Thrombotic microangiopathy (TMA) is a syndrome associated with hemolytic anemia, thrombocytopenia, and various organ disorders. Thrombotic thrombocytopenic purpura (TTP) is a disease that develops when a disintegrin-like and metalloproteinase with thrombospondin type l motif 13 (ADAMTS13) activity decreases to < 10% of that in normal plasma, causing platelet thrombosis in microvessels throughout the body. Currently, ADAMTS13-deficient TMA is diagnosed as TTP. Systemic lupus erythematosus (SLE)-related TMA includes both acquired TTP, in which ADAMTS13 activity is significantly reduced, and secondary TMA, in which ADAMTS13 activity is not reduced. Both diseases have different prognoses.An 11-year-old girl was admitted to our hospital on suspicion of TMA with thrombocytopenia and hemolytic anemia. Because the patient had hypocomplementemia, SLE-related TMA or complement-related TMA was considered. Therefore, we initiated plasma exchange (PE) for the patient. Subsequently, she fulfilled the pediatric SLE diagnostic criteria, and ADAMTS13 activity was shown to be decreased and the anti-ADAMTS13 antibody titer increased. She was thus diagnosed with acquired TTP caused by SLE. Treatment response was good as a platelet count and ADAMTS13 activity improved with three times of PE, followed by methylprednisolone pulse therapy and administration of mycophenolate mofetil. Renal pathology showed thrombus formation in glomerular arterioles and lupus nephritis categorized as Class III (A) of the International Society of Nephrology and the Renal Pathology Society classification. Because the patient was thought to be in the high-risk group of SLE, three courses of intravenous cyclophosphamide pulse therapy were administered as an additional induction therapy. No recurrence of TTP was observed.In SLE-related TMA, measurement of ADAMTS13 activity and the anti-ADAMTS13 antibody titer are necessary for diagnosis, and for predicting prognosis and recurrence of the disease; however, in the acute phase of immune-mediated TMA, it is important to initiate proper treatments even before knowing the results to improve prognosis. Thrombotic microangiopathy (TMA) is a syndrome associated with hemolytic anemia, thrombocytopenia, and various organ disorders . CollageThrombotic thrombocytopenic purpura (TTP), a typical example of TMA, is caused by a deficiency in enzymatic activity of a disintegrin-like and metalloproteinase with thrombospondin type l motif 13 (ADAMTS13), which induces platelet aggregation and systemic microvascular thrombosis . In addiHerein, we report a pediatric case of acquired TTP with the concurrent onset of SLE. We experienced difficulties in managing a platelet count until the ADAMTS13 activity and anti-ADAMTS13 antibody titer were confirmed. Plasma exchange (PE) and methylprednisolone pulse therapy (MPT) were quite effective, but prednisolone and plasma infusion were insufficient to improve a platelet count. In addition, typical renal pathology in TTP was observed with occlusive thrombosis in afferent glomerular arteriole in the present case .2, 98% with room air. The patient appeared pale and ill, although she was alert. Petechia was observed on her soft palate. She had a normal breath sound and no heart murmur. Her abdomen was soft and flat without tenderness. Purpura was scattered on her upper arms, lower legs, and precordium on both sides. No edema was found on her lower legs. She had no past medical history and no family history of blood diseases, autoimmune diseases, or renal diseases. Laboratory findings on admission are shown in Escherichia coli infection; all test results were negative. Finally, we found that ADAMTS13 activity was decreased to < 1% and the anti-ADAMTS13 antibody titer returned positive.An 11-year-old girl had gross hematuria from the morning 2 days before admission and a slight fever of 37°C since that night. On the next day, she visited her home doctor and was revealed to have thrombocytopenia and hemolytic anemia , in addition to hematuria and proteinuria. The patient was transferred to our hospital with suspected TMA. Her height and weight were 142 cm [–0.6 standard deviation (SD)] and 30.8 kg (–1.0SD), respectively. Her vital signs on admission were as follows: body temperature, 37.9°C; heart rate, 105 bpm; blood pressure, 122/80 mmHg; SpOth hospital day. After two courses of MPT, the anti-ADAMTS13 antibody test result was negative, the ADAMTS13 activity increased, and the platelet count rapidly increased (2)] as induction therapy for SLE  Classification III (A)  . Notably III (A) . Immunof III (A) . Electro III (A) .Herein, a pediatric case of acquired TTP with the concurrent onset of SLE is described. In TTP, platelet thrombosis in microvasculature causes severe damage to kidneys, brain, and other end organs due to low ADAMTS13 metalloprotease activity , 7.E. coli infection , and the incidence of acquired TTP was 0.29%  . Sato etMatsuyama et al. analyzed clinical characteristics and plasma ADAMTS13 levels in 127 patients with collagen disease-related TMAs, including 64 patients with SLE. Half of the patients with SLE-related TMA have a subnormal to normal range (> 25%) of ADAMTS13 activity, and 23.4% of the patients with SLE-related TMA have a severe deficiency (< 5%) of ADAMTS13 activity. Furthermore, 32 of the patients with SLE-related TMA were ADAMTS13 inhibitor-positive. The group with severe ADAMTS13 deficiency responded well to treatments, and the prognosis was rather favorable . Yue et th hospital day, indicating the severity of organ damage in the acute phase of the disease.Plasmapheresis is the only treatment that has been scientifically shown to be effective in the treatment of acquired TTP . Since iIn conclusion, measurement of ADAMTS13 activity and the anti-ADAMTS13 antibody titer is necessary for the diagnosis and proper treatment of SLE-related TMA; however, in the acute phase of immune-mediated TMA, it is important to initiate PE even before knowing the results to improve prognosis. Pediatric SLE-related TTP cases need to be accumulated to elucidate appropriate treatment and to improve long-term prognoses as this is a rare condition, and clinical features of pediatric SLE are partially different from adult SLE.It’s already been three years since I was discharged from the hospital. At first I wasn’t sure what happened to me, and I really don’t remember anything from when I was in the ICU. When I moved from the ICU to the pediatric ward, I was worried when I heard from my family that my condition was pretty bad, but with the support of doctors, nurses, other patients in the same room, and my family, now, I am here. All the children in the same room were nice, and each was having a hard time with their own disease. I realized that for a child fighting illness, every single day in the hospital is a battle against time and their body. I am very grateful to my family who accompanied me in the hospital and to the doctors and pharmacists who helped me with the treatment and medicine.The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent to participate in this study was provided by the participants or their legal guardian/next of kin.YT and YK wrote the manuscript and performed the practical work. AH, MT, SO, CY, and YI collected clinical data. AM, YO, HH, and MM contributed to measuring ADAMTS13 activity and anti-ADAMTS13 antibody sequentially and to analyzing the data. HA and TT revised the manuscript. All authors contributed to the article and approved the submitted version.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.


Coxiella burnetii acute infections. Between 2004 and 2007, we reported that C. burnetii was responsible for 24.4% of the 131 CAP hospitalized in Cayenne. The main objective of the present study was to determine whether the prevalence of Q fever pneumonia remained at such high levels. The secondary objectives were to identify new clinical characteristics and risk factors for C. burnetii pneumonia. A retrospective case-control study was conducted on patients admitted in Cayenne Hospital, between 2009 and 2012. All patients with CAP were included. The diagnosis of acute Q fever relied on titers of phase II IgG ≥ 200 and/or IgM ≥ 50 or seroconversion between two serum samples. Patients with Q fever were compared with patients with non-C. burnetii CAP in bivariate and multivariate analyses. During the 5-year study, 275 patients with CAP were included. The etiology of CAP was identified in 54% of the patients. C. burnetii represented 38.5% . In multivariate analysis, living in Cayenne area, being aged 30–60 years, C-reactive protein (CRP) > 185 mg/L, and leukocyte count < 10 G/L were independently associated with Q fever. The prevalence of Q fever among CAP increased to 38.5%. This is the highest prevalence ever reported in the world. This high prevalence justifies the systematic use of doxycycline in addition to antipneumococcal antibiotic regimens.In French Guiana, community-acquired pneumonia (CAP) represents over 90% of  Coxiella burnetii, an intracellular bacterium, which is present worldwide.––Bradypus tridactylus), around the city of Cayenne, and more recently in capybara (Hydrochoerus hydrochaeris) in the context of a rural outbreak.,Q fever is a zoonosis caused by C. burnetii infection in most series, it represents more than 90% of cases in French Guiana.–C. burnetii represents the main pathogen responsible for hospitalized CAP in Cayenne. We reported, between 2004 and 2007, that C. burnetii was responsible for over 24% of 131 CAP admitted in Cayenne General Hospital, the reference hospital in French Guiana.Regarding clinical features, while community-acquired pneumonia (CAP) generally represents less than 50% of cases of primary C. burnetii in the empirical treatment of CAP. The most prescribed empirical antibiotic regimen for CAP, supported by the general practitioners and the emergency department, is a combination of amoxicillin and doxycycline. Currently, the diagnosis of acute Q fever is obtained by serology, with seroconversion during the primary infection occurring between day 7 and day 21 after the onset of the symptoms, thus, in the absence of a local point of care quantitative polymerase chain reaction (qPCR) technique, other tools are useful to help choosing the antibiotic regimen. Our first publication led to a predictive score to promptly identify Q fever among hospitalized CAP.,C. burnetii DNA was detected in a dead three-toed sloth found next to a hill where an outbreak of Q fever had occurred, and carrying a three-toed sloth in arms was an independent risk factor for acute Q fever.,The local treatment recommendations in Cayenne Hospital integrate this epidemiology and cover The very high prevalence observed in this previous study may reflect two possible epidemiological situations: an endemic situation with persistent high incidence or an outbreak at the time of the study. To sort between these two scenarios, we completed data collection for longer stretches of time to see if the trends were the same. Thus, the main objective was to evaluate acute Q fever prevalence among CAP between 2009 and 2012. The secondary objectives were to identify clinical characteristics and risk factors for acute Q fever.2 territory.www.insee.fr). Its location a few degrees from the intertropical convergence zone brings a humid equatorial climate, with the alternance between wet and dry season rhythming natural cycles and human activities.In French Guiana, the Amazonian rain forest covers over 98% of the 84,000 kmC. burnetii serology.We retrospectively analyzed patients with CAP admitted in the Department of Infectious and Tropical Diseases of Cayenne Hospital, French Guiana, between January 1, 2009, and December 31, 2012. Cayenne Hospital is a general hospital and the only hospital of the territory with an infectious diseases department (20 beds) and advanced microbiological diagnostic facilities for the etiologies of CAP; it is in close vicinity to the Institut Pasteur in French Guiana, which performs All patients who had an acute onset (≤ 7 days) of respiratory signs, which were defined as cough, chest pain, expectoration, and dyspnea, associated with at least one of the following signs: body temperature > 38°C, auscultation suggestive of pneumonia , and radiographic evidence of pneumonia  were considered to have CAP.C. burnetii Nine Mile strain phase I and phase II antigen, as previously described.C. burnetii in an indirect immunofluorescence assay. Criteria for a positive C. burnetii serology titers of phase II IgG ≥ 200 and/or IgM ≥ 50. Criteria for the diagnosis of acute Q fever were the following: seroconversion,Screening serologic tests were performed at the Institut Pasteur de la Guyane, and diagnosis was confirmed by the French National Reference Center for Q fever, Marseille, France, with an in-house indirect immunofluorescence assay, using C. burnetii, due to the known importance of this infectious pathogen in French Guiana, microbiological diagnosis of other respiratory infectious agents was performed at the discretion of the attending physician. Diagnostic tests for other pneumonia pathogens were performed. Serologic tests were used to detect Mycoplasma pneumoniae, Chlamydia pneumoniae, Chlamydia psittaci, Legionella pneumophila, Toxoplasma gondii (its Amazonian strains causing severe pneumonia), and Bordetella pertussis. The identification of L. pneumophila and Streptococcus pneumoniae were based on the detection of specific antigens in urine samples by an immunochromatographic assay and blood cultures. Serologic tests and qPCR were performed to detect arbovirosis, measles, and leptospirosis. If pulmonary tuberculosis was suspected, specific direct examination and cultures of sputum smears were performed.Patient with CAP of unknown or other etiology were defined as controls. While all patients were routinely serologically tested for Patient’s medical records were retrospectively reviewed. All data collected were anonymized using standardized forms according to the procedures of the Commission Nationale de l’Informatique et des Libertés (the French information protection commission). The study was approved by the local ethics committee as this research was consistent with the French MR004 reference methodology and fell within the framework of so-called “internal” research, that is, the data were collected as part of the individual follow-up of patients, by the staff ensuring this follow-up and for their exclusive use. In accordance with the European regulation on data protection, the study was registered in the hospital’s registry of processing activities by the person in charge of data protection, and collective information was made available to patients by means of a poster in the department, allowing them to express their refusal to participate, if necessary.The acute Q fever and CAP cases were identified retrospectively using the French PMSI  through the extraction of all patients receiving diagnostic codes of the CIM-10 for pneumonia: J12, J13, J15, J16, J17, J18, and the A78 code for Q fever.A standardized form was completed retrospectively for data collection, including socio-epidemiologic data, clinical symptoms of the first clinical examination, and radiographic and biological results. Risk factors were also included in the data collection. The variable was considered positive if present in the file and negative if absent. All data were recorded retrospectively with Microsoft Excel. The continuous variables of interest were categorized following the laboratory cut-off values or values in the medical literature. They generally were dichotomized because of the sample size.P < 0.20) were introduced in a multivariate logistic regression model with a backward step-by-step selection procedure. The significance level p was fixed at 0.05. The estimated adjusted odd ratios (OR) were presented with their 95% CI (95% CI).A case-control study was performed to identify factors associated with Q fever among CAP, comparing patients with Q fever CAP (cases), to patients with CAP of other etiology or unknown etiology (controls). Statistical analysis of data was performed using the SPSS Software (IBM), version 22.0. Categorical variables were described using frequencies and percentages and compared using Fisher’s exact test. Continuous variables were described using means ± SDs or medians with interquartile ranges; they were compared using the Mann–Whitney test. Logistic regression analysis was performed. Potential variables associated with Q-fever CAP occurrence were selected using bivariate logistic regression. The variables retained after the bivariate analysis  of all patients and 71.6%  of those who had a microbiological identification (Mycoplasma pneumoniae in 21 patients (7.6%), followed by Streptococcus pneumoniae (1.8%) and the Amazonian strain of Toxoplasma gondii, so-called Amazonian toxoplasmosis, for 4 patients (1.5%). Most patients presenting with CAP in Cayenne Hospital had fever (90%) and cough (66%) and radiological abnormalities were present in 83% of cases  . Forty-ofication . Twenty-fication . The secof cases . DigestiC. burnetii CAP versus other etiologies were age between 30 and 60 (P < 0.001), being born in mainland France (P = 0.03), living in Cayenne and its suburbs (P < 0.001), reporting tobacco and frequent alcohol consumption , and the notion of leveling work near the house and gardening activities (P < 0.001)  .Regarding clinical features, the presence of temperature > 38.5°C, headaches, chills, muscle pain, and abnormal auscultation were associated with acute Q fever CAP in bivariate analysis  and 5. IIn the multivariate analysis, living in Cayenne area, being aged between 30 and 60 years old, having a CRP levels > 187 mg/L, and having WBC counts <10 G/L were independently associated with Q fever .C. burnetii infection, the present study, spanning the 5 years after the initial study, now found that 38.5% of CAP were Q fever cases; hence, a prolonged period with a very high proportion of Q fever cases, which is more in favor of high endemicity than a punctual outbreak.–,–C. burnetii among acute CAP is probably closer to the real prevalence than in our first study.While our previous study reported that almost 25% of the CAP hospitalized in the hospital of Cayenne were due to in silico, in vitro, and in vivo than the reference strains Nine Mile and the Z3055 strain, isolated from an ewe in Germany and phylogenetically very close to the strain that caused an important outbreak in the Netherlands,,,Bradypus tridactylus), in the Cayenne area. However, the recent detection of C. burnetii DNA in capybara (Hydrochoerus hydrochaeris),C. burnetii infection. The first reported case of acute Q fever in Cayenne in 1998 was observed in a slaughterhouse worker, so that one could hypothesize that the bacterium may have been transmitted from its classical reservoirs to new hosts in a territory of high wild biodiversity. Moreover, these wild animals are also present in the rest of French Guiana and in all Amazonian countries. Further studies are required to understand this very high prevalence, especially in the Latin-American context, and to clarify the patterns of the wild/domestic reservoir and population features.Recent studies have demonstrated that the unique clone MST17 found in French Guiana is more virulent Coxiella burnetii pneumonia is more frequently found in men, aged between 30 and 60 years old. This is often observed in zoonoses linked to professional or leisure outdoor activities and is quite close to risk groups found elsewhere.,In the present study, we found the same features that had been described before, which are confirmed to be quite specific. ,,C. burnetii by wild fauna, such as three-tooth sloth and capybara, so the survey could not question the contact of the patients with these animals.,Finally, we found environmental exposure risk factors, such as gardening or work involving soil near homes. These activities had already been described earlier, and may be associated with an aerosolization of the dust, which may contain particles of the bacterium.C. burnetii antibiotic regimen when facing a clinical and radiological picture of CAP due to its exceptionally high prevalence. Macrolides, which are the second-choice antibiotic regimen in addition to the antipneumococcal treatment, should not be used as the Guianese strain MST 17 seems to be resistant to this antibiotic family.,Although the first publication suggested that doxycycline should be used only in patients with a high probability of Q fever, the results of the present study are in favor of systematic use of an anti-This study is retrospective, and consequently suffers from several biases and unknown confounders. First, diagnostic criteria for Q fever CAP were heterogeneous, since seroconversion was not systematically identified due to the absence of follow-up for some patients. Second, etiologic investigations were left to the appreciation of the clinicians in charge of the patients, so that not all patients were tested for all the pathogens found in the study. However, we think that the high prevalence of Q fever in these real-life conditions is an important signal. Further prospective cohort studies with more stringent criteria are needed to confirm these data and to increase our knowledge about the long-term consequences of acute Q fever in French Guiana.In conclusion, we observed a persistently high proportion of Q fever among adults with CAP in Cayenne Hospital. The relatively long time span seems more in favor of high endemicity than the punctual outbreak. This stable fact justifies the adaptation of treatment protocols for CAP, which should systematically cover for Q fever.


Background: Coronary artery disease (CAD) is responsible for significant mortality and morbidity among patients. Many factors are associated with the increasing prevalence of CAD in a population, including diet and lifestyle, physical inactivity, high cholesterol levels, and others.Objectives: The purpose of this study is to assess the awareness level and knowledge about CAD risk factors and its prevalence among the general population in Taif city, Saudi Arabia.Methods: This study was a community-based cross-sectional descriptive study carried out from August 2022 to September 2022 by an online questionnaire previously validated in published studies and then distributed via different social media platforms to assess participants' knowledge of risk factors for CAD. The survey included questions about socio-demographic data and risk factors of cardiovascular diseases and their prevalence.Results: A total of 2439 participants met the inclusion criteria and finally enrolled in the current study. About 1671 (68.5%) were found to have good awareness levels, 718 (29.4%) of the participants were considered to be having fair awareness levels, and only 50 (2.1%) of the participants were with poor awareness levels.Conclusion: Most participants have a good level of knowledge and awareness about CAD. Few knowledge gaps were regarding certain factors, including age, gender, and family history of CAD. High educational level and age were found to be linked with a higher level of knowledge regarding CAD. Coronary artery disease (CAD) accounts for more than 4.5 million deaths worldwide. Developing countries continue to experience rapid increases in CAD risk factors and mortality, despite recent declines in developed countries . In deveConsumption of fats and sugars has increased due to the globalization of diet, which is associated with an increased risk of coronary artery disease. Living in an urban area appears to be associated with a higher prevalence of risk factors for CAD. Compared with rural dwellers, urbanites tend to be more sedentary and consume more fat and energy-dense foods. Certain parts of the world are also experiencing a rise in tobacco use due to urbanization. Atherosclerotic plaques in coronary arteries are associated with such lifestyle changes. There is a rapid urbanization trend in many developing countries. CAD is also strongly influenced by genetic factors, and in the past decade, significant progress has been made in this area. Several genome-wide association studies involving more than 200,000 people were conducted, as well as bioinformatics approaches, including 1,000 genomes imputation, expression quantitative trait locus analyses, and interrogation of Encyclopaedia of DNA Elements, Roadmap, and other databases .Several countries, including Saudi Arabia (KSA), have seen an increase in obesity, high cholesterol, and metabolic disorders among adolescents and young adults in the last few decades. Furthermore, unhealthy lifestyle habits are responsible for 78% of all deaths due to heart disease, cancer, and diabetes. As a result of the frequent consumption of fast food, Saudis have been reported to be physically inactive and to consume unbalanced diets high in fat, saturated fats, sodium, and carbohydrates, and low in dietary fiber . It inclStudies on the risks and prevalence of CAD have been conducted for different cities in Saudi Arabia using cross-sectional methods, like studies in Qassim, Jeddah, Dawadmi, and Al-Qunfudah revealed that a large portion of the disease is associated with the diet of the population -11. The There is a lack of knowledge regarding the risk factors for CAD is evident among the population in Taif, Saudi Arabia. Therefore, our study includes an analysis of population awareness of CAD risk factors   in Taif.Study designThis study was a community-based cross-sectional descriptive study conducted in Taif city, Kingdom of Saudi Arabia, from August 2022 to September 2022. Study population and sampling methodologyIn this study, the general population residing in Taif city, Saudi Arabia who agreed to participate in the study were included. Any residents outside Taif city were excluded. Data were collected through a previously validated online questionnaire in a published study by Odah et al. . It was The questionnaire covered the following sections: A) The participants’ socio-demographic data, including age in years, gender, nationality, education, marital status, and employment status. B) Level of participants’ knowledge and awareness about CAD risk factors. C) Prevalence of risk factors for CAD, the questionnaire included 29-item, close-ended questions. Participants were asked to respond to knowledge items as either yes or no. Incorrect responses were given a score of zero, and correct answers were assigned a score of one.Data analysisSPSS software, version 23  was used for data entry and analysis. Descriptive statistics such as mean score and standard deviation, as well as frequency and percentages of all independent variables, were used. Responses were scored by frequency and percentage, then converted to percentage mean scores and transformed into qualitative data. Analytic statistics were applied. The Chi-square test of independence or Fischer exact test was used for the analysis of qualitative data. Significance was considered at a p-value < 0.05.Ethical considerationsEthical approval was provided by the Institutional Review Board (IRB) of King Fahad Armed Forces Hospital, Jeddah (No-2022-45- REC 526). Consent was obtained electronically from all participants after the study aims were explained.Socio-demographics dataOut of a total of 3,680 participants, 1,241 were excluded (did not meet the inclusion criteria), and 2,439 of the participants met the criteria and were included in the analysis. Table Awareness of risk factors for coronary artery diseaseOut of a total score of 12, the mean awareness score was 9.3 ± 2.04 (Range 0-12). Figure Smokers are more likely to develop cardiovascular diseases. Table Prevalence of risk factors for coronary artery diseaseFigure Factors associated with awareness of risk factors for CADTable Evaluation and assessment of the knowledge and awareness levels about cardiovascular diseases among the population will result in the determination of knowledge gaps which could be addressed with suitable intervention methods accordingly, and also greater levels of knowledge about coronary artery diseases allow individuals to correctly assess their risk of having coronary artery disease ,14. ThisOut of a total score of 12, the mean awareness score was 9.3. About (68.5%) were found to be having good awareness levels, less than one-third (29.4%) of the participants were considered to be having fair awareness levels, and only 2.1% of the participants were with poor awareness levels. This was found to be contradictory to the study conducted by Ammouri et al. in which 60.5% of the participants had adequate knowledge scores .Regarding knowledge about the risk factors of CAD, smokers are more likely to develop cardiovascular diseases, as reported by the vast majority (91.7%) of the participants. This was found to be consistent with the study by Akintunde et al., in which (79.6%) of the participants were oriented about the increased risk of CAD with smoking . CardiovConcerning the prevalence of risk factors for cardiovascular diseases, the most prevalent risk factor was the consumption of fast food, followed by physical inactivity. The majority (69.5%) of the participants were taking fast food and two-thirds (67.6%) of the participants lacked physical activity. Soft drink intake was reported by (63.3%) of the participants, (59.5%) of the participants were having a family history of diabetes, and (50.4%) were with a family history of high blood pressure. This was consistent with the congruent study by Sekhri et al., in which the most prevalent risk factors for CAD among participants were diabetes mellitus, hypertension, and high cholesterol levels .A significant association was found between age and level of awareness regarding risk factors of CAD, with the age group of 41-50 and more than 50 years old having a higher awareness level than other groups. Similar findings were reported in the parallel study by Mugamammi et al., in which the middle-aged group was linked with a higher knowledge level of CAD . MaritalStudy limitationsWe are aware of a few study limitations that should be addressed. First, the study collected data using an online questionnaire, which may affect its validity if the answers were researched. The population of Taif city of Saudi Arabia is not high enough to represent the population of Saudi Arabia; hence, the results cannot be generalized to the rest of the kingdom.Most participants have a good level of knowledge and awareness about coronary artery diseases. A few knowledge gaps regarding certain factors, including age, gender, and family history of CAD exist. High educational level and age were linked to a higher level of knowledge regarding CAD. Knowledge gaps should be addressed through health education programs and augmentation of the role of media in more distribution of knowledge.


Dystonia and muscle spasms are a group of common and unfavorable clinical neurological symptoms. The use of botulinum toxin (BTX-A) abroad has achieved good results in the treatment of various movement disorders characterized by involuntary or abnormal muscle contractions. It is expected to open up a new field for the treatment of myelodysplastic syndromes (MDs) such as focal dystonia and muscle spasm. There are theoretical and practical implications for the diagnosis and development of some effective neurological treatments. The efficacy of BTX-A in the treatment of various focal dystonia and muscle spasm disorders is as follows: symptoms were improved to varying degrees after injection of Botox or botulinum toxin type A (CBTX-A), but Botox or CBTx. There was no significant difference in the efficacy of A. 30.4% of patients had complete remission, 57.8% had significant remission, and 8.9% had partial remission. Among them, HFS and BS had the best curative effect, and the symptoms were significantly improved by 95.3% and 89.4%, respectively. The efficacy of CD was also satisfactory, with 75.5% of the patients showing significant improvement in symptoms, followed by Meg/OMD (OMD) with 73.3% and SD with 3.3%. The efficacy of WC is poor, and functional improvement is uncertain. Other forms of focal dystonia and spasticity also showed significant functional improvement in 60% of patients. Most patients start to see effects within 1 week after BTX-A injection, symptoms gradually improve, and the bridge of curative effect is reached in 2-4 weeks, and the healing effect lasts for about 3-5 months on average. The overall severity of adverse effects was not severe and resolved spontaneously within a few days to ten weeks, with the most concerning complications being ptosis and dysphagia. Dystonia and muscle spasms are a group of common and unfavorable clinical neurological symptoms. The patient's symptoms are obvious, often aggravated by activities, causing severe pain and suffering to the patient's body and mind. Dystonia is a functional disease second only to Parkinson's in incidence. The most common clinical disorder is focal dystonia, such as blepharospasm, spastic torticollis, writing spasm, and spastic anxiety disorder. Most symptoms are initially hidden and may gradually get worse. Due to the complex etiology, changeable symptoms, few clear and durable curative effects of previous treatments, difficulty in quantifying functional impairment, and difficulty in examination and evaluation, it has been underemphasized for a long time. Clinical studies of CBTX-A for the treatment of eyelid and hemifacial spasm have been reported, but there is no attempt to treat spasmodic torticollis, Meige, writing spasm, and comparison with foreign preparations. To enable the research carried out in this work, botulinum toxin was piloted to treat various neuropathic MDs characterized by involuntary or abnormal muscle contractions. The study was greatly encouraged by comparing the results of botulinum toxin in the treatment of spasticity. It is hoped to open up a new field for the treatment of MDs such as regional dystonia and muscle spasm. It has important theoretical and practical significance for evaluating and developing some effective treatment methods. The purpose of this study was to explore the methods, doses, clinical indications, complications, and long-term efficacy of botulinum toxin treatment. It also conducts a comparative analysis of Chinese and American preparations, further studies electrophysiological changes, deepens understanding, and promotes the application of botulinum toxin in the treatment of neurological diseases.Botulinum neurotoxins are a class of potent protein neurotoxins produced by the anaerobic bacterium botulinum and are the most toxic toxins known to date. In recent years, botulinum toxin has sometimes caused many civilian poisoning incidents and can also be abused in military warfare as a terrorist and biological agent. Therefore, the study of botulinum toxin has attracted the attention of researchers all over the world. There is currently no effective treatment for botulism, and horse serum extracts are mainly used for treatment. However, horse serum has disadvantages such as the risk of viral contamination and allergic reactions. In recent years, with advances in genetic engineering in the production of engineered humanized antibodies, the use of a single antibody has been found to be ineffective. Combinations of multiple monoclonal antibodies may have positive neutralizing and protective effects. The article examines the combination of monoclonal antibodies against different botulinum toxin epitopes, and the screening of the study is the combination of antigenic epitope analysis and antibody screening. Antibody screening is guided by antibody analysis, and the identification of corresponding antigenic epitopes and receptor-binding monoclonal antibody epitopes in antibody screening lays the foundation for the development of antibody therapy and antibody detoxification mechanisms.In the past ten years, botulinum toxin has taken the place of traditional medicine. Botulinum toxin has been used to treat a variety of movement disorders. And it is considered to be the most effective drug for focal dystonia, especially the first-line treatment of spastic torticollis. The short-term effectiveness of botulinum toxin in the treatment of spastic torticollis has been confirmed, generally taking effect within 7-10 days. However, spasticity is a chronic disease process, and most patients require a long-term treatment. Therefore, it has certain clinical practical value to explore the long-term efficacy of botulinum toxin treatment, its influencing factors, and safety.In the clinical research of focal dystonia and muscle spasm, there are also many research results of world experts. Saito et al. made splints for patients that allow stretching and improve finger muscle tone and contractures. After the patient received 5 doses of botulinum toxin type A, the proximal muscle spasm of the upper extremity gradually decreased . Kaymak Fischoff and Silvia reported changes in pain intensity in patients 19 years of age and older in a randomized controlled trial (RCT) comparing botulinum toxin type A (BoNT-A) with placebo for trigeminal neuralgia (TN) . Marceliμg can cause muscle relaxation paralysis of the whole body and eventually lead to respiratory failure and death [α-helix and β-sheet; the transport domain is the amino terminus of the heavy chain with a molecular weight of 50 kDa. It is mainly composed of α-helix; the binding region is the carboxyl terminus of the heavy chain with a molecular weight of 50 kDa, which is composed of two subunits, and the carboxyl terminus binds to the target cell. Both the heavy and light chains are linked by a disulfide bond [Botulinum neurotoxins are a class of potent protein toxoids produced by anaerobic Clostridium botulinum. According to their different antigenicity, they can be divided into various subtypes. A toxin molecule can inactivate a neuron, and its LD50 ranges from 0.1 to 1 ng/kg body weight, resulting in a very low dose of poisoning in humans. Only 0.1-1 nd death . The subide bond .The poisoning mechanism of BoNT/A is shown in Synaptic vesicle 2 is a transmembrane glycoprotein that is widely expressed in endocytic and synaptic vesicles. SV2 contains a hydrophobic transmembrane moiety, which controls the release of neurotransmitter biomass through intracellular vesicle endocytosis, maintains synaptic vesicle homeostasis, and participates in the regulation of synaptic connection muscles . StudiesFibroblast growth factor receptor 3 is a tyrosine kinase receptor and a member of the fibroblast growth factor receptor family. There were a total of 806 amino acids having relative molecular weight of 110 kD~135 kD . It is mμg/ml with coating buffer. 10 μg/ml BoNT/AHC was added to the positive wells, and coating buffer was added to the blank wells, and the protein FGFR3D23 was diluted with PBST to a concentration of 10 μg/ml. The wells showed a positive reaction compared with the positive wells and the negative wells. The experimental results were analyzed with the P/Y value greater than 2.1 as the criterion for positive reaction. Its findings still meet this requirement, as shown in According to the experimental results, the screened small peptides Nos. 20, 21, and 37 were further truncated to shorten the binding range of the receptor on BoNT/AHC [Domain 2/3 of the protein FGFR3 is the binding domain of BoNT/A, so we expressed the protein FGFR3D23 and identified FGFR3D23 as inclusion body expression, and the inclusion body needs to be renatured into a soluble protein. The renaturation of inclusion bodies is a uniform protein with a similar natural conformation, which is conducive to the formation of complex crystals. As shown in t test was performed on the results, and the results showed that there was no difference in the binding of BoNT/AHC and BoNT/AHCN to receptors (p = 0.064 > 0.05), the binding of BoNT/AHC and BoNT/AHCC to the receptor was different (p = 0.006 < 0.05), and the binding of BoNT/AHCN and BoNT/AHCC to the receptor was different (p = 0.022 < 0.05). In this paper, the successfully sequenced plasmids were transformed into BL21(DE3), coated on LB(Amp) plates, and single colonies were picked and cultured at 37°C 220 rpm to midlogarithmic phase. After low temperature induction by adding IPTG, the expression of protein BoNT/AHCC was identified by 12.5% polyacrylamide gel electrophoresis. Electrophoresis results showed that the target protein was expressed in the form of inclusion bodies. The target protein was dissolved in a solution containing 8 M urea and then subjected to Ni-IDA affinity purification. After SDS-PAGE detection, samples with higher purity were collected for renaturation. In this paper, renaturation was carried out by dialysis, and the purified samples were placed in imidazole gradient dilution renaturation solution and dialyzed each concentration for 6 hours. Finally, it was dialyzed into 2 M urea renaturing solution and then transferred to storage solution. The binding ability of truncated mutants BoNT/AHC, BoNT/AHCN, and BoNT/AHCC to receptor FGFR3 at different concentrations was detected by indirect ELISA. In this paper, grouped p > 0.05), and there was no significant difference in the distribution of MAS among the four groups before treatment, leprosy . Compared with the initial treatment, the MAS scores of each group were significantly decreased at any time after treatment . The MAS score after each treatment was lower than that of group A (p < 0.05), and the decrease was most obvious at 1 month. Then, it increased slightly with the prolongation of treatment time and was higher than the level before treatment 12 months after treatment . The comparison of group B, group C, and group D showed that postoperative MAS grades were not always significantly different . Tables Six cases were not treated according to the prescribed rehabilitation program, 4 cases of recurrence without follow-up, 2 cases of respiratory and obstructive pulmonary disease, and 2 cases of recurrence after 6 months, and the last 78 cases were included in the study. The most common recurrence group was group A, with a total of 21 cases, and the BONT-A injection group was groups B, C, and D, with 19 cases, 18 cases, and 20 cases, respectively. The limbs correspond to 37, 35, 34, and 35, respectively. There was no significant difference in the incidence of spastic cerebral palsy and GMFCS among the four groups . The IEMG values in the passive state of sEMG decreased significantly at each time point after treatment . And it may be stable at 6 months and 12 months after treatment . The comparison shows that there is no significant difference in iEMG value in each passive state of sEMG after treatment .There was no significant difference in iEMG values between the four groups in the passive state of sEMG before treatment  testing, where the orbicularis oculi muscle can be applied to the affected area along with the skin via cell injection. Orbicularis oris injection requires more caution to reduce side effects such as ulceration and avoid midline injections to prevent ptosis. The total dose is 12.5-10 U. In the case of spastic torticollis, the most commonly injected muscles are the head and neck muscles, sternocleidomastoid, trapezius, scapula, and skeletal muscles . MultiplFor the observed cases, the most common preinjection treatment was acupuncture combined with traditional Chinese medicine, benzodiazepines, and antiepileptic drugs. The exploratory oral drug treatments described in this article all have mild or transient side effects. Increasing the dose can improve local symptoms; however, there are systemic side effects that patients cannot tolerate, and surgical treatment has a specific effect, but the trauma is obvious, there is a specific risk, and there is a considerable probability of recurrence. One patient with torticollis underwent accessory nerve clamping, amputation of quadratus muscle, and partial amputation of sternocleidomastoid muscle 3 times. The patient relapsed after less than 2 months of symptom remission, and p < 0.01, the differences were extremely significant. Blepharospasm is reduced or disappeared after treatment, and wrinkles around the eyes are reduced. Some patients' visual function improved significantly, and their self-care ability improved. Symptoms improved significantly in the botulinum toxin group and CBTX-A group by 86.7% and 90.9%, respectively. Patient-reported subject improvement averaged 7.7 and 7.6 points, respectively. The adverse reactions after HFS and BS injections are shown in The grading changes of BS patients after Botox and CBTX-A injections are shown in The most common postinjection complications in CD patients are local pain, neck muscle weakness, and dysphagia. The pain from the injection will disappear within a few days, and neck muscle weakness is most common in patients with injections into the head and neck muscles of the spine and the deep extensor muscles of the neck. Difficulty swallowing with head up, drinking is usually caused by discomfort or numbness in swallowing. These adverse reactions developed rapidly within 1 to 12 weeks. In the CBTx-A group, there were 3 cases of rash within a few days after the injection, which disappeared within two weeks after the treatment with the allergy drug. One patient, 54 years old, male, and CD patient, developed nausea and vomiting on the day of injection of CBTX-A300U. If the patient is fatigued and has difficulty breathing, the patient should be observed in the emergency department, infused for 5 days, and improved after a few weeks of rest. No serious complications occurred, and the specific data are shown in The treatment of dystonia has always been a difficult problem for neurologists. Symptoms of localized muscle spasms can be aggravated by mental factors and thus have a functional color, which can easily be mistaken for the performance of sores. But experience has shown that these patients are rarely cured by psychotherapy. The etiology of most dystonias is unknown, and there is currently no effective drug or radical surgical method. Therefore, it is important for doctors and patients to screen for low-risk first-line treatments. Because BTX-A is used to treat many diseases or symptoms characterized by involuntary, abnormal, or excessive muscle contraction, it has become a preventive treatment method for various diseases due to its strong curative effect, reliable curative effect, and low side effects. It is the method of choice for dystonia due to its simplicity, such as spastic torticollis, blepharospasm, Meige syndrome, occupational spasm, spastic dysarthria, and hemifacial spasm. It also has numerous reports of BTX-A in the treatment of spasticity, tremor, twitching, muscle formation, muscle motility, painful myotonia, and unexplained muscle hypertrophy.Muscle tone and muscle spasms are permanent motion sickness syndromes caused by impaired brain development. During leg cramps, muscle stiffness, increased muscle tone, and hyperreflexia may occur. And with the degree of pain, they cannot balance during exercise, and their posture is different from normal people. In difficult situations, they cannot move or even take care of themselves. It can have a severe impact on daily life, cause severe psychological burden, and make it harder for family members to care for it. Clinical rehabilitation should focus on addressing motor developmental disorders and postural deficits. The main goal of treating lower extremity muscles in SP patients is to maintain a relatively stable hand posture to prevent secondary soft tissue contractions. At present, due to the lack of specific methods for the treatment of spasm, BONT-A injection has the advantages of rapid antispasmodic effect, strong selectivity, and few side effects. It is widely used clinically.Common methods of BoNT-A guidance include freehand stretching, EMG localization, electrical stimulation localization, MRI localization, CT localization, and ultrasound guidance. Reverse posture is comfortable, easy, and painless, but not effective in targeting deep, thin muscles. EMG injection method has its own specific injury, but the family may not accept it, but it can be seen in the muscle position. The correct positioning can be connected through the neuromuscular connection, but the correspondence between the position and the injection point is not high. Electroinjection method easily identifies the muscle movement points and easily stimulates the patient. However, the cost is high and the operation is incompatible, such as exposure to ionizing radiation during CT diagnosis and limited diagnostic area. It results in limited BoNT-A injection guidance. Ultrasound has been used in the field of human vision since it was first used to scan brain structures. It clearly identifies the muscles, glands, and blood vessels of the nerves, and the location is very precise, preventing improper injections.According to the severity of spasticity, assessment results, and clinical manifestations, different doses of BoNT-A were selected for injection. The recommended dose of botulinum toxin for the treatment of spasticity in humans is between 0.5 and 6 U/kg. The American Society of Reconstructive Medicine's botulinum toxin guidelines for the treatment of limb spasticity in adults recommend that an adult dose of 600 U be injected at one time, and each injection site should not exceed 50 U. In addition, the recommended doses for pediatric injections are pediatric GMFCSI~IV16-20 U/kg and pediatric GMFCSV12-16 U/kg. A comparative study of 120 patients with spastic paralysis showed that compared with the lower dose, the younger the age, the better the effect and the higher the dose , the more obvious the effect. 90 children with spastic cerebral palsy were selected for clinical observation. After injection, GMFM and MAS were used for evaluation, and the clinical efficacy of 1, 2, and 3 months was monitored. The results showed no difference in recovery rates and overall development of spasticity, reducing the financial burden. However, the article does not discuss muscle and muscle morphology and the effectiveness of seasonal injections. Although high doses of BoNT-A have been reported to disrupt muscle microarchitecture in animal experiments, the effects of high-dose injections on pediatric muscles cannot be ruled out. And because the maximum dose of adult lower extremity muscle is 6 U/kg, based on safety considerations, this study selected a higher dose of BoNT-A 5 U/kg per injection. Considering the economy, drug resistance, and potential adverse reactions, this study selected 3-5 U/kg for injection, and 3-5 injection points were selected for each target muscle to facilitate the enhanced diffusion of the drug.BoNT-A injections combined with restorative therapy can reduce spasticity and increase physical strength over conventional therapy alone; BoNT-A injections can be varied between doses of 3 U/kg, 4 U/kg, and 5 U/kg depending on appropriate preset settings. Specifically, there was no difference between relief of spasticity and improvement in physical function, changes in spastic muscles, and improvement in all physical functions. BoNT-A injection is safe and effective without side effects. In conclusion, BTX-A injection is the best drug group for the treatment of myocardial infarction and local dystonia without destroying muscle growth. It included drug therapy muscle changes and side effects of different BoNT drugs, which were better than the normal recovery group with no significant difference. However, this study still has limitations, such as enrollment age, number of patients, and duration. Botulinum toxin is also an effective method for the treatment of muscle spasm in patients. Local injection of BTX is used to treat local dystonia, hemifacial spasm, abductor muscle, and other nervous system pain symptoms. They provide safe, easy, effective, and reliable treatment to eliminate symptoms and eliminate physical and mental problems in patients. Botulinum toxin can improve patients' lives as one of the first effective and stand-alone therapies, and there is no doubt that it has effective therapeutic applications. At the same time, we also need to recognize the various flaws and problems that need to be addressed.


Extreme mood variability causes significant difficulties in bipolar disorder (BD) and borderline personality disorder (BPD). It is not clear how to conceptualize or measure mood variability, which makes it challenging to assess how treatments for these conditions work. We developed and deployed a computational model, which estimates whether mood variation is persistent versus transient, in patients with BD and BPD, and in a randomized study of lithium. We found that the BD group displayed persistent changes in mood, whereas the BPD group experienced transient changes. Lithium increased persistent changes of positive mood. This work demonstrates that specific types of mood variability are associated with BD and BPD, and suggests a way of understanding how lithium prevents extreme mood states. The affective variability of bipolar disorder (BD) is thought to qualitatively differ from that of borderline personality disorder (BPD), with changes in affect persisting longer in BD. However, quantitative studies have not been able to confirm this distinction. It has therefore not been possible to accurately quantify how treatments like lithium influence affective variability in BD. We assessed the affective variability associated with BD and BPD as well as the effect of lithium using a computational model that defines two subtypes of variability: affective changes that persist (volatility) and changes that do not (noise). We hypothesized that affective volatility would be raised in the BD group, noise would be raised in the BPD group, and that lithium would impact affective volatility. Daily affect ratings were prospectively collected for up to 3 y from patients with BD or BPD and nonclinical controls. In a separate experimental medicine study, patients with BD were randomized to receive lithium or placebo, with affect ratings collected from week −2 to +4. We found a diagnostically specific pattern of affective variability. Affective volatility was raised in patients with BD, whereas affective noise was raised in patients with BPD. Rather than suppressing affective variability, lithium increased the volatility of positive affect in both studies. These results provide a quantitative measure of the affective variability associated with BD and BPD. They suggest a mechanism of action for lithium, whereby periods of persistently low or high affect are avoided by increasing the volatility of affective responses. Excessive affective variability, sometimes called affective instability, characterizes psychiatric diagnoses such as bipolar disorder (BD) and borderline personality disorder (BPD) –4, and iDifferent types of affective variability are thought to exist; when asked to retrospectively describe their experiences, patients with BD report longer periods of raised or lowered affect, whereas patients with BPD report a higher frequency variation of affect . ConsistAffective variability may be directly estimated from prospectively collected affect ratings, with a variety of different metrics of variability described –14. Howe15An alternative approach to conceptualizing and measuring the variability of an outcome is to construct a generative model of how that outcome is produced and then to invert the model using Bayes’ rule , 20. A g19In this paper, we inverted a simple generative model of affect, as measured using ratings of momentary affect , to estiSI Appendix. The key feature of the filter is that it estimates two forms of variability: that caused by affective volatility  and that caused by affective noise . We first used the filter to characterize prospectively collected, daily, positive, and negative affect ratings (n = 53), BPD (n = 33) and nonclinical controls (n = 53), see SI Appendix, Table S1.The generative model of affect and associated Bayesian filter are summarized in  ratings  from a cF = 1.52, P = 0.26], although negative ratings did differ  = 32.26, P < 0.001), with patients in the BPD group endorsing higher mean ratings than both of the other groups (both bonfps < 0.006), and patients in the BD group providing higher ratings than the control group [bonfp < 0.001]. An identical ordering of the groups was apparent for both positive  = 11.6, P < 0.001) and negative  = 38.2, P < 0.001) affective variability, as estimated using the SD of the ratings  = 7.92, P = 0.001), which did not differ between positive and negative ratings  = 1.91, P = 0.15). As can be seen, across both positive and negative ratings, estimated volatility was higher in the bipolar group than in both the borderline (bonfp = 0.042) and control (bonfp < 0.01) groups, with the difference between the borderline and control groups being nonsignificant (bonfp = 0.6). In contrast, estimated noise was higher in the BPD group than in both the BD (bonfp = 0.016) and control (bonfp < 0.001) groups and was also higher in the BD than in the control (bonfp < 0.001) group. In other words, the filter-estimated types of affective variability are diagnostically specific, with volatility being higher in patients with BD and noise higher in patients with BPD.Applying the Bayesian filter to these data E–H proviF = 6.27, P = 0.023), with no difference in any of the other filter-derived metrics  and no difference in the mean or SD of the ratings . Including lithium treatment as a factor in the analysis of the volatility data from the cohort study indicated that levels of positive volatility did not differ between the groups  = 0.35, P = 0.71), but were influenced by lithium treatment status  = 4.66, P = 0.033). In contrast, negative volatility differed between the groups  = 7.14, P = 0.001) and was not influenced by lithium  = 0.04, P = 0.84). These results raise the possibility that lithium treatment increases the volatility of positive affect, although the design of this longitudinal study does not permit firm conclusions as to the causal effect of lithium treatment.Of the 51 patients with a diagnosis of BD recruited to the cohort study, 22 were receiving ongoing lithium treatment and 29 were not. As illustrated in Fs  < 1.6, ps > 0.21) or SDs  < 0.67, ps > 0.42) of either the positive or negative affect ratings. However, lithium differentially altered affective variability, estimated using the Bayesian filter, as a function of both its type and valence  = 5.68, P = 0.02). As can be seen in t(33) = 2.17, P = 0.04), without altering negative volatility (t(33) = −0.9, P = 0.39) or the noise of either valence (ts(33) < 1.36, ps > 0.18).The causal influence of lithium on affective variability was therefore assessed using data from the Oxford Lithium (OxLith) trial . In thisPatients with BD and BPD were found to have distinct types of affective variability, as defined by a generative model of affect. Affective volatility was increased in patients with BD, whereas affective noise was increased in patients with BPD. Treatment with lithium specifically elevated the volatility of positive affect.There has been debate about the types of affective variability that may exist, how the different types should be defined, and whether they add to simpler metrics such as the mean and SD of affective ratings –14. The SI Appendix).The Bayesian filter estimates different forms of variability within a single framework. A range of alternative measures of affective variability have previously been described . Of thesWe found that lithium, an agent with proven efficacy for treating and averting extreme affective states in BD , 26, speSI Appendix, Methods). This suggests an interpretation of the present results in terms of the “half-life” of affective responses: Patients with BD have a longer half-life of affective response than patients with BPD (at least for negative affect) and lithium acts to increase the half-life of positive affective responses. This formulation is consistent with previous qualitative descriptions of these patient groups that have highlighted the shorter time scale of affective responses in patients with a diagnosis of BPD  of affective response results in higher levels of both volatility and noise. This suggests that both patient groups either experience more provoking events, or react more readily or to a greater degree to such events, than control participants. In the present study we did not measure the occurrence of provoking events and therefore cannot directly test this proposal, although it would amenable to future work incorporating measures of stressful life events.The Bayesian filter attributes changes in affect that persist across sampling points to volatility, whereas changes that do not persist are attributed to noise , and these demographic variables were included in the analyses, it would clearly be desirable to replicate the present findings in separate cohorts in which these demographic factors are more closely matched. There are important differences between the cohort and experimental medicine studies. In the latter, patients were earlier in their presentation to services and not receiving treatment, whereas patients recruited to the cohort study were largely receiving established treatment. Furthermore, the two studies differed in the rating scales used to estimate affect. Although these differences limit the degree to which the studies are directly comparable, the similarity in the apparent effect of lithium across the studies suggests that this effect is not dependent on these factors.An important limitation of this work relates to the characteristics of the cohorts used in the first study. In this study, the control group was specifically matched to the BD, rather than the BPD group. As a result, patients in the BPD group had lower educational achievement and were much less likely to be male. Although the same pattern of results was found when analyzing only female patients  study recruited cohorts of patients diagnosed with BD and BPD, as well as nonclinical participants, to examine the relationship between affect, activity, and physiological measures. Results from the AMoSS study, including summary measures of affect ratings and validation of the ratings used have been previously reported by Tsanas and colleagues . All of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (SCID-IV)   and of BSCID-IV) . ControlSI Appendix, Materials).A total of 53 patients diagnosed with BD, 33 diagnosed with BPD, and 53 control participants were recruited to the study. One participant withdrew consent. For the current analysis, participants were included if they had completed at least 10 affect ratings . The moodzoom app prompted participants to rate their current affect every evening by endorsing each of six descriptors  on a 7-point Likert scale. Summary positive and negative affect scores were calculated as the average of the positive and negative items . The 50-The OxLith trial was a randomized, controlled experimental medicine study of patients with bipolar spectrum disorder, conducted in Oxford, UK . During SI Appendix, Table S1.The study recruited individuals aged ≥18 y, with a diagnosis of BD  for whom there was uncertainty about whether treatment with lithium was appropriate . Individuals were recruited from local clinical services. Individuals were not eligible for the trial if they had any contraindications to lithium treatment, were taking concomitant psychotropic medication that they were unable to discontinue, had clinically significant substance misuse, required urgent treatment for a mood disorder , were pregnant or of childbearing age and not using effective contraception, or were acutely suicidal. Summary demographic data are presented in Participants were randomized using a 1:1 allocation scheme, which was minimized for participant age  and sex . The active group received lithium carbonate 200 mg prolonged release tablets, which were titrated to a target serum level of 0.7 mmol/L as per routine practice. The trial psychiatrist and participants remained blind to treatment allocation. For participants in the placebo group, sham lithium levels were provided to the treating psychiatrist who then adjusted the placebo “dose.”Participants completed an online daily version of the positive and negative affect scale, 10-item version (PANAS) . The PANSI Appendix, Materials. In the generative model : F: FSI AppThe Bayesian filter inverts this generative model. It starts with the affect ratings, SI Appendix, Materials for an illustration of how the Bayesian filter deals with missing data and for sensitivity analysis of data missingness).Where more than one set of ratings was provided in a day, the first was used. Days in which no ratings were provided were treated as missing with no data extrapolation  before entry into the analysis. As demographic data were missing from some participants , the reported statistical analyses are limited to participants with complete demographic data . Data from all of the participants are included in the figures. The nonfilter-based metrics (mean and SD) were analyzed separately (as the mean is not a cause of variability) with a single within-subject variable of valence.Analysis of filter-based data from the cohort study was performed using repeated measures ANOVAs with the within-subject factors of cause of variability  and valence  and the between-subject factor of group . In addition, age, sex, and educational attainment were included as control variables in all of the analyses. In these analyses, the dependent variables were the filter-derived estimates of volatility and noise at day 50. Where post hoc comparisons between the three groups were performed, Bonferroni correction was carried out. These are indicated in the text and report the obtained Analysis of data from the experimental medicine study was carried out using a repeated measures ANOVA with the within-subject factors of cause of variability  and valence  and the between-subject factors of group . The dependent variables used were the change in filter-derived estimates of variability between the end of the run-in period and the end of the treatment period. These data did not violate normality assumptions and so were not transformed. All of the inferential statistical tests were two sided. Analyses were performed using IBM SPSS version 25.Supplementary File


Sleep disorders are the most common and disabling symptoms in patients with Parkinson's disease (PD). Understanding the associations between sleep characteristics and motor and non-motor symptoms (NMSs) in PD can provide evidence to guide therapeutic interventions and nursing strategies. We aimed to investigate the association between sleep characteristics and motor function and NMSs in PD using multiple approaches.A total of 328 participants were included, and all participants underwent Pittsburgh Sleep Quality Index (PSQI) evaluation and clinical assessments of PD symptoms. We conducted Spearman's correlation to evaluate the associations between sleep and PD symptoms, nonlinear regression to assess the relationships between sleep habits and PD, and mediated analyses to test the effects of NMSs on global PSQI and PD severity, quality of life, and motor symptoms.Poor sleep was associated with more severe PD symptoms. In addition, the reflection point for bedtime was around 21:52, associated with motor symptoms, and insufficient and excessive total time spent in bed and nocturnal sleep duration were correlated with higher NMS burdens. The optimal points were 8–9.2 and 6.2–6.9 h, respectively. It was also discovered that NMSs played the mediating roles in global sleep with the quality of life, PD stages, and motor symptoms to a varying range of 6.8–95.4%.Sleep disorders have a significant effect on the burden of PD symptoms. The current findings provide new insights into the monitoring and management of sleep and PD and need to be further explored in the future studies. Parkinson's disease (PD), the second most common neurodegenerative disease in the elderly, is brought into focus since it cannot be cured; therefore, an increasing number of studies pay close attention to early diagnosis of PD , disease severity, motor subtypes, and motor and NMSs. Trained researchers performed all examinations.Early onset PD (EOPD) and late-onset PD (LOPD) were defined as the disease onset age before and after 50 years of age, respectively. Additionally, tremor dominant (TD) and postural instability gait disorder (PIGD) were divided based on the ratio of TD to PIGD scores: patients with ratios >1.15 were classified into TD, those with ratios <0.90 to the PIGD, and patients with ratios among 0.90–1.15 were classified as “undetermined”  stage  and χ2 test . Spearman's rank correlations were used to explore the associations between sleep parameters (sleep components and times) and the clinical characteristics of PD. Furthermore, non-linear regression analyses using the quadratic model (y = αx2 + βx + c) were employed to investigate the non-linear associations between sleep habits  and PD characteristics ; therefore, they were log10-transformed to approximate the normal distribution. The Bonferroni method was used for multiple corrections (for seven sleep components), except where specifically noted. Next, mediation analyses were used to evaluate whether the associations between sleep and PD severity were mediated by NMSs  and GraphPad Prism version 8.0, and the statistical significance threshold was set at two-tailed SD = 10.1; 145 women) were enrolled. There were significant differences in disease duration among the three groups (p = 0.005), whereas there were no differences in age, sex, educational level, BMI, disease onset age, and subtypes . Additionally, poor sleep quality was associated with more severe motor and non-motor symptoms (The characteristics of the participants included in the present study are summarized in symptoms .p < 0.01). Poorer sleep levels were also associated with worse cognitive function, although only the total MMSE score, total MoCA score, and executive function survived after Bonferroni correction (p < 0.002). Furthermore, elevated total PSQI scores correlated with more serious NMS burden, depression, anxiety, autonomic dysfunction, apathy, and fatigue (p < 0.05). Additionally, different sleep components were associated with PD characteristics, as shown in Sleep characteristics and habits were significantly associated with PD characteristics as well as motor and NMSs scores . SpecifiThere were significant non-linear relationships between sleep habits and motor and non-motor symptoms in individuals with PD . The refp < 0.001).Mediation analyses were performed to investigate whether NMSs contributed to the quality of life and severity of PD as assessed by sleep levels . We founThis study comprehensively evaluated the association of sleep characteristics and habits with motor symptoms and NMSs in patients with PD using a Chinese cohort. The primary results showed that poorer sleep levels were linked to more severe motor and non-motor symptoms in individuals with PD. Notably, we found several reflection points that showed the best bedtime, as well as the appropriate TIB and NSD, which were most beneficial to PD symptoms. Equally, we discovered that the associations between sleep quality and PD severity, quality of life, and motor symptoms were mediated by a number of NMSs to varying degrees, which provides new insights for clinical practice to intervene in PD deterioration with sleep disorders. Our findings also highlight the importance of increasing the awareness of sleep problems in patients with PD.The PSQI was chosen to evaluate global sleep quality because it has been generally used for the occurrence of sleep disturbances in PD populations with good sensitivity and specificity .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.


Epilepsy is a chronic neurological disorder caused by abnormal neuronal activity that is diagnosed visually by analyzing electroencephalography (EEG) signals. Background: Surgical operations are the only option for epilepsy treatment when patients are refractory to treatment, which highlights the role of classifying focal and generalized epilepsy syndrome. Therefore, developing a model to be used for diagnosing focal and generalized epilepsy automatically is important. Methods: A classification model based on longitudinal bipolar montage (LB), discrete wavelet transform (DWT), feature extraction techniques, and statistical analysis in feature selection for RNN combined with long short-term memory (LSTM) is proposed in this work for identifying epilepsy. Initially, normal and epileptic LB channels were decomposed into three levels, and 15 various features were extracted. The selected features were extracted from each segment of the signals and fed into LSTM for the classification approach. Results: The proposed algorithm achieved a 96.1% accuracy, a 96.8% sensitivity, and a 97.4% specificity in distinguishing normal subjects from subjects with epilepsy. This optimal model was used to analyze the channels of subjects with focal and generalized epilepsy for diagnosing purposes, relying on statistical parameters. Conclusions: The proposed approach is promising, as it can be used to detect epilepsy with satisfactory classification performance and diagnose focal and generalized epilepsy. Epilepsy is a chronic disorder inducing subjects to experience seizures, leading to cognitive impairments, medical and psychiatric comorbidities, social stigmatization, and, in general, poor quality-of-life (QOL) . A recenLiterature shows that the focus in the majority of epilepsy studies is summarized in seizure detection using machine or deep learning techniques to determine the type of epilepsy . This stFeature extraction of machine learning technique is done in time, frequency, or time–frequency domains . Time–frAfter feature extraction, feature dimensionality reduction is a vital step in analyzing signals in cases where we want to reduce irrelevant features and determine the most effective ones with a high model performance. This can be done through various methods such as feature selection or a combination of features, both of which rely on mathematical solutions behaving as filters, wrappers, and embedded strategies ,21. DeteClassification steps have been taken by a variety of linear and non-linear classifiers, such as the decision tree , logistiThe drawback of machine learning algorithms, albeit still beneficial, is that their performance is limited to the ability of those handcrafting the features . ArtificAn RNN is developed to process timeseries data through cyclic connections based on feedforward neural networks. The method has been vastly used for seizure prediction with classification approaches. The history of input in an RNN is mapped in order to predict each output by weighting the temporal relationships between the data at each time point. The issue is that a vanishing gradient problem causing the given input influences hidden and output layers, thus decaying or exploding exponentially over time . One of p-values of Pearson’s linear correlation coefficient. Signals were segmented, and the network was trained by a sequence of selected features extracted from each segment. Instead of raw signals, we used features extracted from segments as sequenced data to feed the network. The optimal group of features and the best model are employed to diagnose focal and generalized groups via classifying their LB channels as epileptic or normal, as depicted in In the present study, a model using RNN-LSTM is proposed for distinguishing normal subjects from subjects with epilepsy without observing IEDs. The model is further validated by correctly diagnosing focal and generalized epilepsy. Hence, retrospective EEG data from normal subjects and patients with focal and generalized epilepsy were used. The data of normal subjects and focal epilepsy patients were used for classification purposes, whereas the data of focal and generalized epilepsy patients were used for validating our classification model. After pre-processing using DWT, a longitudinal bipolar (LB) montage was calculated for all groups. Next, features were extracted in time and frequency domains for further selection based on In this study, two sets of data were used for two purposes: to train the classification model (classification approach) and to validate the model (diagnosing approach). EEG data were collected from the hospital Canselor Tuanku Muhriz (HCTM) in Cheras, Malaysia. In the classification approach, the focus is classification between normal and epileptic subjects. In this regard, the temporal lobe channels of 42 patients suffering from non-lesional temporal lobe epilepsy (TLE) and the temporal lobe channels of 62 normal subjects were used. In the diagnosing approach, i.e., distinguishing between focal and generalized epilepsy, whole EEG channels of 50 patients with generalized epilepsy and whole EEG channels of 42 TLE patients were used. Some generalized patients had a normal EEG and were diagnosed as generalized epilepsy patients based on clinical symptoms. EEG was recorded from Fp1, Fp2, F3, F4, F7, F8, C3, C4, P3, P4, T3, T4, T5, T6, O1, and O2: a total of 16 electrodes via the Nicolet EEG device based on the 10–20 EEG standard electrode placement system for each case. For the measurement of EEG signals, subjects  were prepared to contain a contact impedance of less than 5 kΩ and recorded at a 500 Hz sample rate, and data recording was done during a resting state. The affected channels in the TLE cases were deemed as the epilepsy group, and the same channels in the normal cases were deemed as the normal group. From EEG reports and patients’ clinical profiles, we determined that the placements of the affected channels were identified by neurologists in the inferior, mid, and superior areas of the temporal gyrus, i.e., in the right, left, or both hemispheres reflected in specific EEG channels under LB montage: Fp1-F7, F7-T3, T3-T5, T5-O1, Fp2-F8, F8-T4, T4-T6, and T6-O2. The affected channels were referred to as the channels with epilepsy localization. Therefore, the montage was calculated for 10 s of all datasets, 51 affected channels were identified as the epilepsy group, and 62 channels of the same regions were considered as the normal group. This data were studied to train our network. In the final stage, the classification model was validated by testing all LB channels from 50 generalized patients and the same 42 TLE patients . The classification model and all EEG analysis were implemented via MATLAB (R2020a).Pre-processing focused on signal preparation in the aspect of eliminating artifacts due to muscular movement and blinking as well as swallowing manually. DWT using coif3 from the Coiflet family was applied to 10 s of raw signals for both the epileptic and the normal groups to eliminate power line noise by three levels of signal decomposition . A longiLB calculation is defined by replacing targeted leads, as shown by arrows in Fifteen features in the time and frequency domains were extracted from each channel of both the epileptic and normal group: mean, standard deviation (STD), peak-to-peak (P2P), min, max, skewness (Skew), kurtosis (Kurt), peak-to-root sum square (P2RMS), root sum square (RSS), power of delta frequency band , power of theta frequency band , power of alpha frequency band , power of beta frequency band , and power of gamma frequency band . p-value <0.05, i.e., theta, alpha, beta, mean, min, skew, and kurt, were considered if they show a high classification performance. In addition, the features with the lowest correlation (≤20%) were considered, and the features with a high correlation (≥80%) were added separately to the group. Therefore, three groups of five features with low correlations were considered to feed the network.Pearson’s rank correlation coefficients between all pairs of variables were calculated. The hypothesis test was considered in order to determine which correlations are significantly different from zero. Features with In this research, we used the RNN-LSTM architecture to identify epilepsy and diagnose focal and generalized epilepsy. Hence, the network was implemented with five layers: a sequence input layer, a bidirectional LSTM (BiLSTM) layer with 200 hidden units, a fully connected layer, a SoftMax layer, and a classification output layer. p < 0.05, i.e., theta, alpha, beta, mean, min, skew, and kurt, indicating significant features for discrimination , and negative predictive value (NPV), referring to Equations (1)–(5), respectively. The sensitivity presents the percentage of detecting case subjects, while specificity emphasizes the ability to detect normal subjects. The accuracy is the amount of total detection for both patients and normal subjects from the study population. PPV and NPV represent the proportion of subjects with a positive test result who actually have the disease and those with a negative result who do not have the disease, respectively.The classification model was applied to each LB channel of EEG recordings from subjects with generalized and focal epilepsy. Turning back to feature extraction step, the power of the theta frequency band were more effective in the classification model compared to the alpha and beta frequencies, albeit being accompanied with four other features . There is an assumption that epilepsy characteristics are related to theta band connectivity in patients suffering from epileptic seizures . A systeFurthermore, the hippocampus has been claimed as the main structure involved in generating theta oscillations . In 2021In this work, we defined two approaches in proposing a classification model for detecting epilepsy. The first approach was an essential one (the classification approach), and the second approach (the diagnosing approach) was focused on using the model to diagnose focal and generalized epilepsy using statistics. In the classification approach, brain signal processing techniques were implemented for signal pre-processing. De-noising signals and discovering affected channels were performed via DWT and LB montage calculation, respectively. Feature extraction was performed using methods in the time and frequency domains. Feature selection was performed using correlation coefficients. Classification was performed using RNN-LSTM. In this approach, the first aim is to find optimal features in distinguishing epileptic subjects from normal subjects, whereas the second aim is to extract features from segmented EEG signals. Continuous features are fed to the network. In the diagnosing approach, the best classification model was used for each LB channel of focal and generalized epilepsy subjects. The variance of the overall affected channels represented the type of epilepsy, where a high and low variance refers to focal and generalized epilepsy, respectively. In this work, three groups of EEG data were considered: normal subjects (non-epilepsy) and subjects with focal (TLE) and generalized epilepsy. Affected channels were collected from subjects without epilepsy and with focal epilepsy using the classification approach, whereas subjects with focal and generalized epilepsy were considered in the diagnosing approach. The results show that the best classification model was achieved through employing mean, min, skewness, kurtosis, and the power of the theta frequency band, with 96.70% accuracy, 94.44% sensitivity, and 97.6% specificity. Furthermore, it seems that the theta frequency band was more successful than alpha and beta in the detection procedure. The results show a remarkable difference in variance in the diagnosing approach via the proposed classification model. The most important limitation here is the potential lack of IEDs in epileptic EEG signals during interictal periods. Therefore, confident affected signals according to EEG reports were considered as a reference for training network. Furthermore, we could not test the model for other different types of focal lobe epilepsy due to the lack of data caused by a lower prevalence. In our study, we used affected signals from TLE cases because TLE is significantly prevalent in the HCTM dataset. TLE is also known as one of the most common causes of focal epilepsy and one of the most frequent indications of epilepsy surgery. Therefore, TLE became the only option for checking the validity of the model in the diagnosing approach. There is a thread to validate in the classification stage. Despite the selected features that significantly distinguished epileptic subjects from normal subjects, the validation may become confronted with a lower variance in diagnosing focal versus generalized epilepsy by increasing the amount of data. In future work, investigation on more data is suggested. Moreover, it would be beneficial not to combine both hemispherical focal epilepsy in the same diagnosing process. The model then might be needed to optimize the internal parameters that indicate the affected hemisphere.


Psychological empowerment is generally understood to be associated with job satisfaction among nurses. However, recently published literature has questioned this association.We aimed to systematically investigate through a meta-analysis the association of psychological empowerment with job satisfaction among nurses.r was calculated by Fisher's Z and standard error (SE).PubMed, Medline, Cochrane Library, PsycInfo, and Embase were used to search targeted studies from conception to 20 January 2022. The correlation coefficients of each study were extracted and converted into Fisher's Z. Finally, pooled P < 0.01) was significantly stronger (P < 0.05) than that of the Caucasian nurses (P < 0.01).A total of 28 studies encompassing 27 articles with 7,664 registered nurses were included. The pooled correlation coefficient between psychological empowerment and job satisfaction was 0.55. Subgroup analyses were conducted according to ethnicity, and the correlation in the Asian participants (Psychological empowerment is strongly correlated to job satisfaction for registered nurses, especially among those from Asian countries. Interventions designed for psychological empowerment could be one of the strategies to promote the retention of nurses. Nonetheless, additional future studies are essential for more investigations. Several factors, such as complications in nursing practice, workload, and workplace conditions, might individually or in combination lead to internal frustration or emotionally exhaust the nurses , and leaDespite the shortage of human and financial resources, the management of nurses must maintain high-quality standards regarding patient care and job satisfaction. Psychological empowerment mainly focuses on the nurses' workplace and is deemed as a strategy to prevent emotional exhaustion. However, whether psychological empowerment is an internal incentive factor and can influence nurse job satisfaction and outcomes is yet controversial –5.In 2018, a meta-analysis  focused This current study was performed following the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines (PRISMA) statement.PubMed, Medline, Cochrane Library, PsycInfo, and Embase databases were used to search for studies from their inception to 20 January 2022. The search terms included: “nurse”, “nurses”, “empower”, “job satisfaction”, “work satisfaction”, “psychological empowerment”, and “empowerment”. We used these search strings as broadly as possible. Google Scholar was used for studies citing relevant studies.Articles that addressed the topic of the impact of nurses' psychological empowerment initiatives on their job satisfaction were included. Studies that met the following criteria were included: (1) studies included nurses as participants; (2) studies explored the association of psychological empowerment with job satisfaction; (3) necessary data could be obtained or calculated.Studies reporting on other types of empowerment and including non-registered nurses, such as nursing students, nursing assistants, and allied healthcare professionals, were excluded. Qualitative studies, reviews, case reports, comments, conference abstracts, and studies that were not available were also excluded.All studies obtained from the above databases were screened and assessed independently by two authors. All needed information was extracted using a standardized form by the two authors independently, and a consensus was reached on all items in discussion with a third author. For each included study, the authors extracted the characteristics of the studies , participant information , constructs measured , and the correlation coefficients.The two authors used the published quality assessment and validity tool for correlational studies. A consensus was reached on all inconsistent items through a discussion with another author. The tool assessed the quality of the included studies using 13 items to score the study design, sample size, measurements of result, and statistical analysis. The studies were awarded a maximum of one point for each of the 12 items , and a maximum of two points for one item . The detailed items are presented in r) for each study was extracted and transformed to Fisher's Z and standard error (SE), and the final effect size was calculated as the pooled r and 95% confidence interval (CI) based on the random-effects model. Due to different ethnicities and cultural backgrounds, subgroup analysis was done according to the source of the study population (Caucasian group vs. Asian group).The correlation coefficient . A P-value of <0.05 was considered statistically significant.The standard heterogeneity test based on the No ethical approval and informed consent were required because the present study was a network meta-analysis of published studies.The flowchart of study retrieval and selection is displayed in A total of 28 studies were included in the present study and these were published between 1997 and 2019. The sample size of nurses included in these studies ranged from 56 to 1007, with a total of 7664 nurses. Most of the studies included clinically registered nurses and two nurse managers , 12, oner < 0, P < 0.05) and four studies observed weaken correlations . Five studies reported a strong correlation . The pooled r for all studies was 0.55  with a significant heterogeneity (I2 = 90%). The detailed data and funnel plot are depicted in The correlation between psychological empowerment and job satisfaction in the included studies varied largely. Two studies reported negative correlations . The pooled correlation among the Asian group presented a coefficient (P < 0.05) of 0.63 . The data are graphically summarized in The studies from Canada , 14–21, r for the studies with high-quality was 0.54 . The heterogeneity (I2 = 61%) decreased to a moderate level. Additional analysis was carried out according to the sample size; however, high heterogeneity was observed.To explore the source of existing heterogeneity, we first pooled the studies by study design, cross-sectional method, and mixed method. The heterogeneities were found to be 90 and 89%, respectively. Then, the studies with high quality were pooled. As shown in P-values of Begg's rank correlation analysis and Egger's weighted regression analysis >0.05  irrespective of the source of the study population. Furthermore, the correlation among Asian group presented a slightly higher coefficient (P < 0.05) (r = 0.63) than that among the Caucasian group (r = 0.52).In our meta-analysis, 28 studies with a total of 7,664 registered nurses were included for data analysis. All the included studies were of moderate or high quality. The correlation between psychological empowerment and job satisfaction was 0.55 , but only moderately correlated (r = 0.353). Compared to the previous meta-analysis, the current meta-analysis revealed a strong correlation between psychological empowerment and job satisfaction (r = 0.55). Notably, the number of studies included in the current meta-analysis was 28, which was significantly more than that of the previous meta-analysis (n = 11). In addition, a significantly larger sample size of nurses was included . Undoubtedly, the current meta-analysis yielded more reliable and robust results than the previous meta-analysis. Moreover, the current meta-analysis also performed subgroup analyses to determine the correlation between psychological empowerment and job satisfaction from different population sources, providing more accurate results on this topic.To date, one meta-analysis has investigated the association between psychological empowerment and job satisfaction in registered nurses . In thisPsychological empowerment was deemed as a process that accompanied interaction between one's internal personal characteristics and the organization's environment. Specifically, psychological empowerment consists of four cognitive experiences : alignmeOn the other hand, the current meta-analysis revealed that the correlation between psychological empowerment and job satisfaction in the Caucasian group was slightly lower than that in the Asia group. These inconsistent findings between the two groups might be explained according to the following reasons. First, nurses in various countries or regions have a diverse understanding of empowerment. In China, psychological empowerment is explained as a dynamic complementarity to prevent conflicts with authority figures, which might be influenced differently by Asian and Western cultures. Second, the working environments for nurses in Asian and Western countries varied markedly. Among the items assessing job satisfaction, supervision, nature of work, and communication were identified as crucial factors. The high workload and low compensation in Asian hospitals could be intervening obstacles in Asian studies, establishing a higher correlation between psychological empowerment and job satisfaction.It is necessary to consider the limitations of the present study while interpreting the findings. First, most studies were cross-sectional, which might limit the ability to estimate causation and decrease the generalizability of the results. Second, a small number of studies were included, and a majority of them were conducted in Western countries and focused on the Caucasian population. The findings might be affected by environmental, medical level, and genetic factors, which can only partially annotate the associations, and the representativeness for the target population might be weakened. Moreover, the varied scales used in the included studies to examine both constructs of interest might also cause heterogeneity. Third, the measure of psychological empowerment and job satisfaction varied largely. A large proportion of the studies used widely applied methods. In addition, there are several definitions of psychological empowerment and job satisfaction. The definition of the targeted population is based on heterogeneity; also, it reduced the stability of the results. Fourth, the estimation of the reliability by Cronbach's coefficient varied according to the studies. Therefore, we could not correct attenuation, which might reflect the true effects. Finally, there were many intermediary factors affecting the relationship between psychological empowerment and job satisfaction; however, relevant data could be analyzed and summarized yet. Therefore, more studies are needed in the future to investigate the role of these intermediary factors.In this study, we summarized the correlations between psychological empowerment and job satisfaction and pooled results obtained from 28 studies. Next, we observed a significant correlation between psychological empowerment and job satisfaction. Moreover, the pooled correlation among the Asian group was slightly higher than that of the Caucasian group. Strategies to provide relief from psychological burdens would be beneficial to address mental exhaustion.This meta-analysis will first assist administrators and hospitals in developing strategies for creating and maintaining an empowered workplace which will in turn increase job satisfaction among nurses and reduce turnover. Second, this study also suggests that additional research with larger sample sizes should be conducted in various counties to verify our findings. Finally, it is necessary to conduct more longitudinal, qualitative, and interventional studies to confirm the causal link between psychological empowerment and nurse job satisfaction.The original contributions presented in the study are included in the article/Study design: LG. Data collection: LW and BP. Data analysis: LG, LW, and BP. Manuscript writing: LG and LW. All authors contributed to the article and approved the submitted version.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.