not met, instead of paired sample t-tests, the Wilcoxon signed-rank test was used. Statistical tests were performed separately for each of the dimensions of the ASE and MAS. For ease of reference, we will be referring to rooms according to their condition in the following parts of the paper .Self-reports assessed with questionnaires  in addition to the cognitive task scores were analyzed using paired samples two-tailed Considering that we collected 33 separate outcome variables, and conducted two different tests with each , eventually we had to conduct 66 frequentist statistical tests. When performing multiple statistical tests, one should take into account that setting the alpha value to 0.05 will result in 5/100 significant results purely by chance, in our case 3.3 significant tests. According to the Bonferroni correction method, which strongly controls for family-wise error rate, the critical value for each comparison is the type I error rate divided by the number of comparisons: α/k = 0.05/66 = 0.00076. However, we also checked for the false discovery rate (FDR) correction, as the Bonferroni correction has been considered overly conservative . FDR cor01 in the Bayesian framework indicates how much more likely it is that the data occur given the null hypothesis.To examine if the observed non-significant results in the frequentist approach represent an absence of the predicted relation between room contour and dependent variables measuring mood and cognition, we examined the amount of evidence in favor of the null hypothesis using the Bayesian framework . The BF0The analyses within the frequentist approach were conducted using R Studio—v1.4 Tiger Daylily , and Bayesian analyses using JASP—version 0.14.1.0 .t-test revealed that participants rated angular rooms higher compared to curved rooms on dimensions novelty (t(40) = 3.95, p < 0.001), order (t(40) = 6.20, p < 0.001) and symmetry (t(40) = 2.13, p = 0.039), whereas curved rooms were rated as more exciting  and harmonious than angular rooms (t(40) = −2.39, p = 0.022). The paired-samples Z = 5.31, p < 0.001), more simple (t(40) = 6.26, p < 0.001), more ordered (t(40) = 2.78, p = 0.008) and more spacious  compared to classic rooms, while the latter were rated as warmer (t(40) = −3.23, p = 0.002) and more enclosed  than modern rooms.Regarding the room style, modern rooms were perceived as more novel , to moderate evidence for a null result in the case of self-reported fear (BF01 = 8.41). Similarly, there was no effect of style on momentary affective state, and Bayes factors span from anecdotal evidence for the absence of the style effect—on the heartbeat (BF01 = 2.00) up to moderate evidence—in the case of alertness (BF01 = 5.37). Participants’ responses are shown in Contrary to our hypothesis, we did not find any effects of contour on momentary affective states. Moreover, Bayesian factors show that the evidence for no effect ranges from anecdotal evidence for a null result for contour effect on the self-report of being active (BFt(35) = −0.79, p = 0.436, nor in modern compared to classic rooms—t(35) = −0.94, p = 0.352. Bayesian factor indicates that there was anecdotal evidence in favor of an absence of effect of contour (BF01 = 2.7) and moderate evidence of absence of style effect on perceived restorativeness (BF01 = 3.7).There was no difference in self-reported restored attention after having been immersed in angular compared to curved rooms—Z = −0.43, p = 0.667) or room style  on cognitive performance. The evidence in favour of null results is moderate for both contour (BF01 = 5.12) and style (BF01 = 4.79) effects on cognitive performance.In line with the behavioral data, we found no effect of contour  from pre-  to post- measurements   . This suM = 3.93, SD = 0.91), SP , INV , and REAL , indicating above medium values for all the subscales, and an acceptable feeling of presence.IPQ scores were computed for each of the subscales. On a 1–5 scale, mean scores were respectively GP  in the case of the five aforementioned dimensions in the respective comparisons. All statistical tests and Bayes factors are reported in In line with the frequentist approach findings and the FDR correction, the harmonic mean of the Bayesian factors BFhttps://drive.google.com/drive/folders/1rIPx0GBHubAsQaWxBWnkY7odOPXn_yiL, Accessed on 19 September 2021). However, we respected the recommended guidelines to reduce VR-induced symptoms and effects by providing high-quality graphics and ensuring that the immersive session did not exceed the recommended maximum duration [Within the scope of the present study, we primarily examined the potential psychological response to indoor virtual living rooms with contrasting contour conditions (angular and curved) on affect, behavior, and cognition. Such findings would contribute to understanding the relationship between humans and the built environments they occupy, and would inform the design of therapeutic settings in ways to optimize cognitive functioning, physical and mental health, and well-being. The very few studies that have investigated these conditions in indoor architectural settings have used for that purpose either photos of existing spaces ,8,49, coduration . Moreoveduration . Hence, To our surprise, we did not find relevant positive effects of contour in most of the outcome measures, although the study had a comparably large sample size , when compared with previous ones, which mostly relied on gut reactions, by either presenting the stimuli very shortly 84 to 3000 ms) , or by 00 ms . Participants had to provide ratings in each room for 31 questions. This might have caused an effect known as the “museum-fatigue effect” , which hFuture studies may want to focus more strongly on implicit measures of emotions, less stress-inducing cognitive tasks, a lower number of outcome variables, and a more positive set of emotions. Sex could be further explored through the selection of a well-balanced sample. One route is to examine inter-individual differences, which include personality traits and expertise in arts and design. However, more differences should be taken into account, such as cultural background, previous experience with VR, information on familiar and lived architectural environments, among others.In summary, while the evidence for curved contour preference in the context of abstract shapes and lines seems robust, it does not appear to be as strong in architectural settings, as multiple studies fail to demonstrate or replicate findings. The present study addressed previous limitations and found that exposure to contrasting contours in virtual interiors within a heterogeneous sample did not elicit significant differences in response to a broad set of psychological dimensions, with tasks and questionnaires administered directly after free exploration, yet within the virtual space, to record an immediate response. The fact that we assessed multiple domains during a close-to-reality architectural experience of fully controlled stimuli, not finding major effects in any of them, makes the study the most comprehensive in the field until now. This suggests that the psychological response to indoor design is much more complex and cannot be reduced into a generalized effect of contour or style, and could involve further multifaceted layers that affect the judgment of spaces on a more individual and contextual level. These results will help to convey a more real-life perspective of the response to the architectural experience in experimental settings and highlight the necessity of further investigations by providing directions for future research.


Porphyromonas gingivalis (Pg) and Aggregatibacter actinomycetemcomitans (Aa) has been suggested in periodontitis and rheumatoid arthritis (RA), as these bacteria could initiate the formation of rheumatoid factor (RF) and anticitrullinated protein autoantibodies (ACPA). We assessed whether serum antibodies against Pg and Aa in RA patients and non-RA controls reflect the subgingival presence of Pg and Aa, and evaluated the relationship of these antibodies to the severity of periodontal inflammation and RA-specific serum autoantibodies. In 70 Indonesian RA patients and 70 non-RA controls, the subgingival presence of Pg and Aa was assessed by bacterial 16S rRNA gene sequencing, and serum IgG levels specific for Pg and Aa were determined. In parallel, serum levels of ACPA  and RF  were measured. The extent of periodontal inflammation was assessed by the periodontal inflamed surface area. In both RA patients and the controls, the presence of subgingival Pg and Aa was comparable, anti-Pg and anti-Aa antibody levels were associated with the subgingival presence of Pg and Aa, and anti-Pg did not correlate with ACPA or RF levels. The subgingival Pg and Aa were not related to RA. No noteworthy correlation was detected between the antibodies against Pg and Aa, and RA-specific autoantibodies.A particular role for  Periodontitis is epidemiologically associated with rheumatoid arthritis (RA), a chronic autoimmune disease characterized by inflammation of the joints, causing pain, bone damage, and disability, although the directionality of this relationship is not known . The devPorphyromonas gingivalis (Pg), which secretes a peptidyl arginine deiminase enzyme (PAD) that can citrullinate bacterial and human proteins [Aggregatibacter actinomycetemcomitans (Aa) has also been implicated in the initiation of autoimmunity in RA. A secreted leukotoxin of Aa (LtxA) was shown to dysregulate activation of the human PAD enzymes in host neutrophils, leading to the release of hypercitrullinated proteins that mimic the repertoire of citrullinated antigens found in the RA joint [RA was hypothesized to start at chronically inflamed mucosal surfaces, as encountered in periodontitis . In addiproteins ,7,8. Rosproteins  suggesteproteins ,9. PerioRA joint .A recent meta-analysis concluded that periodontitis may represent a risk factor for RA because of the genetic risks, bacterial infection, and proinflammatory profile shared between both diseases, although there was considerable heterogeneity among studies . The reaThe included subjects were derived from a previously described Indonesian cohort . In 70 RThe STROBE guidelines for human observational studies were followed. In short, RA patients were consecutively recruited at the outpatient Rheumatology Clinic, Sardjito Hospital, University of Gadjah Mada, in Yogyakarta, Indonesia. The inclusion criteria were in conformity with the 2010 RA classification criteria of the American College of Rheumatology (ACR) [All periodontal measures and subgingival samplings were taken by the same examiner (PSR) who was calibrated by a periodontist (MJdS) that was trained in performing PISA and subgingival sampling.Subgingival microbial samples were taken from the deepest bleeding site per quadrant based on pocket probing depth measurements. If there were no bleeding periodontal pockets, the mesial site of the first molar, or in the absence of the first molar, the mesial site from the adjacent anterior tooth in the dental arch, was selected. Sample sites were isolated with cotton rolls, and supragingival plaque was carefully removed with curettes and cotton pellets. Subsequently, 2 sterile paper points per site  were inserted and left in place for 10 s. Paper points were pooled per patient and stored in a sterile microtube  at −20 °C.Three paper points of the microbial sample were added to 0.5 g of 0.1 mm zirconia beads  in 500 µL sterile phosphate-buffered saline and were beaten at 5.5 m/s for 3 × 1 min at room temperature . Hereafter, samples were heated at 95 °C for 15 min and centrifuged at 4 °C. The supernatant was collected, 2 µL of 10 mg/mL RNase H  was added, and it was incubated for 15 min at 37 °C. Microbial DNA was isolated using the DNeasy Blood & Tissue Kit (Qiagen) according to the manufacturer’s instructions. The purity and concentration of the DNA were measured with a NanoDrop 1000 spectrophotometer . Illumina MiSeq preparation, and the sequencing and analysis of sequence reads were performed as described in Heida et al. . FASTQ fThe IgG antibodies for Pg and Aa were measured by an in-house ELISA, in which pooled lysates of four randomly selected clinical isolates of Pg or Aa from patients with periodontitis were used as an antigen. Standard curves were made from protein standards . The detection of anti-Pg and anti-Aa antibodies was carried out with mouse antihuman IgG . The variation coefficient was 20% [n = 50).The serum RA autoantibodies (ACPA and RF) were determined as described previously . In shorThe RF IgM and IgA levels were determined using an in-house validated ELISA , and then = 44) of non-RA individuals with (n = 19), and without (n = 25), cultivable subgingival Pg . Based on the literature, the prevalence of subgingival Pg is hardly different between RA and non-RA subjects and ranges from around 20% [The major objective of our study was to evaluate to what extent serum antibodies against Pg and Aa in RA patients and the NC reflect the subgingival presence of Pg and Aa, and to assess whether antibodies against these two pathogens can be related to the severity of periodontal inflammation and the levels of serum autoantibodies specific for RA. Based on our own previous data ,22, we cound 20% . Aiming Statistical analyses were performed using GraphPad Prism software . All data, except for age and DAS28, were non-normally distributed (based on QQ plots). For group comparisons, a Mann–Whitney U test was used for continuous variables, and a Fisher’s exact test was used for categorical variables. The correlations between different parameters were assessed by Spearman’s ρ. The significance level α was 0.05.The participant characteristics are listed in 2 has been shown to be associated with the case definition of periodontitis as defined by the Center for Disease Control and Prevention and the American Academy of Periodontology (CDC-AAP) [p = 0.908).A PISA value of ≥130 mmCDC-AAP) . The preSubgingival Pg was detected in around 80% of the RA patients and the NC, while Aa tended to be more frequently detected in the NC than in RA patients. For details on periodontal characteristics, see P. gingivalis (Pg) and anti-A. actinomycetemcomitans (Aa) antibodies in relation to the presence or absence of periodontitis (PD)  had higher anti-Aa levels compared to RA patients with medication (p = 0.014). Moreover, the levels of anti-Pg tended to be higher in RA patients without medication compared to RA patients with medication .RA patients with no medication or treated only with herbal medication  and in the NC   . The aveIn the present study, we showed that in both RA patients and the NC from an Indonesian cohort, the levels of serum anti-Pg and anti-Aa antibodies were associated with the detection of subgingival Pg and Aa. This implies that the measurement of antibodies against whole bacterial cell lysates of Pg or Aa is indicative of a subgingival Pg or Aa infection. As serum IgGs against Aa and Pg were previously shown to be extremely stable over 15 years in subjects with or without periodontitis; these levels indicate an infectious encounter with these pathogens at some point in time .In our present cohort, the detection of subgingival Pg and Aa was comparable for RA patients and the NC, and the levels of anti-Pg and anti-Aa were comparable for RA patients and the NC at the group level. No noteworthy correlation was detected between antibodies against Pg and Aa- and RA-specific autoantibodies. In addition, antibodies against these two pathogens could not be related to the severity of periodontal inflammation. RA medication might influence anti-Pg and anti-Aa levels, although the group of RA patients without medication was small.n = 287).The prevalence of subgingival Pg in RA patients and the NC, and its possible relationships to antibodies or autoantibodies, has been investigated in several studies. However, no other group has investigated IgA antibodies, which are specific for mucosal immunity. In a previous study by our group, we observed that the subgingival prevalence of Pg was not different for the RA patients and the NC, and that there was no correlation detectable between the anti-Pg levels and arthritis autoantibodies in the serum . Based oFusobacterium nucleatum and Pg were found in ACPA seropositive patients with RA. These different observations may relate to the use of different detection techniques and the inclusion of different patient groups. For instance, Scher et al. [n = 31), in 47% of patients with chronic RA (n = 34), and in 27% of healthy controls (n = 18). The difference in Pg prevalence could, however, be explained by the higher numbers of periodontitis cases in their RA population. When combining the findings from 16S rRNA pyrosequencing and/or a positive anti-Pg P18γ antibody response (against a chaperone peptide), the overall exposure to Pg was essentially the same for RA patients (78%) and the controls (83%), which is comparable to our present findings. Thus, it appears from both this study and ours that, overall, the exposure to Pg is relatively high in patients with and without (present) periodontitis.Schmickler et al.  showed br et al.  analyzedThe subgingival prevalence of Pg in a Norwegian cohort of 78 established RA patients was 22%, which is much lower than observed in the present study, although the same sequencing techniques were used . NonetheThis study has some limitations. As radiographic assessment is necessary to confirm a periodontal diagnosis, the PISA in our study does not necessarily reflect the periodontal diagnosis, but the inflammatory burden. Therefore, the division of the presence or absence of periodontitis according to the cut-off is somewhat artificial. Furthermore, the prevalence of periodontitis according to the PISA was relatively low in our groups, but this is a common finding amongst women in Indonesia . In the The present study shows that, in our Indonesian cohort, antibody levels against whole bacterial cell lysates of Pg or Aa reflect subgingival infection by Pg or Aa, which was equally prevalent in RA patients and the non-RA controls. Importantly, no evidence for an association of antibodies against these periodontal pathogens and RA-specific autoantibodies was detected. Thus, it seems that the levels of antibodies against these two oral pathogens have no predictive value for arthritis development, as has been shown by our group for anti-Pg in clinically suspect arthralgia patients ,36.


Objectives: Whether there is a link between assisted reproductive technology (ART) and brain damage in premature infants remains unclear. The aim of this study was to determine whether premature infants conceived by ART are at a greater risk of developing white matter injury (WMI), as detected by magnetic resonance imaging (MRI) or diffusion-weighted imaging (DWI) within 14 days, than those naturally conceived (NC).Methods: A retrospective case-control study was conducted on singleton premature infants with a gestational age of ≥28 weeks and <34 weeks delivered between 2017 and 2019 at Shengjing Hospital, China Medical University. This study included 638 live births that were stratified into case group (n = 218) and control group (n = 420), depending on the presence or absence of WMI. The exposure proportion of ART was compared between the case and control groups, and a logistic regression model was used to identify whether ART was an independent risk factor for WMI.Results: In the univariate analysis, the exposure proportion of ART conception was higher in cases than in controls . According to the multivariable analysis, after adjustment for other variables, the association between ART and WMI remained significant .Conclusions: Singleton premature infants conceived by ART have a higher risk of WMI than NC infants. Given that ART is an independent risk factor for WMI in premature infants, more attention should be paid to neurodevelopmental outcomes in this group. In recent years, the proportion of newborns conceived by ART has been increasing. In developed countries, the proportion of live births after ART can reach 1.5–5.9% , and in vitro culture of the fertilized zygote, which may affect the offspring  and diffusion-weighted imaging (DWI); this study also aimed to determine whether ART is an independent risk factor for WMI. We hypothesized that ART would be associated with an increased risk of WMI.This retrospective case-control study was conducted on singleton premature infants treated between January 2017 and December 2019 at the first neonatal intensive care unit of our institution. All singleton premature infants with a gestational age (GA) of ≥28 weeks and <34 weeks who underwent head MRI and DWI within the first 2 weeks after birth were included. Because of the retrospective study design, the clinical data of only preterm infants <34 weeks could be collected for comparison, necessitating the exclusion of late preterm infants from this study. The exclusion criteria were as follows: (a) congenital brain malformations; (b) brain damage due to severe cerebral hemorrhage or inherited metabolic diseases; (c) vanishing twin pregnancies; and (d) incomplete medical records. The infants were stratified into case and control groups, depending on the presence or absence of WMI. The study protocol was approved by the ethical committee of Shengjing Hospital Affiliated to China Medical University .3, section thickness = 5 mm; T2WI: TR/TE = 5,000 ms/80 ms, matrix = 240 × 135, field of view = 180 × 150 × 90 mm3, section thickness = 5 mm; DWI: TR/TE = 3,500 ms/63 ms, matrix = 112 × 112, field of view = 180 × 180 × 89 mm3, section thickness = 5 mm. Two neuroradiologists who were blinded to the type of conception evaluated all MRI scans.All babies relied on natural sleep to cooperate with the MRI and DWI sequence examinations of the head when they were clinically stable. The MRI scan was performed using a Philips Intera Achieva 3.0T superconducting MR instrument, and the scan parameters were as follows: T1WI sequence, TR/TE = 200 ms/2.3 ms, matrix = 224 × 162, field of view = 180 × 150 × 89 mmWMI was diagnosed following Cornette's criteria and divided into punctate white matter injury (PWMI) and diffuse white matter injury (DWMI), based on the MRI and DWI results within the first 2 weeks after birth. PWMI manifests as a point, cluster, and linear DWI high signal at the centrum semiovale or periventricular area, with or without a T1-high signal and T2-low signal. DWMI manifests as varying hyperintensity ranges on DWI in the white matter around the lateral ventricle and involves the deep periventricular, central, and subcortical white matter .Completed demographic and clinical data were extracted from the medical records. The neonate's sex, GA, birth weight, 1- and 5-min Apgar scores, conception method, patent ductus arteriosus (PDA), and the use of invasive ventilation were recorded. The mother's information included the type of delivery, age, perinatal steroid administration, premature rupture of membranes (PROM), chorioamnionitis, gestational hypertension, and gestational diabetes. ART was defined as infants conceived using standard IVF or ICSI.P-value ≤0.15 were considered as potential significant determinants of WMI and were included in multivariable logistic regression. Multicollinearity between the independent variables was assessed by studying the variance inflation factor. Data were analyzed using the SPSS version 25.0 at 0.05 significance level.All data were classified as follows: sex , GA (<32 vs. ≥32 weeks), birth weight , small-for-gestational age , asphyxia (Yes vs. No), PDA (Yes vs. No), invasive ventilation (Yes vs. No), ART (Yes vs. No), mother's age (<35 vs. ≥35 years), type of delivery , prenatal steroid administration (Yes vs. No), PROM (Yes vs. No), chorioamnionitis (Yes vs. No), gestational hypertension (Yes vs. No), and gestational diabetes (Yes vs. No). The data are expressed as the number of cases and the percentage [n (%)], and were compared using the Chi-square test. Univariable logistic regression was conducted to estimate crude association between mother and infant variables and odds of WMI. Variables with There were 1,114 singleton premature infants with a GA of ≥28 and <34 weeks, of which 476 infants were excluded . These ep = 0.011) and require invasive ventilation . The case group had a higher exposure proportion of ART conception  and gestational diabetes ; however, a lower proportion of mothers in the case group had cesarean delivery  and gestational hypertension (20.18 vs. 31.67% p = 0.002) than those in the control group (A greater proportion of mothers in the case group than in the control group had PROM (44.95 vs. 33.10%, ol group .After adjusting for the influence of confounding factors, ART conception was identified as an independent risk factor for WMI. After adjusting for the effects of SGA, asphyxia, PDA, invasive ventilation, cesarean, PROM, gestational hypertension, and gestational diabetes, the odds ratio of ART conception was 1.82 (95% confidence interval: 1.04–3.21; ART has been available for 40 years, and people are increasingly concerned about the possible adverse effects of this technology on the health of mothers and babies. Previous studies on the health risks of children conceived through ART have focused mainly on the impact of ART on birth defects, and the research on ART and its neurodevelopmental risk on offspring was insufficient. Previous studies have shown that ART is associated with poor neurodevelopmental outcomes. An Australian cohort study observed an increased risk of cerebral palsy in singletons conceived with ART . In addiTo the best of our knowledge, only few previous studies have investigated the impact of ART on WMI in preterm infants. In our study, regardless of whether univariate or multivariate analysis was performed, we found that ART is associated with WMI in preterm infants, confirming that ART is an independent risk factor for WMI in preterm infants. However, we did not follow up these children and, therefore, our study only provides a potential partial explanation of the association between ART and poor neurodevelopmental outcomes.There are many potential mechanisms by which ART may be related to WMI, such as the effects of fertility hormone therapies used during ART, micromanipulation involved in ART procedures, and prenatal and perinatal complications related to ART treatment. Kalra et al. believe that during the routine ART superovulation stimulation process, the mother's internal environment will change, and that these changes can affect embryo transfer, trophoblast cell implantation, and placenta formation, thereby causing early embryo development retardation . The plaThe main advantage of this study is that all research participants were singleton premature infants, which controls the confounding influence of multiple births and preterm birth on WMI to a certain extent. In addition, the case and control groups had different exposures to hypertension and diabetes during pregnancy, but this potential confounding effect was adjusted through multivariable logistic regression.However, this study has some limitations. Because only fewer babies are conceived with ART, we could not investigate the impact of different kinds of ART on WMI alone. In addition, we could not identify the infants who were conceived only with ovulation induction or intrauterine insemination; therefore, they are included in non-ART. If these treatments are also associated with an increased risk of WMI, our risk estimates may be small. However, there is limited literature in this area. Owing to clinical instability, some infants did not complete the head MRI examination within 2 weeks, which may have introduced selection bias. There remains considerable gaps in the literature on the impact of ART on the neurodevelopment of offspring, and greater work needs to be done in the future. Well-designed prospective studies with large sample size need to be conducted to further verify the conclusions of our study, control for as many potential confounders as possible—such as uterine placental blood circulation, and compare the effects of different ART protocols.In summary, our study results show that premature infants conceived by ART are at an increased risk of WMI. This finding is relevant for providing appropriate information to parents considering assisted conception. Doctors providing ART need to be informed of the potential risks of the technology so that they can strictly grasp its indications. Neonatologists need to consider the health risks of ART on premature infants and pay attention to their nervous system development outcomes. In addition, this finding needs confirmation in larger studies and further research is necessary to investigate the underlying mechanism.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 studies involving human participants were reviewed and approved by the ethics committee of Shengjing Hospital Affiliated to China Medical University. Written informed consent from the participants' legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements.XJH and JHF contributed to the study design. XJH performed the data collection and analysis and drafted the manuscript. JHF reviewed the manuscript. All authors have read and approved the final 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.


After adjusting for age, BMI (child), and educational status, the results remain the same. Results of linear regression analyses for boys' sedentary time showed that fathers' sedentary time was significantly associated with boys (p < 0.01), but not with girls. The association of grandmothers' and grandfathers' MVPA activity with that of children showed that grandparents' MVPA, when adjusted for age, BMI, and educational status, was not a significant predictor (p > 0.05) of children's MVPA . In contrast, grandfathers' sedentary behavior was a significant predictor  of children's sedentary behavior . The results of the current study suggest that parental involvement in PA, particularly by mothers, is important for children's PA and, accordingly, healthy outcomes.Studies of the familial association of physical activity (PA) and sedentary behavior (SB) have increased in recent years. However, there is a lack of studies that have objectively examined the correlates between parents, grandparents, and childrens' PA. Therefore, the purpose of this study was to measure PA using accelerometers to determine the extent to which PA and SB correlate among parents, grandparents, and children. A sample of 169 children between 11 and 14 years (77 boys and 97 girls), 225 parents , and 52 grandparents  were recruited for the current study. Accelerometers RM42  were used to determine PA levels of children, parents, and grandparents. Epoch length was 6 s. Mothers' moderate-to-vigorous PA (MVPA) was associated with children's MVPA ( Routines created in early childhood can strongly influence children's health. According to current guidelines  and their families (225 parents and 52 grandparents) were recruited for the current study. The descriptive characteristics of the participants are presented in The participants were primary school children from nine primary schools from urban and rural areas of Republic of Slovenia and their parents. The collection of participants was led by school coordinators who presented the research at parent meetings and collected signed consent forms from participants . Due to the nature of the study, which requires consent from all family members, a voluntary response sample was used . Data in present study were obtained within the project EUPASMOS No. 590662-EPP-1-2017-1-PT-SPO-SCP under the Erasmus+ Programme of European Union.The measurements were performed in autumn 2018 (October to November). They took place at two time points, one week apart. At the first time point, the accelerometers were distributed to the participants and familiarized them with their use. The accelerometers were worn for a full week. Participants were instructed to wear the accelerometers continuously throughout the whole day (24-h) for consecutive seven days, except when bathing or swimming. At the second time point, participants returned the accelerometers.MET = 3.5 mL/kg/min oxygen consumption) for each epoch . PA was measured with an RM42 accelerometer , which is a triaxial accelerometer (data on duration and intensity of activity were recorded), and the data were later processed using the MAD approach (mean amplitude deviation). MAD values have been validated as indicators of energy expenditure during locomotion   denotes the logarithm of the child's moderate and vigorous PA time, ln(MVPA parenti) represents the logarithm of the parent's moderate and vigorous PA time, ln(SB childi) is the logarithm of the child's sitting and laying time, while ln(SB parenti) represents the logarithm of the parent's sitting and laying time. In addition, adjusted models were estimated including covariates and potential confounders that could influence the relationships between the parent's and the child's PA, namely the child's age and BMI, as well as the parent's education level. Both unadjusted and adjusted models were estimated separately for boys and girls. Finally, the study estimated additional models to assess the relationship between grandparent's and grandchild's PA. Unfortunately, these models could not be estimated separately for boys and girls due to small sample size. All presented statistical analyses were conducted in Stata Statistical Software 2017: Release 15 .where ln, and educational status .p < 0.05). The situation was the same after adjusting for age, BMI (child) and educational status (Model 2), only mothers' MVPA was a significant predictor of children's MVPA. Although mothers' and girls' PA were associated, the model explained only 10.1 % of the common variance. The situation was better for boys: after adjusting for age, BMI (child) and educational status, the model explained 18.1 %.It was found that mothers' MVPA was significantly associated with children's MVPA (p > 0.05). In addition, girls' SB was associated with an increase in children's age (p < 0.01).The results of linear regression analyses for SB (both models) showed that parents' SB was not significantly associated with neither boys nor with girls' SB (p > 0.05) of children's MVPA . In contrast, grandfathers' SB was a significant predictor  of children's SB , in a Model 2 that explained 35.8 % of the variance. It was also found that age was a significant predictor of the relationship between grandmothers and children .Linear regression analyses for the association of grandmothers' and grandfathers' MVPA activity with that of children (Model 1) showed that grandmothers' and grandfathers' MVPA was a significant predictor  of childp < 0.05); (ii) when adjusting for age, BMI (child) and educational status, only mother's MVPA showed as significant predictor of child's MVPA  (iii) parental SB is not significantly associated with child's SB; (iv) grandparents' MVPA is a significant predictor of children's MVPA (p < 0.05); (v) only grandfathers' SB is a significant predictor  of children's SB, explaining 35.8 % of the common variance.The current study is important and unique because it contributes to the literature examining family-child associations in measuring PA with objective measures such as accelerometers. The main findings include the following: (i) mothers' MVPA is significantly associated with children's MVPA , having a potential impact on the family correlates of PA and SB. In addition, a methodological limitations regarding the use of accelerometers should be mentioned: (i) although validated for measuring PA and SB, the present study did not not capture certain types of activities, such as light PA and very high PA; (ii) daily PA minutes (means and standard deviations) were very high, which may be a consequence of “cherry-picking,” where only the most active families decided to participate in the study; (iii) as in all PA studies, participants were aware that they were being monitored, which might have resulted in the changes of their habitual PA patterns; (iv) high measurement and equipment costs limited the availability of accelerometers and did not allow the measurement of PA of all included participants during the same week which means that the PA patterns could be affected by other factors such as different weather conditions; (v) MVPA and SB were measured for only one week, so the results cannot be interpreted as behavioral PA; (vi) biomechanical and physical factors could affect the results as increased mass give lower acceleration and the increased and/or different height of participants produces longer or shorter pendulum, resulting in potentially different measures od PA and SB; (vii) external factors could influence PA and SB: family problems, friendship problems, dietary habits and changes of environment/school, socioeconomic status, which have not been controlled for; (viii) this study was conducted in October to November, so the conclusions cannot be interpreted for a longer period of time, as previous studies have shown that older adults change their PA depending on the season . Written informed consent to participate in this study was provided by the participants or parents/legal guardian for children involved in this study.VZ, SD, VS, and GJ conceptualized the study design and recruited subjects into the study. GJ conducted the research. VS and VZ analyzed and interpreted the data. VZ drafted the manuscript. VS, SD, and GJ reviewed the manuscript. All authors have read and approved the final 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.


Time is a key factor to consider in Autism Spectrum Disorder. Detecting the condition as early as possible is crucial in terms of treatment success. Despite advances in the literature, it is still difficult to identify early markers able to effectively forecast the manifestation of symptoms. Artificial intelligence (AI) provides effective alternatives for behavior screening. To this end, we investigated facial expressions in 18 autistic and 15 typical infants during their first ecological interactions, between 6 and 12 months of age. We employed Openface, an AI-based software designed to systematically analyze facial micro-movements in images in order to extract the subtle dynamics of Social Smiles in unconstrained Home Videos. Reduced frequency and activation intensity of Social Smiles was computed for children with autism. Machine Learning models enabled us to map facial behavior consistently, exposing early differences hardly detectable by non-expert naked eye. This outcome contributes to enhancing the potential of AI as a supportive tool for the clinical framework. Autism Spectrum Disorder (ASD) identify a highly complex and pervasive neurodevelopmental condition. It is characterized by a range of symptoms related to socio-communicative abilities and repetitive patterns, restricted behaviors, or interests. Early diagnosis of ASD is a key research and clinical goal. Identifying the presence of the condition as early as possible is crucial to enhance the impact of the treatment, thus directing a vigorous research effort for the identification of behavioral markers that can support the anticipation of a clinical diagnosis ,2,3,4,5.The early detection of ASD is an essential objective to improve treatment and long-term quality of life of persons with this condition. From a practical perspective, being able to diagnose the condition as soon as possible offers the opportunity to achieve greater efficacy through specialized intervention pathways and generate more promising prospects for improvement ,5. BeingOverall, the detection of early prodromal symptoms has proved challenging. There is solid evidence that indices of atypical development can be identified in the second year of life when the deficits in the socio-communicative domain and the presence of stereotyped behaviors are more pronounced ,17,18,19Further, the investigation of signs of atypical behaviors within the first year of development can shed light on the primary components of subsequent symptoms . HoweverThis approach exploits the availability of novel technologies supporting quantitative behavior analysis. For instance, eye-tracking can detect anomalies in the early attentional components of social stimulus processing, showing that infants with ASD are less likely to seek social stimuli and show atypical processing of faces already at 6 months of life ,34,35,36In summary, identifying ASD earlier means starting treatment earlier and anticipating the overt emergence of social symptoms. Moreover, creating an approach to automated marker identification would enable therapists and caregivers to provide the infant with the necessary tools to properly interact with the environment and gain appropriate experiences while compensating as much as possible for the atypical developmental patterns.Over the last few years, the adoption of AI has increased substantially in human behavior research, achieving promising successes also in the ASD context, where Machine Learning models have the potential to provide enormous support in studying and monitoring symptoms . A firstConsidering primary motor components, AI-based analysis revealed anomalies in the head movements ,43. ToddFurther, Sapiro and colleagues  highlighFinally, in a more research-related perspective, AI-based methods can be used to study new indicators of the condition, thanks to a richer characterization of patterns and features that could add to markers already known in ASD literature, such as attentional and motor deficits ,8,9,43. The current study aims at experimenting with the potential of CV to explore novel markers of ASD from videos. Based on findings in the literature about early deficits in socio-attentive abilities within ASD ,35,36, wAll procedures of our study were in accordance with the ethical standards of the Italian Association of Psychology (AIP), the ethical standards of the Ethics Committee of the APSS , and the up-to-date Declaration of Helsinki . The resMost of the study population was male , consistent with the asymmetric relationship with sex in ASD pathology . All theA measure of cognitive development was determined by administering the Griffiths Mental Development Scales  to 8 chiFor each of the subjects, Home Videos (HVs) of early interactions between caregivers and the child aged between 6 and 12 months were collected. From the HVs, positive interactions, defined as continuous exchanges between the child and caregiver during playtime, have been extracted . The selection criteria of the interactions required that exchanges were continuous (with no interruptions longer than 5 s) and free of any emission of discomfort or crying, involved the mother, lasted no less than 20 s each, and that the child′s face was frontally visible. Since we wanted to analyze Social and Simple Smiles and non-Social Smiles do not necessarily involve visual coordination, gaze direction was not considered in the inclusion criteria. In this manner, only sequences that met these criteria were extracted and merged from HVs. As a result, video segments of positive interactions were collected for each subject. The average number of interactions selected for each subject was 4 (SD = 1) in the ASD group and 3 (SD = 1) in the TD group. Once merged, a composite video was collected for each subject, with an average duration of 122 (SD = 6) s in the ASD group and 123 (SD = 6) s in the TD group. The HVs were edited for effective analysis of the child’s face by obscuring other faces in the frame and cutting frame sequences in which the child’s face was covered or not frontal.Finally, by comparing the descriptive variables , no statistically significant differences emerged between the distributions of the ASD and TD groups .The facial expressions analysis was based on the manual Facial Action Coding System (FACS). Developed by Ekman and Friesen , the FACOf interest for this study, the FACS describes a set of different types of positive expressions (smiles) linked by the AU12 activation, corresponding to the contraction of the zygomaticus major muscle . We consIn this study, positive facial expressions with communicative value  and more neutral expressions  were analyzed in the HV dataset described in the previous section, referring to the FACS system for the encoding .The FACS has been widely used in the literature for systematically coding facial expressions. However, it is dependent on time-consuming manual coding of AUs by trained experts. Recently, the development of new AI-based models has allowed the automatic measurement of AUs effectively, highly simplifying the annotation effort ,64. OpenOpenface is based on an architecture trained on multiple datasets of AUs, manually coded by trained experts . OpenfacThe Openface framework procedure starts with a face detection step, followed by a facial landmark detection analysis. In the final step, face detection and landmarks are processed to compute the AUs for each frame of the video . The iniOpenface provides a confidence score (C) of the estimations for each frame of the video through a three-layer CNN trained to predict landmark detection error . In thisThe software output was then processed using the pyphisio python library for physiological signal processing . In ordeFor all dependent variables of duration, frequency, and intensity for the two types of smiles: Social (SO) and Simple (SI), a one-way Multivariate Analysis of Variance (MANOVA) was performed with the groups (ASD vs TD) as an independent factor. Two series of Spearman’s Rank Order Correlations (rho) controlling for IQ scores and sex were calculated within the ASD group to assess the correlations with the dependent variables, to ascertain that results were not related to IQ or gender. Follow-up analysis included one-way Analyses of Variance (ANOVAs) for the dependent variables. A Bonferroni test was also included to adjust probability (p) values due to the increased risk of a type I error when performing multiple statistical tests.Dependent variables included: activation intensity, duration, and frequency of facial expressions. Simple (AU12) and Social (AU12 and AU06) smiles were considered. Two series of Spearman′s rank-order correlations were conducted to understand the relationship between IQ, gender, and the dependent variables. No statistically significant correlation emerged .p < 0.01). Despite the violation of the assumption, the MANOVA remains an optimal statistical model thanks to its robustness against deflections from normality. There were no multivariate outliers in the data, as assessed by Mahalanobis distance. There was no multicollinearity, as assessed by Pearson correlation . Variances were homogenous, as assessed by Levene’s test (p > 0.05).A one-way MANOVA was applied to test for statistically significant discrimination between TD and ASD groups, comparing features of two smile types. Preliminary assumption checking revealed that residuals were not normally distributed for some of the dependent variables, as assessed by Shapiro–Wilk’s test (p < 0.0001). Univariate one-way ANOVAs were performed as follow-up analyses, with a Bonferroni adjustment such that statistical significance was accepted at p < 0.00714 ,  = 14.513,  0.00714 .p = 0.644, partial η2 = 0.008) and Simple Smiles  = 0.992, p = 0.328, partial η2 = 0.035)  = 0.219, = 0.035) .p < 0.0001, partial η2 = 0.723); in the Social smiles, both the AU06  = 80.293, p < 0.0001, partial η2 = 0.748) and the AU12  = 66.925, p < 0.0001, partial η2 = 0.713) were hypoactive in the ASD group  = 70.528, SD group .p < 0.00714, partial η2 = 0.299), whereas the Simple Smiles frequency did not reveal a significant difference between the two groups  = 3.133, p = 0.088, partial η2 = 0.104)  = 11.526, = 0.104) .p-values were made for all dependent variables (p < 0.0001) for Simple and Social Smiles. Moreover, a significant difference in the adjusted mean for the frequency of Social Smiles was also found (p < 0.01). All other pairwise comparisons were not statistically significant.Finally, pairwise comparisons with Bonferroni-adjusted ariables . AdjusteWe applied computerized methods for human behavior analysis with the aim of exploring novel early markers of atypical socio-interactive development in infants with ASD. In this attempt, we have implemented a combination of Computer Vision and machine learning models for the refined analysis of facial dynamics through videos. The emphasis on attentive components in the processing of social stimuli has been highlighted in defining the early indicators of atypical neurodevelopment in ASD ,34,35,36The findings seem to suggest that subjects with ASD produce positive facial expressions with significantly lower intensity compared to those with typical development during the first year of development. This reduced activation of facial movements (measured by AUs ) occurs Moreover, the expressive deficit does not seem to correlate with the general cognitive functioning level in our ASD sample. This result is consistent with previous studies that suggested a relationship between IQ and compensatory strategies to reduce the expressive deficit in ASD ,79. It iIn the clinical context, the findings seem to suggest that it could be interesting to include the quantification of expressive dynamics as a potential feature in the early detection of ASD. To our knowledge, this study is the first to highlight potential differences in positive expressive dynamics already within the first year of development in infants with ASD. Our findings seem to suggest that fine-grained analysis of social smiling carries salient cues for early detection of anomalies in social development already starting at 6 months of life. Furthermore, the difference that emerged in frequency potentially contributes to underlining the importance of the attention component in identifying the condition at the early stages of development. Compared to Simple Smiles, less charged with a communicative social value, Social Smiles displayed differently both in intensity and frequency. This discrepancy between social and non-Social Smile dynamics seems to corroborate previous research emphasizing the importance of the primary attentive components ,34,35,36Although the nature of the data collected through this study is not sufficient to define conclusions about specific mechanisms underlying an atypical socio-cognitive development, it may have heuristic value, including speculations. One possibility is that the lack of use of such a powerful communication tool  could induce the toddler with ASD to miss the experience or feedback from effective interactive exchanges during the first months of development. Such atypical behavior could cause a reduction of social experiences in a critical period  for the The innovative contribution of this study is also linked to methodological aspects of the analysis. Digital approaches allow for high-quality data and analyses by relying on quantitative and objective measurements to categorize behaviors, which could be non-invasive and automated ,80. ThesMoreover, this study offers the opportunity to once again underline the promising contribution that AI-based methods may offer to clinical research and practice. The use of automated technologies allowed the extraction of fine features and potentially uncovered subtle atypia in the development, hardly detectable with the naked eye ,42. In AThe present research also carries some relevant methodological limitations. Home Videos provide the huge benefit of being able to have early ecological data, but at the expense of data control. The study has intentionally focused on retrospective material, intending to analyze features in a domestic and natural context. The literature suggests investigating facial expressions in as spontaneous environments as possible . HoweverTiming is a major concern in the diagnosis of ASD. To achieve treatment effectiveness, the condition must be detected as soon as possible. In this study, the combination of Machine Learning models and a systematic approach uncovered new subtle indicators. Facial dynamics seem to play a salient role in this perspective, consistent with what has already been found in the literature. This study’s contribution is towards exposing novel early markers of ASD through behavior imaging. Moreover, the findings highlight the potential of expressiveness as a target for early intervention and the benefit of AI as a valuable support source for clinicians and family members in the detection of ASD.