Longitudinal studies describing centenarians’ health trajectories are currently lacking. We compared health trajectories of older adults becoming centenarians and their shorter-living counterparts in terms of chronic diseases, disability, and cognitive decline.We identified 3,573 individuals participating in the Kungsholmen Project and the Swedish National Study on Aging and Care in Kungsholmen who lived <100 years and 222 who survived to their 100th birthday. Trajectories of chronic diseases, disability (impaired activities of daily living), and cognitive status were obtained via linear mixed models over 13 years.p < .001), disability , and cognitive impairment .Centenarians had fewer chronic diseases than noncentenarians. Before age 85, centenarians showed slower health changes. In centenarians, multimorbidity, disability, and cognitive impairment occurred 4 to 9 years later than in noncentenarians. After age 85, the speed of accumulation of chronic diseases, disabilities, and cognitive decline accelerated in centenarians. At age 100, 39% of the centenarians were cognitively intact and 55% had escaped disability. Only 5% were free of multimorbidity at age 100. When compared with their shorter lived counterparts, in terms of years spent in poor health, centenarians experienced more years with multimorbidity (9.4 vs 6.8 years; Older people who become centenarians present a delay in the onset of morbidity, but spend more years in this condition compared to their shorter lived peers. The observation of older adults’ health trajectories might help to forecast healthier aging, and plan future medical and social care delivery. The global increase in life expectancy has led to an unprecedented rise in the proportion of very old people . For insAccording to Fries and colleagues the burden of illness and disability will be compressed into a shorter period during the last years of life as a consequence of the demographic transition in which we are living. This can be attributed to improvements in biomedical sciences and public health, which will delay and reduce the onset of several noncommunicable diseases ,5. On thThe aims of this study were to compare the trajectories of chronic disease, disability, and cognitive function of older adults who will become centenarians with those of their shorter lived counterparts.Data were gathered from two population-based longitudinal studies, both carried out in the Kungsholmen district in central Stockholm, Sweden, namely the Kungsholmen Project KP, 1987–2000) , 1,810 (76.4%) agreed to participate in the baseline survey (1987–1989). Health assessments were conducted at approximately 3-year intervals until 2000, and the survival status of the participants was assessed until 2013.The KP targeted all inhabitants of the Kungsholmen district aged 75 years and older (range 75–102 years) in October 1987 (born before 1912). Of the eligible people  were examined, and their health and survival statuses were assessed until 2013 and 2018, respectively.SNAC-K is an ongoing longitudinal study that includes a random sample of people aged 60+ years (range 60–104 years) from 11 age cohorts. To compensate for the potential attrition at follow-up, the two youngest and the four oldest age groups were oversampled. The current study includes data from baseline (2001−2004) and three follow-ups, up to 2013. At baseline (2001−2004), 3,363 (73.3%) of all eligible persons , or if they died before turning 100 years in the same period. By the end of the follow-up period, 222 centenarians were identified. Of them, three had missing data for activities of daily living . The age of all participants was confirmed by their unique Swedish national identification number .In all waves of KP and SNAC-K, data were collected at the Aging Research Center, Karolinska Institutet, Stockholm, in accordance with standard procedures. Trained staff performed: face-to-face interviews; clinical, functional, and laboratory examinations; and cognitive tests. Home visits were carried out for those who agreed to participate but were unable to visit the research center. The same protocols were used at baseline and follow-ups to collect information about each person and their context, and similar protocols were used for the data collection in both KP and SNAC-K ,20. PartChronic diseases were diagnosed or ascertained by physicians on the basis of clinical examination, medical history, laboratory data, current drug use, and linkage to the outpatient and inpatient registers. Chronic diseases were classified in accordance with the International Classification of Diseases 10th Revision (ICD-10). A disease was defined as chronic if it was of prolonged duration and either (a) left residual disability or worsened quality of life or (b) required a long period of care, treatment, or rehabilitation (Disability was measured through number of impairments (dependence) in the Katz’s ADL (scoring 0–6) scale, which includes the following activities: bathing, dressing, toileting, transferring, continence, and eating. Cognitive function was assessed through the Mini-Mental State Examination (MMSE), a 30-point questionnaire that includes items related to different cognitive functions such as: orientation to time and place, attention and calculation, recall, language, ability to follow written and verbal commands, and visual construction .,24.Chrontruction . A cutofn = 3,573) and centenarians . In addition, among centenarians we identified two subgroups according to each of the three health indicators. Centenarians were considered healthy if they had no more than one chronic disease and unhealthy if they had two or more chronic diseases; healthy if they had no more than one ADL impairment and unhealthy if they had two or more ADL impairments; and healthy if they had an MMSE score greater than or equal to 25 and unhealthy if they had an MMSE score below 25 by the time they reached 100 years or during the last assessment.Participants were classified as noncentenarians  elementary school (Grade 1–9), (ii) high school (Grade 10–12), or (iii) university or above. Information on housing type was categorized as: (i) living in nursing homes or (ii) living in all other types of housing . Marital status was categorized as: (i) married, (ii) single, or (iii) widowed or divorced. Cohabitation status was categorized as: (i) living alone or (ii) living with someone. Finally, information on smoking habits (current vs former/never) and alcohol use was collected.Health status before death of noncentenarians was compared with that of centenarians at study entry. Linear mixed-effects models were used to estimate the trajectories of the health indicators using repeated measurements over 13 years, and models were adjusted for potential confounders . Trajectories were built, centering the covariates on their means; they can thus be interpreted as the trajectory of an individual with average characteristics within each survivorship group. The age of the participants was used as the time scale, and the two-way interaction between follow-up time and survival profile was added in each model. The intercept and follow-up time provided the fixed and random effects. Unstructured covariance between both random-effect parameters was assumed, and potential nonlinear relationships between the three outcomes  and survivorship status (centenarians vs noncentenarians) were investigated using a quadratic transformation of the follow-up time (age). Departure from linearity was assessed by testing the null hypothesis that the coefficient of the quadratic term was equal to zero. The interaction between survival profile (centenarians vs noncentenarians) and birth cohort was also assessed. To investigate the differences between centenarians and their counterparts in terms of years lived with chronic diseases, disability, and cognitive impairment, a two-tail ANOVA was used to compare the time from the onset of such conditions (including when these were present at baseline) to death across the two groups. Finally, heterogeneity among centenarians was assessed by estimating the age-adjusted prevalence of each of the three health indicators  across the two survival profiles. When the information at exactly the age of 100 years was not available, the nearest (±3 years) available assessment was considered. All analyses were performed using Stata version 15 .p = .001). Moreover, centenarians were less educated, more frequently widowed or single, less likely to be institutionalized, and more cognitively impaired than noncentenarians . On average, centenarians had fewer chronic diseases than noncentenarians before their ninth decade of life, as suggested by nonoverlapping CIs. However, given the faster accumulation of chronic diseases experienced by centenarians (p for linear interaction with time = .004), this difference became nonsignificant after 95 years. Before the age of 85 years, centenarians demonstrated slower changes in disability (p for quadratic interaction with time <.001) status and cognitive function in comparison to noncentenarians (p for quadratic interaction with time = .02). However, after the age of 85 years, an acceleration  in the accumulation of ADL impairments and cognitive decline was observed. In terms of physical and cognitive function, the decade between 75 and 85 years was the period when trajectories started to diverge between the two groups. On average, while noncentenarians were observed to suffer from three or more diseases at the age of 75 centenarians did so at the age of 83, 8 years later. Moreover, noncentenarians presented with one or more impaired ADL at the age of 92 and centenarians at the age of 98, 6 years later. Finally, while noncentenarians scored on average below 25 on the MMSE at age 84, centenarians did so 9 years later at age 93. Estimated means and 95% CI of the health indicators for individuals with average characteristics are reported in β for interaction −0.02 for every 10-year increase in birth cohort, 95% CI −0.05; −0.01) but a faster decline in cognitive function .When testing two-way interactions between survival profile and birth cohort, we found that younger cohorts experienced a slower decline in ADL performance (p < .001), disability , and cognitive impairment .When we compared centenarians with their shorter lived counterparts in terms of years spent with poor health, we found that centenarians the formers spent more years with multimorbidity , Stockholm, Sweden. Swedish Research Council for Health, Working Life and Welfare. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.DLV, GG, and DR contributed to the conception and design of the study. DR conducted the statistical analyses. DLV and GG conducted the literature search. All the authors contributed to interpretation of the results. DLV, DR, GG, and AM drafted the first version of the manuscript. All the authors critically revised the manuscript for important intellectual content. All the authors made a significant contribution to the research and the development of the manuscript and approved the final version for publication. The K-P and SNAC-K personnel collected the data for the study.None reported.glaa152_suppl_Supplementary_Tables-and-FiguresClick here for additional data file.


The Bland–Altman Limits of Agreement is a popular and widespread means of analyzing the agreement of two methods, instruments, or raters in quantitative outcomes. An agreement analysis could be reported as a stand-alone research article but it is more often conducted as a minor quality assurance project in a subgroup of patients, as a part of a larger diagnostic accuracy study, clinical trial, or epidemiological survey. Consequently, such an analysis is often limited to brief descriptions in the main report. Therefore, in several medical fields, it has been recommended to report specific items related to the Bland–Altman analysis. The present study aimed to identify the most comprehensive and appropriate list of items for such an analysis. Seven proposals were identified from a MEDLINE/PubMed search, three of which were derived by reviewing anesthesia journals. Broad consensus was seen for the a priori establishment of acceptability benchmarks, estimation of repeatability of measurements, description of the data structure, visual assessment of the normality and homogeneity assumption, and plotting and numerically reporting both bias and the Bland–Altman Limits of Agreement, including respective 95% confidence intervals. Abu-Arafeh et al. provided the most comprehensive and prudent list, identifying 13 key items for reporting . An exemplification with interrater data from a local study accentuated the straightforwardness of transparent reporting of the Bland–Altman analysis. The 13 key items should be applied by researchers, journal editors, and reviewers in the future, to increase the quality of reporting Bland–Altman agreement analyses. Lancet paper to date [The Bland–Altman Limits of Agreement (BA LoA), or simply Bland–Altman plots, are used widely in method comparison studies with quantitative outcomes, as evidenced by more than 34,325 citations of the seminal  to date . In this to date ,2,3,4. UThe BA LoA are sample-based estimates of the true, but unknown population limits. Bland and Altman  originalGuidelines for Reporting Reliability and Agreement Studies (GRRAS) by Kottner et al. [The r et al.  compriser et al. ). Item nr et al. . Stöckl r et al.  proposedr et al. ,23). The present study aimed to identify reporting standards for BA agreement analyses, to single out the most comprehensive and appropriate list, and to exemplify this proposal using data from an interrater Bland–Altman analysis conducted at our institution.reporting) OR checklist)) AND ((((“method comparison”) OR bland–altman) OR ) OR agreement) within the timeframe of 1 January 1983 to 3 March 2020 and without further field restrictions  statement [MEDLINE/PubMed was searched for ). Subsequently, lists of proposed items were compared, and the most comprehensive list was chosen and applied to the following worked example.In a recent study on the association of left atrium enlargement (measured by non-contrast computed tomography) with traditional cardiovascular risk factors, intra- and interrater differences were analyzed using the BA LoA, supplemented by their exact 95% confidence intervals according to Carkeet , and shoThe literature search resulted in 5551 hits. This is likely to be sensitive but not very specific as search results comprised as farfetched topics as negotiation of protective sex in West African countries, understanding foreign accent syndrome, effect of playing position on injury risk in male soccer players, and agreement in reporting between trial publications and current clinical trial registry in high impact journals ,27,28,29Three out of seven studies were published in anesthesia journals, while the remaining stemmed from various fields . Four stx-axis (#15). Upfront declaration of conflicts of interest (#16) also appeared only once, but this can generally be presumed to be covered by the ethics of authorship.Sixteen reporting items were proposed across the included studies. Broad consensus was seen for the a priori establishment of acceptable LoA Item #1, ; estimatThe list of reporting items proposed by Abu-Arafeh et al.  was the a guidance paper clearly showed the dependence of the usefulness of the BA LoA on the range of the values studied (#10);replicated data affects the calculation of confidence intervals for the BA LoA (#11); anddetails on computing methods are desirable in any report using statistics .Abu-Arafeh et al.  identifix-axis must show average values of the two methods compared (#15), as also discussed by Bland and Altman [Across guideline proposals, there seems to be a tacit consensus of the fact that the d Altman . The issThe list of reporting items proposed by Abu-Arafeh et al.  was appl2 (range: 12.9–44.3). Unfortunately, acceptable LoA were not established a priori. From the clinical perspective, the judgement of whether the BA LoA of −2.39 to 2.36 with outer 95% confidence limits −2.71 and 2.69 were sufficiently close had to be made post hoc, in light of a mean area of 24.1 cmLeft atrium size was measured by 7 trained radiographers  = 2.98.Repeatability coefficients were derived by means of a linear mixed effects model, with  factors . The repp = 0.64). The scatter of differences did not depend on the means, indicating homogeneity of variances across the measurement range  was –0.21 to 0.19. This area has been highlighted in olive-teal in The BA LoA were –2.39 and 2.36 . The 95% confidence intervals for the BA LoA were –2.71 to –2.14, and 2.12 to 2.69. These areas have been highlighted in light blue in According to the Preiss–Fisher procedure , the meaThe confidence intervals of the BA LoA were derived by taking the data structure into account. Non-repeated, paired ratings were used as replicates were only performed for the 7 radiographers. However, the inclusion of repeated measurements for the main investigator would have yielded two paired observations per subject. This would reflect the inherent natural variation within the rater, and thereby provide a more precise picture of agreement .All analyses were conducted using STATA/MP 16.1 .The differences were assumed to be normally distributed see  above.The present study revealed 7 lists of reporting items for BA analysis, with most stemming from the field of anesthesiology. The work of Abu-Arafeh et al.  turned oResearch traditions vary across fields with respect to method comparison studies on quantitative outcomes, in particular when contrasting clinical and laboratory research ,38,39. TThe main limitations of this work are the ad hoc literature search in only one database (MEDLINE/PubMed) and the fact that only one reviewer screened titles and abstracts, read full-texts, extracted data, and performed the qualitative evidence synthesis . This mathe unbowed popularity of BA plots, as judged by the number of citations of the seminal papers ,3  subgroups of subjects of the main investigation; e.g., data for our worked example stemmed from an epidemiological study on 14,985 subjects;in a study with repeated measurements, it is easier to conduct sample size planning in terms of confidence interval width rather than using a TOST procedure ,13,56; athe a priori definition of acceptable limits for the BA LoA may be more challenging in imaging studies (comparing raters) than it is in method comparison studies (comparing methods or instruments).In the context of method comparison studies, though TOST procedures date back to 1998 , softwarStandards for Reporting Diagnostic Accuracy (STARD) and PRISMA aim to improve the quality of reported research [Since Altman  indicateresearch . Unforturesearch . Moreoveresearch  reckonedresearch  could beresearch  postulatresearch . Why are guidelines and statistical advice not followed optimally? The pressure on individual researchers continues to reflect the pressure on institutions, which are judged by the crude number of research publications and on grant income . In Denmp-values. This supports their original assertion that authors, reviewers, and editors must make a joint effort in using and reporting statistics consistent with best practices. Furthermore, the Journal of Physiology and the British Journal of Pharmacology jointly undertook a similar editorial series in 2011 [Even explicit editorial guidance on improved statistical reporting practice may be insufficient. Curran-Everett and Benos  publishe in 2011 ,70,71. S in 2011  reviewedUndoubtedly, training in research methodology in general, and especially in statistics, is the key to well-conducted research. In pre-graduate education, the MSc thesis is usually the first account of a research project. At the University of Southern Denmark, the MSc education in medicine was reformed in 2019. It now offers 5 profiles, one of which focusses on research. In postgraduate education, PhD programs are dedicated to research education. Otherwise, statistical guidance and support needs to be acquired at one’s research institution or within one’s own research network. Ultimately, it is evident that a research paper will live up to best practices in the use of statistical methods and respective reporting of results only if authors, reviewers, and editors make a joint effort . AuthorsFuture studies need to explore nonparametric alternatives to the BA LoA in case of non-normality of the data when normalizing transformations fail ,4,42. HoClassically, a BA analysis concerns the study of method comparison, i.e., the comparison of two methods or instruments. The agreement of more than two methods, instruments, or, especially, raters is also an area for further research ,74,75.Further, assuming that a basic set-up employs two raters performing two measurements on each scan or subject, it is essential to consider what advice can be given in multi-rater situations with respect to the number of raters, number of replicates, and sampling procedure ,76. Considering GRRAS as a broad reporting framework for agreement and reliability studies, Abu-Arafeh et al.  concreti


Echinococcus granulosus infection diagnosed by IFE.Isoelectric focusing electrophoresis (IFE) is currently recognized as the gold standard for detecting oligoclonal bands (OCBs) in cerebrospinal fluid (CSF). To the best of our knowledge, however, no study has reported on type III OCBs using IFE. In this paper, we report on a rare case of multiple myeloma (MM) with A 71-year-old man complained of weakness of the right lower extremity accompanied with fever (temperature range 37.8°C–38.2°C) for more than 6 months.E granulosus infection.MM with The IFE results identified a unique monoclonal band, indicating that the patient may have MM in conjunction with a distinct pathogen infection. He received anthelmintic treatment and bortezomib-thalidomide-dexamethasone therapy.Medical Research Council Grading of Muscle Power scale became 5, and his vital signs stabilized.The patient was followed up for 15 months. During that time, his temperature returned to normal, his E granulosus infection. Thus, IFE of CSF may be an auxiliary diagnostic method for MM in the future.Detection of OCB type III indicated that the patient was diagnosed with MM accompanied by  There are 5 types of OCBs:Isoelectric focusing electrophoresis (IFE) of cerebrospinal fluid (CSF) has important value in revealing the synthesis of immunoglobulin in the central nervous system (CNS). The appearance of oligoclonal bands (OCBs) in CSF is indicative of the occurrence of a humoral immune response in the CNS and is the most reliable indicator of immunoglobulin synthesis in the sheath of inflammatory demyelinating lesions of the CNS.type I, no bands in serum or CSF;type II, 2 or more bands in CSF but no bands in serum;type III, several bands in both serum and CSF, but more in CSF than in serum;type IV, same number of bands in serum and CSF, with mirror distribution; andtype V, monoclonal bands in serum and CSF. Both type II and type III are recognized as OCB positive.E granulosus infection.OCB type III in this patient has unique characteristics and has not been reported yet. Comprehensively analyzing clinical data and valuable laboratory tests, the patient ultimately confirmed MM with E granulosus in the human body. Hepatic echinococcosis is the most common clinical echinococcosis, with the incidence of cerebral echinococcosis relatively low.Echinococcosis, also known as hydatid disease, is caused by infection of 2A 71-year-old man experienced weakness of the right lower extremity accompanied by fever (temperature range 37.8°C–38.2°C) for more than 6 months, during which time he received treatment in local community hospitals. He had no contact history with an epidemic area. He was admitted to our hospital  when his symptoms relapsed. This study was approved by the Ethics Committee of the First Affiliated Hospital of Zhengzhou University, China , and informed consent was obtained from the patient.On admission, neurological examination of the patient did not show any apparent abnormalities. Electrolytes, coagulation function, and brain natriuretic peptides were normal. Tumor markers and tuberculosis-related tests in serum were negative, as were the results of relative examination of connective tissue disease. Dynamic electrocardiogram of the heart showed no significant changes, and the electroencephalogram was normal. Antibodies against neuronal cell-surface antigens  and onconeuronal antibodies  were all negative in serum and CSF. However, leukocytes were increased, glucose was significantly decreased, and eosinophils and plasma cells were found in the CSF cytology  with focal distribution. Fig. . For who0%–40% wiImmunohistochemical results of bone marrow tissue showed CD38+, CD138+, κ+, λ-, CD56+, CD20-, CD3-, Mum1+, suggesting plasma cell myeloma, consistent with the flow cytometry results.E granuloses were detected by next-generation sequencing (NGS) of whole blood. Based on the above results, it was concluded that the patient was diagnosed with MM, accompanied by a parasite infection.Positron emission tomography-computed tomography showed that the metabolism of the central bone marrow was active, consistent with the features of myeloma Fig. A and B. His fever was treated with cefminox sodium and biapenem. The deworming treatment lasted for a month, and he also accepted chemotherapy, immunoregulation, and other treatments for MM. The patient was followed up for 15 months, during which time his temperature returned to normal, his muscle tone became 5 and his vital signs stabilized. Head MRI showed no significant changes.3 with 5 types defined, as described above. In the current case, the OCBs were identified as type III. The bands in the red boxes in Figure  Type III OCBs are often found in inflammatory demyelination of the CNS caused by autoimmune diseases. In this case, the antibodies of autoimmune encephalitis and paraneoplastic syndrome were negative in serum and CSF, and the electroencephalogram was normal, suggesting that neuroautoimmune diseases could be excluded.OCBs refer to the formation of several narrow discontinuous bands in the γ-globulin region during electrophoresis, In recent years, the incidence of MM has seen an increase. The characteristics of MM include abnormal proliferation of plasma cells in the bone marrow accompanied by the over production of monoclonal immunoglobulins or light chains.,10 MM is often misdiagnosed because of its insidious onset and lack of specificity. Bardwick et al indicated that the affinity of plasma cell clones to human peripheral nerve myelin sheaths is related to the pathogenesis of the disease. In the current case, the patient's main symptoms were weakness of the right lower limb accompanied by a fever for half a year. We speculated that pathogenesis was related to plasma cell disease, i.e., toxic substances secreted by plasma cells impacted organs of the whole body, resulting in multiple system damage.MM is a malignant monoclonal B cell disease, which shows frequent occurrence in the elderly.,13 Thus, the above results suggested that the patient had recent hydatid infection and early cysticercosis. No hydatid features were found in the head MRI of the patient. This was likely related to the long incubation period of hydatid disease and difficultly in diagnosing early infection by imaging examination.In this reported case, eosinophils were increased in CSF cytology Table . Thus, wParasitic infection and MM are 2 clinically unrelated diseases, and cases showing both are rare. As such, this case could be easily misdiagnosed because of its rarity and particularity. The reasons are as follows:(1) The clinical manifestations of MM are complex and diverse due to the different degrees of malignant hyperplasia and infiltration ranges of MM, different numbers and types of monoclonal immunoglobulins, and lack of specificity in clinical symptoms. In this case, limb weakness was the initial symptom.(2) MM is occult but can cause multiple lesions. In clinical practice, we often pay attention to the lesions of a single system but fail to analyze the symptoms of multiple systems. In the current case, the patient's condition was complex, and the above symptoms could be explained by the primary disease. Without the identification of distinct OCBs and application of years of clinical experience, it can be difficult to diagnose MM.(3) According to imaging and CSF cytology, the patient was diagnosed with a parasite infection and received appropriate treatment. After subsequent examination, a unique OCB was identified, and further experimental examinations were carried out. Finally, the patient was diagnosed with MM.4E granuloses infection and MM. Thus, IFE of CSF could be applied as an auxiliary diagnostic method for MM in the future.To the best of our knowledge, this study is the first to report on a case of OCB type III-related myeloma, which presented as a motor disturbance in the right lower extremity. The OCB findings indicated type III with Methodology: Jinghong Li, Hongjun Hao, Yuming Xu.Validation: Xiaoyun Zhang, Shiheng Fan.Writing – original draft: Jinghong Li, Hongjun Hao.Writing – review & editing: Jinghong Li, Xiaoyun Zhang.Investigation: yuming Xu.Project administration: yuming Xu.Software: Shiheng Fan.Supervision: hongjun Hao.Validation: hongjun Hao.Visualization: xiaoyun Zhang, hongjun Hao.Writing – original draft: Jinghong Li.Writing – review & editing: xiaoyun Zhang, Shiheng Fan.


Here we propose a new machine learning algorithm for classification of human activities by means of accelerometer and gyroscope signals. Based on a novel hierarchical system of logistic regression classifiers and a relatively small set of features extracted from the filtered signals, the proposed algorithm outperformed previous work on the DaLiAc (Daily Life Activity) and mHealth datasets. The algorithm also represents a significant improvement in terms of computational costs and requires no feature selection and hyper-parameter tuning. The algorithm still showed a robust performance with only two (ankle and wrist) out of the four devices  placed on the body (96.8% vs. 97.3% mean accuracy for the DaLiAc dataset). The present work shows that low-complexity models can compete with heavy, inefficient models in classification of advanced activities when designed with a careful upstream inspection of the data. Physical activity monitoring with wearable sensors has various scientific, medical and industrial applications, such as physical activity epidemiology , fall deDespite these advances in the field, studies in physical activity epidemiology have mostly used opaque, proprietary algorithms ,10,11, hExisting transparent HAR methods usually rely on supervised machine learning models to map between motion signals and activities. All methods rely on the assumptions that different physical activities are reflected by different, characteristic signals and that it should be possible to discriminate between activities with appropriate, meaningful features extracted from the signal ,12. HAR The automatic feature detection of neural network models makes them capable of detecting very complex, highly discriminative features and patterns in the data . CNN draClassical supervised machine learning methods, in contrast, are easier to train but their shallow learning can make them less performant in difficult classification tasks . To makeSeveral studies demonstrated the usefulness of a hierarchical classification system for HAR with increasing accuracy while keeping the algorithm reasonably simple ,21,22. TThe goal of this article is to propose a high-performance, fast and easy-to-implement algorithm for HAR, which could compete with state-of-the-art complex algorithms, including those based on neural network models. The proposed algorithm relies on a novel hierarchical system and a relatively small set of highly informative features extracted from the filtered signals, and was evaluated against the public Daily Living Activity (DaLiAc) dataset presented below . BecauseThe DaLiAc (Daily Living Activity) dataset consists of the signals of accelerometers and gyroscopes placed on the chests, wrists, hips and ankles of 19 adults performing thirteen daily activities in semi-controlled conditions. The activities include a wide range of simple and complex activities: lying, sitting, standing, dish washing, vacuum-cleaning, sweeping, walking, running, ascending stairs, descending stairs, bicycling with a resistance of 50 Watts, bicycling with a resistance of 100 Watts and rope jumping. Details about the subjects and the experimental designs can be found elsewhere . Acceleration signals are known to be composed of a dynamic component (acceleration of the body) and a gravitational one. As a consequence, some authors suggested applying a low-pass filter to the acceleration signal in order to isolate the gravitational component and infer the inclination of the device in space ,24. UsinAll signals were segmented along the time axis into windows of five seconds with a 50% overlap, as done by other authors , in ordex the signals  over an N-length window . For each windowed signal x, the following statistics were computed in the time-domain:-Mean, standard deviation, skewness and kurtosis;-The following percentiles: ;-x) − min(x);Range: max for the 19 leave-one-subject-out rounds. To present a complete picture, for models based on the four devices, we also presented the confusion matrix, and the f-score, which is the harmonic mean of precision ) and recall ).The algorithm presented in this article was designed to address the specific classification task of the DaLiAc dataset. It was therefore deemed desirable to validate this algorithm on other data, collected in different conditions and presenting a different classification task. To do so, we used the algorithm on the mHealth dataset  that conFor the five classification models , accuracy is reported for each combination of devices and for each task in the hierarchical system . OverallThe training time varied significantly across the models studied. Using Google Colab (with GPU accelerator) and the parameters mentioned above, training and predicting data following the leave-one-out procedure  for the DaLiAc dataset lasted 4.5 min with LR and KNN, 7.2 min for SVM, 10.7 min for GB and over half an hour for CNN . The entRegarding the locations of the devices on the body, the best choices of one, two and three locations out of the four studied were chest (93.39% with SVM), ankle + wrist (96.81% with LR) and ankle + wrist + chest (97.06% with LR), respectively . Table 4The ability of our algorithm to generalize was further validated on the mHealth dataset, using all accelerometer, gyroscope and magnetometer signals. We obtained very good average scores on the mHealth dataset with GB (98.7% ± 2.6%), LR (98.2% ± 2.7%) and SVM (97.2% ± 3.7%), but less good ones with KNN (92.7% ± 4.3%) and CNN (87.7% ± 7.5%).Compared with previous works tested on the DaLiAc data set, the proposed algorithm, based on careful handcrafted features extracted from the signals, represents a threefold improvement. First, the proposed algorithm performs better than major works tested against the DaLiAc dataset (97.30% accuracy with LR versus 96.40% for the best model so far with CNN ) see Ta. LikewisSecond, compared to state-of-the-art CNN, the proposed algorithm performed best with fast-training models, such as logistic regression (32 min for the former versus 4.5 min for the latter).Third, these superior results were obtained with simple and robust tools in machine learning that do not require preliminary hyper-parameter optimization and feature selection, such as LR. In fact, hyper-parameters optimization of classifiers  and feature selection can be a daunting, time-consuming task, and was shown to lead to over-fitting and poor generalization . This waIt is difficult to fully explain how our algorithm outperformed previous algorithms using classical machine learning classifiers by around 4%, as authors do not always specify all the decisions that they make during data processing before reaching the results. Using the DaLiAc dataset, we undertook a few steps to identify the innovations that made our algorithm more accurate. First, running our algorithm with a flat classification system instead of the hierarchical system proposed here resulted in 1.81% decrease in mean accuracy. Second, by extracting features performed on the acceleration signal only, without including the AC and DC components as we did, the decrease in accuracy amounted to 2.63%. The additional 1.27% difference with the two best-performing algorithms using classical methods by Chen  and by ZLarge-scale past public health studies in activity monitoring, such as NHANES , have reDespite this promising improvement, two caveats need to be highlighted. The first caveat relates to the nature of our data. HAR algorithms are tested against clean data of activities performed in a characteristic manner as part of a relatively structured protocol. Realistic data, however, can contain fewer characteristic activities  which represent a greater challenge to classify. To that extent, very recent attempts to create benchmark activity datasets simulating real conditions  are an iA second caveat pertains to the ranking of the models tested in this study. A better choice of the hyper-parameters of the powerful SVM, GB or CNN models could have resulted in another ranking. Our points are to emphasize that a simple approach based on domain knowledge can result in a fast, robust and performant model; and that issues of generalizability and tedious processes of model selection must be acknowledged in the evaluation of a new algorithm.In this paper, we propose a novel algorithm for HAR from motion signals (accelerometers and gyroscopes), which significantly improves upon previous work in terms of computational expenses, inferential robustness and classification accuracy. Using a hierarchical classification system with LR, and a relatively small set of features extracted not only from the acceleration signal, but also from low-pass filtered and high-pass filtered signals, proved highly useful in solving our classification task. From a practical perspective, we showed that two devices placed on the wrist and the ankles resulted in an accuracy that is practically as good as with two additional accelerometers on the chest and the hip, and that using the method proposed here, the additional information brought by the gyroscope was marginal. Future research should focus on data that better simulate real life conditions, with their swift transitions between activities and less characteristic behaviors. New, simple models should be developed to better adapt to these conditions, while relying, as much as possible, on domain knowledge.


Sarcopenia is associated with instrumental activities of daily living (IADL) and basic activities of daily living (BADL) disabilities. We developed an index for assessing sarcopenia degree (sarcoscore) and compared it to the Asian Working Group for Sarcopenia (AWGS) criteria. Principal component analyses of walking speed, handgrip strength, and skeletal muscle index were performed to develop a sarcoscore using 3088 Japanese population-based cross-sectional data. During the nine-year follow-up, 278 of 2571 and 88 of 2341 participants developed IADL and BADL disabilities, respectively. Adjusted Cox proportional hazards regression models showed that the sarcoscore criteria, defined as proportional to the sarcopenia prevalence diagnosed by the AWGS criteria, had higher hazard ratios (HRs) and 95% confidence interval (CI) for disability onset than the AWGS criteria (IADL disability: 2.19 (1.64–2.93) vs. 1.79 (1.32–2.43), BADL disability: 4.28 (2.63–6.96) vs. 3.22 (1.97–5.27)). The adjusted HRs for IADL and BADL disabilities were reduced by 4% and 8% per point increase in the sarcoscore, respectively. The sarcoscore assessed the degree of sarcopenia and had a satisfactory performance for predicting functional disabilities in older Japanese adults, suggesting its usefulness as a complementary composite marker for clinical diagnosis. Sarcopenia is defined as a muscle disorder that is characterized by the progressive and generalized loss of skeletal muscle mass or quality, strength, and physical performance . Over thIn 1998, Baumgartner et al.  proposedSarcopenia diagnosis based on the AWGS had good predictive validity for the incidence of physical limitations and mortality; this was similar to that obtained using the other operational definitions . The AWGIn order to meet this need, we aimed to develop a novel index which can estimate the degree of sarcopenia (sarcoscore) by using integrated data from three population-based samples, and to compare its predictive value to the AWGS criteria in predicting functional disabilities in community-dwelling, older Japanese adults. We hypothesized that sarcoscore would have predictive validity of functional disabilities, as with sarcopenia diagnosis based on AWGS criteria.In order to develop the sarcoscore, we conducted a cross-sectional analysis, and in order to examine the association between the index and the onset of functional disability, we conducted a longitudinal analysis.Three population-based cohort samples were subjected to cross-sectional and longitudinal analyses, including participants from the Itabashi Cohort Study, the Kusatsu Longitudinal Study, and the Hatoyama Cohort Study.Itabashi ward is a large urban area located in the northwest area of 23 special wards in Tokyo, Japan. This study was initiated from 2011 as an open cohort and new participants were added from 2013. The detailed selection process in 2011 has been described in previous publications ,23. BrieKusatsu town is a rural community located in the northwest Gunma prefecture in Japan. The Kusatsu Longitudinal Study was an open cohort which was initiated from 2002 and new participants were added every year. The detailed selection process for this cohort was described in a previous study . BrieflyHatoyama town is a suburban area outside of Tokyo located in the center of Saitama prefecture in Japan. The Hatoyama Cohort Study was initiated from 2010 as a closed cohort. The detailed selection process was described in a previous study . Brieflyn = 1665, 53.9%) were utilized to develop the sarcoscore formula and for the comparison of baseline characteristics according to the levels of the sarcoscore. In the longitudinal data, the data of 2834 IADL and 2968 BADL participants with initially nondisabled status were followed-up to examine the association between the baseline sarcoscore and the onset of IADL and BADL disabilities. Of the included patients, 2571 (90.7%) IADL and 2341 (78.9%) BADL participants did not have missing data and thus they were able to be followed-up for the whole study period. Thus, they were included in the final multivariable analyses.Overall from 2008 to 2017, 3690 adults aged ≥ 65 years participated in the baseline survey; All cohort studies were conducted in accordance with the Declaration of Helsinki and the study protocol and all participants provided written informed consent. This study was approved by the Ethics Committee of the Tokyo Metropolitan Institute of Gerontology.The variables for developing the sarcoscore were selected from three reliable and validated measurements  that were used as diagnostic markers for sarcopenia based on six major operational definitions ,17,18,19WS was measured as the time taken to walk 5 m or 10 m with acceleration and deceleration phases of 3 m each. The examiner instructed the participant: “Please walk on this pathway at your usual speed”. After the participant stood with their feet touching a start-point marked at 0 m, the examiner said “Are you ready? Please, go ahead”. As the participant began to walk, the examiner pushed start button of the stopwatch on the marked at 3 m and pushed stop button of the stopwatch on the marked at 8 m (or 13 m) . As the HGS was measured using a Smedley-type dynamometer . First, 2) [ALM was measured using a bioelectrical impedance analyzer . This analyzer consists of a tetrapolar, eight-point tactile electrode system that separately measures impedance of the trunk, arms and legs by using six different frequencies  and has a good validity for estimating ALM in a community-dwelling older population, compared to estimation using the standard dual-energy X-ray absorptiometry method . Partici2) .The primary outcome was onset of disability in functional capacity. Functional capacity in older adults consists of two abilities: IADL and BADL . IADL inAge, sex, height, weight, body mass index (BMI), educational attainment, hospitalization, medical histories, and cognitive function were measured as other covariates. Educational attainment was classified into ≥9 years (graduation from junior high school or higher) or <9 years. We asked participants whether they experienced hospitalization over the past year. Additionally, participants were asked about their medical history including stroke, heart disease, hypertension, hyperlipidemia, diabetes, and chronic obstructive pulmonary disease (COPD) over the past year. Cognitive function was measured using the Mini-Mental State Examination. We defined cognitive impairment as <24 points .p values of <0.05 considered to be significant.First, we applied principal component analysis to the three variables of WS, HGS, and SMI, in order to develop the sarcoscore. Each standard score of the three measurements was multiplied to the first principal component score coefficient which was computed automatically by principal component analysis. Principal component analysis was stratified by sex. We then summed these variables and defined it as the sarcoscore that represents the first principal component score. To help users (physicians and patients) understand the significance of the sarcoscore per point, the sarcoscore was calculated as the T score that described a normal distribution, with a higher score indicating better muscle condition. Next, to identify the optimal cut-off values of the sarcoscore that could discriminate sarcopenia diagnosed using the AWGS criteria , we condA principal component analysis extracted the first principal component with corresponding eigenvalue ≥1.0 in both men and women. These components accounted 53.3% and 53.0% of the total variance in men and women, respectively. First principal component score coefficients were obtained as follows: HGS: 0.838 in men, 0.835 in women; SMI: 0.740 in men, 0.694 in women; WS: 0.591 in men, 0.642 in women. We multiplied these coefficients to standard scores for the three measurements and developed the sarcoscore formula by summing those values. Finally, these formulas were converted to T scores as follows.p for log-rank test, <0.001).IADL and BADL disabilities were observed in 278 participants (10.8%) during the follow-up period of 13,122 person-years (median of the follow-up: five years) and in 88 participants (3.8%) during the follow-up of 11,846 person-years (median follow-up: five years), respectively. In the stratified analyses based on potential risk factors, significant differences in heterogeneity were found in subgroups of age, sex, hospitalization, diabetes, and cognitive impairment for IADL disability a, and agThe present study has two novelties. First, to the best of our knowledge, the present study was the first to develop a comprehensive and continuous index (sarcoscore) for assessing sarcopenia, which summarized three-dimensional information including HGS, SMI, and WS into a one-dimensional format using three population-based samples. Second, this study was the first to identify that the sarcoscore had enough predictive value in predicting functional disabilities as compared to the AWGS criteria. These results supported our hypothesis and suggested that the sarcoscore would be useful in assessing the degree of sarcopenia and predicting functional disabilities in community-dwelling older Japanese adults. Thus, it may help physicians and patients in estimating the degree of progression, prevention, and treatment effect of sarcopenia and may contribute toward a quantitative understanding of those process.The cut-off value for discriminating sarcopenia was extremely accurate , since tPrevious studies have reported that individual sarcopenia diagnostic markers are associated with the risk of adverse events in the elderly population ,41,42. HA sarcoscore would allow for the largest clinical benefit in terms of allowing continuous assessment of the degree of progress with aging and improvement due to treatments. For example, in the case of an older man for whom all measurements were average upon the baseline survey, if all measurements worsened by 1% during the 1-year followed-up period, the sarcoscore would decrease by 1.4 points. Theoretically, the degree of this reduction would increase the risk of IADL disability by 5.6%. Thus, the sarcoscore can acutely respond to the slight change in all of the sarcopenia-related markers with aging and can predict adverse outcomes. Conversely, in the case of an older woman for whom all measurements were average upon the baseline survey, if all measurements were improved by 3% based on a treatment, the sarcoscore would also increase by 3.9 points. This gain would sequentially decrease the risk of BADL disability by 31.2%. When physicians and researchers assess the effects of intervention programs using the algorithm of cut-off values, then the effects of the program can only be assessed as a reversal rate; however, if the sarcoscore is used, the degree of the effects can be assessed using a continuous variable. Physicians and researchers should be aware that risk estimates per point of sarcoscore differ depending on the potential risk factors . If the β error and enables clearer identification of the strength of the association between the sarcoscore and the onset of functional disabilities in this population.Our study has several strengths in terms of its methodology. First, the sarcoscore might well reflect a population of elderly, community-dwelling Japanese adults, since present study integrated three population-based cohorts from the urban (Itabashi), suburban (Hatoyama), and rural (Kusatsu) areas in Japan. This increases the generalizability of the use of the sarcoscore among various community settings in Japan. Second, the sample size in the present study was relatively large compared to that of previous population-based studies which examined the associations between sarcopenia-related markers and functional disabilities in Australia , Italy , and GerConversely, our study was also subject to several limitations. First, unmeasured information including depression symptoms, smoking and drinking status, and habitual dietary and physical activity levels are potential confounders that were not accounted for in this study. Therefore, the strength of the association between the sarcoscore and the risk of functional disabilities, which was adjusted for other potential confounders, is unclear. Future studies should be designed to collect these data prospectively. Second, the use of the sarcoscore should be limited to older Japanese adults, since the sarcoscore formula would change depending on the mean and standard deviation of the sample. Also, associations of sarcoscore with other adverse outcomes were not examined. In the future, it would be useful to develop a sarcoscore for use in different populations and to assess whether the sarcoscore is associated with other adverse outcomes.The present study developed a sarcoscore to assess the degree of sarcopenia and identified that it had sufficient predictive value in predicting the functional disabilities in community-dwelling older Japanese adults compared to the AWGS criteria. These results suggest that a sarcoscore may contribute to assisting physicians and patients in the estimation of the degree of progression and the effects of the treatment of sarcopenia in clinical settings, as “a complementary composite marker” when using AWGS criteria.


The aim of this study was to evaluate the parameters of visual and brainstem auditory evoked potentials in patients occupationally exposed to arsenic, cadmium and lead. The study group comprised 41 copper smelter and refinery workers (average age: 51.27) with occupational exposure to arsenic, cadmium and lead. The control group consisted of 36 healthy volunteers . Neurological examination, brain imaging, and visual and brainstem auditory evoked potentials were performed, and the relationship between blood Cd, Pb concentration , blood zinc protoporphyrin (ZnPP), and urine As concentration (As-U) were assessed. In the workers, exceedances of allowable biological concentrations were observed, with the urinary concentration of arsenic being 5.2%, the cadmium and lead in blood being 1.3%, while the case of ZnPP was 2.6%. The mean P100, relative P100, and N145 visual evoked potential (VEP) latencies were significantly longer in exposed workers than in the controls. The mean wave III and V brainstem auditory evoked potential (BAEP) latency and the mean wave III–V and I–V interpeak latencies were longer, and the I and V amplitude was lower in the workers than the controls. In summary, occupational exposure to As, Cd, and Pb is associated with prolonged latency and reduced evoked potential amplitude, but As-U, Pb-B, Cd-B, and ZnPP concentrations are not linearly related to potential components. The analysis of evoked potentials may be a useful method of assessment of the central nervous system in patients with occupational exposure to heavy metals. Disorders resulting from chronic exposure to heavy metals affect various organs, including the nervous system. The chronic neurotoxic effects of heavy metals are revealed in workers who are professionally exposed to them. Permanent exposure in the work environment can lead to absorption by the body and, consequently, to damage to the nervous system ,2. KnowlArsenic, cadmium, and lead are among the most common toxic metals. Occupational exposure to arsenic (As) occurs during the production of pesticides, herbicides, and other agricultural products. Significant exposure to high concentrations of arsenic smoke and dust may occur in the steel industry . TrivaleOccupational exposure to cadmium (Cd) is usually inhaled. Workers involved in the purification of lead and zinc ores, the combustion of fossil fuels, galvanization, cement production, and the production of pigments and nickel-cadmium batteries are particularly vulnerable. Cd neurotoxicity most likely results from the mechanism of induction and the intensification of oxidative stress, in particular the intensification of the lipid peroxidation processes ,11. EpidLead (Pb) is a ubiquitous toxic metal that is present in all elements of the environment and biological systems. Depending on the dose and duration of exposure, Pb can cause many side effects in people . ProfessAn evoked potentials study is a precise, non-invasive, and very sensitive technique for assessing brain bioelectrical activity. It is especially useful for detecting small, subclinical disturbances in patients without signs of damage to the CNS or with only a slight neurological deficit.The aim of our study was to evaluate the electrophysiological parameters of visual and brainstem auditory evoked potentials in patients without clinical neurological deficits occupationally exposed to arsenic, cadmium, and lead. The analyzed parameters were correlated with basic toxicological parameters.A total of 77 people were qualified for this study, including 75 men and 2 women. The study included 41 patients  with occupational exposure to arsenic, cadmium, and lead, who were workers of the copper smelters and refineries “Legnica” and “Głogów” (Poland). The criteria for inclusion in the group of persons professionally exposed to arsenic, cadmium, and lead were: current employment at workplaces with documented exposure to a steel mill according to the safety and health departments, a total period of work in positions with documented exposure to metals of at least 5 years, and lack of current professional exposure to other chemical and physical substances documented by foundry services responsible for work safety and hygiene.The control group consisted of 36 healthy volunteers , appropriately selected in terms of sex and age. Everyone included in the study lived in areas with similar environmental exposure characteristics, so they did not differ in the size and quality of environmental exposure. All patients gave informed written consent to participate in the study.Exclusion criteria from the study were the same for the control group and the testing group. Exclusion criteria included factors that may affect visual evoked potential (VEP) and brainstem auditory evoked potential (BAEP) parameters, namely: visual and auditory receptor damage, current and/or past neurological, psychiatric, metabolic and deficiency diseases, and taking medications that may affect brain bioelectrical activity . The general characteristics of the studied groups are presented in All study participants completed a standardized survey to obtain information on employment history , lifestyle-modifying factors , health status, and medical history.Approximately 25 mL of venous blood and a standard urine sample were collected from all subjects in the group exposed to lead, cadmium, and arsenic. Laboratory tests determined the levels of blood cadmium (Cd-B), blood lead (Pb-B) blood zinc protoporphyrin (ZnPP), and urine arsenic (As-U). Determination of lead and cadmium in blood was performed by atomic absorption spectroscopy in a graphite furnace with a Solaar M6 apparatus, Thermo Elemental, UK. Arsenic concentration in the urine was determined by atomic absorption spectroscopy using the hydride generation method (HGAAS) with a VP100 Continuous Flow Vapor System. The concentration of ZnPP in blood was determined with a fast fluorimetric method using a Hematofluorymeter ProtoFluor Helena (USA). The determinations were made in accordance with the standards of the Institute of Occupational Medicine in Łódź. More information on the applied methodology for the determination of lead, cadmium, arsenic, and zinc protoporphyrin can be found in our previous work . For theDetailed subjective and objective neurological examination, VEP, and BAEP studies were performed on both groups. Each of the exposed patients underwent head imaging—either computed tomography (CT), or magnetic resonance imaging (MRI). All of them underwent mini-mental state examination (MMSE), clock drawing test (CDT), and symbol digit modality test (SDMT) tests to assess basic cognitive functions.Evoked potential studies were carried out using the Nicolet Viking Quest apparatus, in accordance with the standards of the International Federation of Clinical Neurophysiology (IFCN) and the American Society of Electroencephalography ,16. In tThe research was approved by the Bioethics Committee of the Medical University in Wroclaw.p <0.05 were considered statistically significant.Statistical analyses were performed based on the statistical program “STATISTICA 13” . Arithmetic means (X), medians (Me), and standard deviations (SD) were calculated for the quantitative variables. The distribution of variables was checked by the Shapiro–Wilk W test. For independent quantitative variables with normal distribution, the t-test for unrelated variables was used for further statistical analysis. For variables with a non-normal distribution, the Mann–Whitney U test was used for independent quantitative variables. The results for qualitative  variables were expressed as percentages. For qualitative variables, the chi-square test of maximum likelihood was used for further statistical analysis. To determine the relationship between the studied variables, a correlation analysis was performed. The results at the level of The average concentrations of blood cadmium, blood lead, and urine arsenic in the examined group of workers exposed to metals were 1.19 ± 1.40 μg/L, 181.85 ± 139.88 μg/L, and 15.60 ± 15.58 μg/g creatinine, respectively. In contrast, the mean concentration of zinc protoporphyrin in the blood was 18.35 ± 22.00 μg/dL. Exceedances of allowable biological concentrations were observed in the urinary concentrations of arsenic of 5.2% of subjects, in the blood cadmium and lead of 1.3% of subjects, and the ZnPP of 2.6% of subjects. The toxicological characteristics of the studied group of people professionally exposed to metals are summarized in The neurological examination was normal in 33 patients (80.5%). In 8 cases (19.5%), symptoms of peripheral nervous system involvement were present. Symptoms were attenuation of superficial sensation in the distal parts of the legs and decreased ankle and knee reflexes. The results of the MMSE, SDMT, and CDT tests were normal in all patients. None of the patients showed abnormalities in the brain CT or MRI studies.Abnormal VEP was recorded in 4 patients (9.75%). In all patients, there were unilateral prolonged P100 VEP latencies. Abnormal VEP did not occur in patients with symptoms of peripheral nervous system involvement. No abnormal BAEP was found in any of the patients.The mean P100, N145, and P100 Lo-Po VEP latencies were significantly longer in the arsenic-, cadmium-, and lead-exposed group, compared to the control group .The mean wave III and V BAEP, and the III–V and I–V interpeak latencies were significantly longer in the arsenic-, cadmium-, and lead-exposed group than in the control group, and the I and V BAEP amplitudes were significantly lower .The correlation analysis did not show the existence of statistically significant linear relationships between the basic toxicological parameters and the VEP and BEAP parameters.In the next stage, univariate regression analyses were performed between the toxicological variables and the tested VEP and BEAP parameters. Statistically significant relationships between the fact of occupational exposure to As, Cd, and Pb and selected VEP and BAEP variables were demonstrated: positive in the context of P100, N145, III, V, III–V and IV, and negative in the context of amplitude I and amplitude V. Significant relationships between As-U, Cd-B, Pb-B, and ZnPP concentrations and the studied VEP and BAEP variables were not demonstrated in the group of people exposed to As, Cd and Pb .Metals that are often used in industry are the main source of exposure to toxins for workers. For this reason, government agencies regulate acceptable exposure levels, which is important for the safety of employees. While the necessary metals play important physiological roles in the body, heavy metals pose a significant health risk in cases of acute and chronic exposure at high levels. The CNS is particularly sensitive to intoxication ,7,11. ThUnder normal conditions, Cd rarely reaches the brain in adults, because it is protected by a highly selective blood-brain barrier (BBB). This xenobiotic can bypass the BBB to reach the CNS through the olfactory pathway, especially in cigarette smokers and those exposed to air pollution. Cd-dependent BBB changes have also been shown to increase its permeability . The conBoth experimental animal and human studies have shown that early exposure to lead is associated with reduced BBB integrity, altered synaptogenesis, myelin microstructure, and metabolic brain content . Magnetip = 0.01), there were no significant changes in the amplitude and relationship between VEP parameters and arsenic concentration in the urine of employees and the air [p = 0.001). Discalzi et al. also showed that in the case of Pb> 50 μg/dL in the blood, the I–V BAEP wave latency was longer than in patients with a concentration below 50 μg/dL  [p <0.001) [Evoked potential (EP) studies are a particularly useful electrophysiological method used in the diagnosis of functional CNS disorders. In contrast to imaging techniques, which reveal only anatomical and structural changes, EPs allow for the assessment of the integrity and functional activity of the nerve pathways. They are particularly helpful in detecting clinically silent disorders, locating lesions, confirming questionable and ambiguous changes, and monitoring the course of some neurological diseases. Previous reports on both exogenous and endogenous evoked potentials in patients with occupational exposure to heavy metals are few and often relate to casuistic cases of rare complications ,9,28. Th= 0.034) . Other r= 0.034) ,31. Ejma <0.001) .Few experimental studies of animal heavy metal intoxication also suggest a significant effect on the CNS. Yargicogluo et al. analyzed the VEP of rats exposed to cadmium in prenatal life and after birth and showed extended latencies and reduced amplitudes of VEP components in rats exposed to cadmium compared to the control group . In expeIn our patients, we found a significant increase in the N75 and P100 VEP latencies. Analyzing BAEP, we found a significant increase in the latency of all components and a significant decrease in the amplitude of the I and V waves. Our research shows that patients with occupational exposure to arsenic, cadmium, and lead show signs of brain bioelectrical dysfunction, manifested by the impairment of nerve conduction in the visual and auditory pathways.Recent studies devote substantial attention to the significant and persistent harmful effects of heavy metals on developing organisms. However, our research subjects were exposed to Cd, As, and Pb only in adulthood. These people did not have symptoms of a central neurological deficit or visible cognitive impairment, and the concentration of toxic elements in the blood and urine in most employees did not exceed the acceptable biological concentrations (maximum admissible concentrations were exceeded only in approx. 5% of the subjects in the case of As-U, approx. 3% of the subjects in the case of ZnPP, and approx. 1% of the subjects in the case of Cd-B and Pb-B, see The EP test is a highly sensitive method that can be useful for recognizing and monitoring occupational exposure to heavy metals. It can also be easily and cheaply used in preventive examinations, allowing for the detection of early, small, and possibly reversible CNS disorders. The authors recommend regular preventive examinations of infants and children living in areas with exposure to toxic substances in the future.The main limitations of the study were the small size of the study group and no measurements of metals concentration in the control group, as it was not possible to recruit people agreeing to determine the concentration of metals in the blood and urine.Occupational exposure to As, Cd, and Pb is associated with prolonged latency and reduced evoked potential amplitude, but As-U, Pb-B, Cd-B, and ZnPP concentrations are not linearly related to potential components. An evoked potential analysis may be a useful method of assessment of the central nervous system in patients with occupational exposure to heavy metals.


Mycobacterium tuberculosis DNA, which has significantly improved the diagnosis of tuberculosis. In this study, our main objective was to evaluate the diagnostic efficacy of Xpert MTB/RIF for lymphoid tuberculosis to determine whether Xpert MTB/RIF could be used as a routine detection method.  The World Health Organization approved the use of Xpert MTB/RIF for the detection of  We searched four databases for the relevant literature published from May 2007 to December 2019. The quality of the literature was evaluated with reference to the evaluation criteria. Data that were extracted from the literature on Xpert MTB/RIF diagnosis of lymphatic tuberculosis were used to plot the summary receiver operating characteristic (SROC) curve, after which the software was used to combine and analyze the accuracy of these data. Q = 0.8470 (SE = 0.0163).  A total of 27 studies were included. The sensitivity of Xpert MTB/RIF for detecting lymphatic tuberculosis was 0.79 ), the specificity was 0.88 ), and the positive likelihood ratio (PLR) was 7.21 ). In addition, the negative likelihood ratio (NLR) was 0.25 ) and the diagnostic odds ratio (DOR) was 40.23 ). At the same time, we used the extracted data to make the SROC curve, obtaining the following parameters: area under the curve (AUC) = 0.9144,  Xpert MTB/RIF has high accuracy in detecting lymphatic tuberculosis, and it can be used to quickly and easily diagnose lymphatic tuberculosis at an early stage as a general method. M. tuberculosis that invades the human body, and especially lungs. It can also cause extrapulmonary tuberculosis, which is caused when the bacterium infects the lungs and then spreads through the lymphatic system, invading other organs of the body [Tuberculosis is the leading infectious cause of death worldwide. It is caused by the body . Lymphatthe body . In resoConventional methods for detecting lymphatic tuberculosis include smear microscopy, culture, or cytology; nevertheless, these methods have certain limitations. Mycobacterial culture can be used as a reference standard but is time-consuming and requires an operator or contact. With a reasonably high level of biosafety, cytological methods for detecting lymphadenopathy require expert human cytological interpretation, while small laboratories often do not have equipment such as fluorescence microscopes or light-emitting diode (LED) microscopes. These factors make it impossible to accurately and quickly diagnose patients with lymphatic tuberculosis in a low resource environment .M. tuberculosis, is a box-based isothermal nucleic acid amplification test, which requires less time to detect M. tuberculosis. It is also characterized by short cycle, speed, automaticity, and operator need to have the advantage of too high professional skills [M. tuberculosis and rapid diagnosis of the function of tuberculosis [M. tuberculosis culture. However, large-scale implementation of Xpert does not require specialized equipment or culture of a large number of talents to meet the culture process demand. In relation to the tuberculosis control plan, some countries are ready to abandon traditional mycobacterial culture and switch to Xpert for the detection of M. tuberculosis [Xpert MTB/RIF, a complex for detecting l skills . In 2010rculosis . Accordirculosis . There aWe first confirmed the inclusion and exclusion criteria and relevant keywords, which was followed by a literature search, preliminary screening, and rescreening. Next, data extraction and literature quality evaluation were performed, after which the statistical analysis was performed; the specific processes are shown in M. tuberculosis using Xpert MTB/RIF.The inclusion criteria were the following: (1) subjects: clinical specimens of lymph node tissues identified as tuberculous lymphadenitis by test methods, and tuberculosis detected in the lesions; (2) types of study: analytical test for diagnostic accuracy data for identification of bacterial species could be extracted from literature; only literature in English literature was considered; and (3) diagnostic test method: detection of Exclusion criteria were (1) duplicate literature; (2) conference abstracts, lectures, letters, and reviews; (3) literature lacking reference standards; and (4) literature lacking a fourfold table.The “Xpert” and “Lymph” keywords were used to jointly search the PubMed database, the Web of Science database, the Embase database, and the Cochrane Library database for relevant documents published between May 2007 and December 2019. Possible matches were also retrieved from the related references and were incorporated with standard literature.Four evaluators independently searched for the “Xpert” and “Lymph” keywords in view of the predefined inclusion and exclusion criteria. PubMed database, Web of Science database, the Embase database, and the Cochrane Library database were searched for the relevant literature published between May 2007 and May 2019. The studies were extracted and analyzed, and those documents that met the inclusion criteria were evaluated for quality. If the four evaluators cannot reach an agreement on the results of data extraction, analysis, and evaluation results, differences would be resolved by review and negotiation. If differences remained, the third party would be introduced to reach consensus, who was blinded to the authors or institutions of the studies undergoing review. The extracted data included author, year, type of experimental design (prospective or retrospective), gold standard, classification, type of specimens (FNA or tissue), TP, FP, FN, TN, errors and the total number of samples, and other related information, during which a fourfold table was regarded as the standardized data extraction form. In the process of data extraction, we found that the gold standards are culture and composite reference standard (CRS), which even appears in some of the literature at the same time. We regard such articles as two articles for extraction and label “a” with culture as the gold standard and “b” with CRS as the gold standard in the figure .The literature was evaluated for quality, mainly based on the quality evaluation criteria of the diagnostic test recommended by the Cochrane Collaboration Network-QUADAS-2 . The quaP value of <0.05 represented a statistically significant difference. If the results of the data graphs such as the forest map and the funnel map were not satisfactory, the four evaluators solved the problem by negotiating and inspecting whether the effect model (fixed-effects model and random-effects model) and effect quantity  were satisfactory.The following data were extracted: total number of samples, specificity, sensitivity, true positive, false positive, true negative, and false negative. The data of Xpert MTB/RIF for the diagnosis of lymphatic tuberculosis were accurately combined and analyzed by Stata 12.0 software and meta-disc v.1.4 software. The accuracy of each diagnostic method was analyzed using a random-effects model and presented in the form of a funnel plot and a forest plot, respectively. We used the form of a forest map to obtain an accurate estimate for each study in a general overview and then analyzed and interpreted the estimates of the forest map summary. In the forest map, a By applying the above-described search strategy, 260 articles were identified. After deleting duplicate articles, 180 articles were left. Next, we screened the title, abstract, and conclusion of the research. Finally, we conducted a full-text review and meta-analysis of 27 articles , 8–33 S, Table 1Among the 27 documents included, 21 were prospective and 6 were retrospective studies. Besides, in these 27 articles, the sample types were fine needle aspiration (FNA) and tissue, and the storage conditions were also divided into frozen and fresh. In this article, we only present part of the type of specimen.P value was 0.182 (P > 0.05), which suggested that the included articles did not have the threshold effect.As can be seen from the SROC curve , it did Q = 99.82, P ≤ 0.01 (P < 0.05), inconsistency = 65.9% (inconsistent > 50%).A forest map, which was used to plot the ratio, revealed that there was no heterogeneity in nonthreshold effects: Cochran‐Q index was 0.8470 (SE = 0.0163). Since AUC and Q index was close to 1, this indicated a high overall accuracy, which suggests that Xpert MTB/RIF can be used to diagnose lymphatic tuberculosis more accurately.The obtained meta-analysis data were used to generate the SROC curve, which illustrated the total score of the test . As the The results are shown in Figures 2P > 0.05 was not statistically significant, which confirmed that there was no bias in this study . The AUC was close to 1, which suggests a relatively high overall accuracy of the study. Taken together, the Xpert MTB/RIF technique has a better diagnostic effect for lymphatic tuberculosis.In the current study, we included 27 studies and extracted 33 fourfold figures to make a systematic diagnosis of lymphatic tuberculosis by Xpert MTB/RIF. The results of the evaluation showed that Xpert MTB/RIF had a sensitivity of 0.79 ), a specificity of 0.88 ), a PLR of 7.21 ), a NLR of 0.25 ), and a DOR of 40.23 ). At the same time, we also used the extracted data to make the SROC curve and obtained the following parameters: AUC of 0.9144 and M. tuberculosis culture is widely used as the gold standard for the diagnosis of tuberculosis. However, this technique has the disadvantage of being time-consuming since it can take up to several weeks to confirm the results [M. tuberculosis. In contrast, Xpert MTB/RIF technology provides fast diagnostic results in less than 2 hours, which significantly increases the clinical efficiency of tuberculosis diagnosis. At the same time, Xpert MTB/RIF is more porFigure and widely used than M. tuberculosis culture, which is difficult to perform in low-income countries. Its automation features also reduce the requirements for medical personnel [Currently,  results , 35. Thiersonnel . The Worersonnel . BecauseSince Xpert MTB/RIF is prone to “error” in clinical application, that is, it cannot be detected, we also extracted the number of “error” in various studies during data extraction . Of the The results show that the “error” situation often occurs in the detection of extrapulmonary samples. Some researchers pointed out that this situation may be due to the presence of PCR inhibitors in the extrapulmonary samples, which prevented the test from being performed . In anotM. tuberculosis. If M. tuberculosis in the sample has rpoB gene defects, it cannot be detected, which will increase the negative rate of Xpert MTB/RIF testing [During the analysis of the extracted data, we found that the Xpert MTB/RIF test results and culture as the gold standard test results are very different in some studies. After reviewing the 27 articles included in the analysis, we summarized some of the main reasons. First, the culture method needs to use the N-acetyl-L-cysteine and sodium hydroxide method (NALC/NaOH) for digestion and purification of the sample, which may result in the loss of live bacteria and uneven distribution of bacteria in the sample, thus making the culture test result negative , 14, 23. testing . These cDuring this study, a related study was published , whose aOur study also has some limitations. First of all, we only extracted data from the published literature in the four English databases, which may lead to defects in the comprehensiveness of this study. Secondly, although some of the studies , 31–33 aIn summary, Xpert MTB/RIF is a highly sensitive and highly specific method for diagnosing lymphatic tuberculosis, which is of great value for the early diagnosis of lymphatic tuberculosis. It can reduce treatment time and the use of antibiotics, reduce the suffering of patients, and save their lives. In the future, this technology could become the optimal auxiliary diagnostic method for tuberculosis.In conclusion, Xpert MTB/RIF is highly sensitive and specific for the diagnosis of lymphoid tuberculosis, and it also has the advantages of convenience, simple and fast operation, and a good economy. Xpert MTB/RIF can be used as a routine detection method for lymphoid tuberculosis in the early clinical stage.


Aims: Millions have fled from the civil unrest in Syria, and half of these are children and youth. Although they are a population with an elevated risk of health problems due to adverse pre-migratory and post-migratory experiences, few studies have explored their health-related quality of life (HRQoL). This is considered a fundamental construct in public health and might provide complementary descriptions of their health and well-being after resettling in a new country. Methods: This was a cross-sectional study of 160 Syrian youth aged 13–24 years. Using KIDSCREEN-27, the results for five dimensions of HRQoL was compared to population norm data. Demographic factors and war-related adverse events were used to predict HRQoL in hierarchical regression. Results: For most participants, the overall HRQoL was good, but it was lower in the dimensions for friends, physical well-being and psychological well-being compared to population norms. Scores in the dimensions for autonomy/parental relation and the school environment were high and were the main contributors to a positive HRQoL. Age and number of reported stressful events (SE) had the greatest impact on HRQoL, but the final regression model only accounted for 21% of the total variance. Conclusions: HRQoL is a relevant and non-invasive measure for refugee youth. Contributors to lower scores in physical and psychological well-being should be explored further and indicate the potential for future interventions focussing on general psychological well-being and networks, regardless of the SE that have been experienced. These interventions could potentially be based in schools or in families in order to benefit from these being seemingly safe environments for the majority of the group. The global population of forcibly displaced people has grown to more than 70 million . The armMany Syrian children have experienced war and violence at close hand and have been forced to move, leaving their home, family and friends. They have seen or heard guns, bombs and fighting; many have seen someone die, and sometimes these were family members or loved ones –6. Pre-m7HRQoL is a multidimensional construct covering physical, emotional, mental, social and behavioural components related to health as perceived by the individuals themselves . Some ofPrevious studies have indicated slightly lower well-being among immigrant populations. However, results often vary due to the heterogeneity of the concepts measured, migrant groups included and context ,17. For Due to limited knowledge of HRQoL in refugee youth and conflicting results in previous studies, the purpose of this study was to explore the HRQoL in young Syrian refugees who have recently resettled in Norway, and its relationship with settlement factors and war- and flight-related events. The results might help discern dimensions of strengths and areas of concern for refugee youth who resettle in high-income countries.n=9 schools), no Syrian students (n=6 schools) or already participating in other studies (n=2 schools). The schools participating had between 1 and 23 Syrian students attending. The teachers distributed written information about the study in Arabic and Norwegian to the students in advance, and consent forms were given to parents with children <16 years of age. The youth completed the questionnaire whilst at school with a researcher present to answer questions. Norwegian schools do not regularly record students’ country of origin. Therefore, the total number of Syrian students attending each school was not available. Of the students present on the day of the visit, three students declined to participate due to exam preparations or language difficulties. Students absent from school were not included. Due to challenges collecting consent forms from parents of children aged <16 years, efforts were focussed on including upper secondary schools.The study has a cross-sectional design using a questionnaire in both Arabic and Norwegian. Using strategic sampling to recruit recently resettled youth, 40 schools with introductory classes for newly arrived immigrants were contacted. Of these, 23 schools located in nine different regions of Norway agreed to participate. Reasons for not participating were: no response to request  to fit the age and context of the participants . The lisAge, sex, mother tongue, time as a refugee (time since they left their own house in Syria), residence time , moves (number of times they have moved during the last five years) and family situation were included. The latter was dichotomised into living with parents  or not living with parents .t-test using Bonferroni corrections for multiple comparisons. One-way analysis of variance (ANOVA) was used to investigate differences in mean HRQoL scores between three age groups in the sample. Lastly, Pearson’s correlation coefficients together with hierarchical multiple regression were used to explore the relationships among the variables. All analyses were conducted using IBM SPSS Statistics for Windows v21.0 , with statistical significance set at p<0.05 (two-tailed). This study was reviewed and approved by the Regional Research Ethics Committee of Norway East (reference number 2018/192).All KIDSCREEN-27 scores were summed and converted to sum scores with a range of 0–100 according to KIDSCREEN scoring manuals. In dimensions with one missing value, the missing value was replaced with the individual mean for the dimension estimated by the remaining items . The comMage=20.1 years, range 16–24 years), lived alone and were mostly male (89%).In total, 160 youth were included in the study. The mean residence time in Norway for the study population was two years (range 0–8 years). The mean age was 18.6 years (range 13–24 years). The sex distribution was slightly uneven, with 62.5% boys and 36.9% girls. For the majority of the youth (76.3%), Arabic was their mother tongue, and they lived with their parents 75%; see . The youFrom data obtained from Statistics Norway (SSB), we know that there were 5553 Syrian youth between the ages of 13 and 24 years registered in Norway at the start of the study. The mean age and sex distribution in this population is close to that of our study population.n=147) reported a mean of 4.2 SE (SD=2.76), the most prevalent being witnessing war (68%), feeling your life was in danger (59%) and seeing someone die (55%). A total of 88% reported at least one event, with 61% reported having experienced four or more events.Participants . The dimensions where the youth indicated best satisfaction were autonomy/parents, with a mean score of 69.50 (SD=21.43) and school, with a mean score of 67.25 (SD=21.40). The dimensions with the lowest scores were physical and psychological well-being, with mean scores of 58.82 (SD=23.00) and 59.02 (SD=21.07), respectively. This is a distinctly different HRQoL profile than the European population norm data, where friends and psychological well-being are the dimensions with the highest scores, and school the lowest  with a moderate effect size. The three dimensions that contribute to the lower HRQoL Index are physical well-being, psychological well-being and friends. The effect size for the difference in physical well-being and friends are moderate, but for psychological well-being they are large.The age range of the European population norm data is up to 18 years of age, whereas we included youth up to 24 years of age. Assuming age was relevant to HRQoL, we ran the same comparison including only our study participants in the same age range as a sensitivity analysis. The adjustment increased the mean scores for all dimensions in our study sample see . The sigIn further analysis, we investigated the impact of different sociodemographic variables, including settlement factors, starting with age. Dividing the sample into three age groups, r=−0.36, p<0.001). Of the sociodemographic variables, increasing age, not living with parents and number of moves had significant negative effects. Age correlated significantly with an increase in SE, longer residence time and not living with parents.To investigate the relationship between HRQoL, SE and sociodemographic variables, Pearson’s product moment correlation coefficients were calculated. As F=9.39, p<0.001). SE therefore explained an additional 8% of the variance in HRQoL Index scores after controlling for age and sex =12.93, p<0.001). After adding the settlement factors, the p-levels were similar in models 3 and 2, and the total variance explained was 21%. Repeating the same procedure for the two highest scoring dimensions, we found similar influences, with 19% of variance explained in autonomy/parents, but less of the variance was explained for school environment (12%). When repeated for the dimension with the lowest score, psychological well-being, 23% of the total variance was explained. In the fully adjusted models, being female decreased the scores significantly for the HRQoL Index and psychological well-being scores, and in the latter, increasing age reduced the scores significantly. Having experienced SE was a significant negative factor across all dimensions analysed. The other variables were not significant.Hierarchal multiple regression analyses were done to examine the predictive value of SE and settlement variables on the HRQoL Index and the highest and lowest scoring dimensions , controlling for age and sex . The varSupplemental Material).A sensitivity analysis including only the age group 13-18 years (n=95) showed that the effect of age as a predictor for psychological wellbeing was reduced (β -.22 vs -.08). This suggests that the effect of age is only present in the older age group  were excluded. SE had a small and negative impact on scores in all dimensions. Settlement factors  showed no influence, apart from living with parents which was significant only for the 13- to 18-year-olds in the dimension of autonomy/parents. The results will now be discussed in relation to each dimension, and the cultural and developmental sensitivity of the measurements.The overall HRQoL Index in our study population of young Syrians was moderately good, with an average of 64 for the age range 13–24 years and 67.5 for the age range 13–18 years. This is lower than European population norm data and Norwegian youth, with HRQoL Index scores of 72 ,26. The 4This dimension had the lowest score in this study and was significantly lower than the population norm data. Some studies have found that exposure to violence is an important predictor for physical health , but thi7This dimension explored positive and negative emotions, life satisfaction and self-esteem. A substantial portion of the literature concerning refugee youth shows a high prevalence of mental and emotional health problems . These rThis dimension explored the perceived autonomy, financial resources, interaction and support from parents. Lower scores for the oldest age group living alone could potentially be connected to financial resources. Family and home life is important for general well-being, and unaccompanied refugee minors are therefore regarded as an especially vulnerable group lacking the support from parents or family . HoweverThis dimension relates to both social support and friendships, vital to the experience of well-being for adolescents . A stronThis dimension explores perceptions of concentration, learning, feelings about school and relationships with teachers. Many Syrian youth have interrupted and incomplete education before arrival , and ourWhen interpreting the present findings, the cultural and developmental sensitivity of the measurements needs to be considered. Cultural differences in perceptions of health, illness and the meaning of quality of life might influence responses. KIDSCREEN was therefore chosen due to its cross-cultural development and validation on several continents in order to ensure that concepts were culturally relevant with some level of universality . Some st4The same consideration when interpreting the results should apply to developmental aspects, as developmental differences in cognitive, emotional, social and relational dimensions may affect the measure of HRQoL. In studies including children and adolescents, increasing age predicts a reduction in HRQoL ,26, whicFor some of the HRQoL dimensions in this study, the developmental context varied greatly between a 13-year-old and a 24-year-old, especially for autonomy and parental relations. Other studies using KIDSCREEN-27 in young adults also suggest that autonomy/parents must be interpreted with more caution for older age groups. However, a Rasch evaluation also suggests acceptable results for all other dimensions in the KIDSCREEN-27 [One important shortcoming is the lack of information on the actual number of Syrian students attending the schools included in the study, as students’ country of origin is not normally noted in their records. The total attrition rate and whether participants and non-participants differed in any respect is not known, and evaluating their representativeness is difficult. There were fewer girls than boys participating. However, this reflects the sex distribution for the age group residing in Norway. Although care was taken to inform the participants, language difficulties, fear or compliance might have affected their answers and might have contributed to the difficulties in obtaining consent forms from parents. Considering the high levels of poor mental health in unaccompanied refugee youth , it woulThe strengths include the use of well-validated measures and recruiting resettled refugee youth living with their families. Using HRQoL highlights its importance as an important outcome that enables an ecological and developmental perspective, describing the health and well-being of a whole population to complement other measurements. A common critique of studies on migration and health is the heterogeneity of participants originating from all over the world , which tFor most participants, the overall HRQoL was moderately good, despite possible risk factors. Autonomy/parents and school environment contributed the most to a positive HRQoL. Friends, physical well-being and especially psychological well-being were lower than population norms, highlighting areas of strength and concern. Sociodemographic factors had little explanatory value, but SE had an impact across all dimensions. Age was only predictive for reduced psychological wellbeing in the eldest age group. Total variance explained was only 21%, suggesting that more modifiable factors are relevant to explore in future research.For future research, HRQoL is a non-invasive measure with the potential of exploring dimensions of strengths and concerns, and an important complement to mental-health measures in studies of refugees. To improve contextual relevance, the generic HRQoL measurements could be augmented by adapting the general measure or developing more migration or refugee specific modules. These modules could include impact or stress related to acculturation, identity or discrimination, for example, inspired by how disease-specific modules in HRQoL measures for disabled or chronically ill children have been developed (DISABKIDS ).For schools, this study illustrates their importance as a resource for well-being, and this role needs to be continually supported. Teachers’ competence and multicultural environments might be important contributing factors, since lower school satisfaction is reported in other studies. Being a safe arena means interventions targeting areas of concern, such as social support and psychological well-being, could be based here. Such interventions could be network building, mentorships and school-based mental-health services.For public-health professionals, this study shows that HRQoL was good for most youth, despite difficult circumstances, suggesting resilience. Parents seemed to be an important resource, emphasising the importance of including families in interventions. SE showed a small but consistent explanatory power, indicating that traumatic events are central. However, more universal public-health interventions targeting a wider range of mental-health problems might be just as beneficial, especially as HRQoL might also be a valuable resource for negotiating other settlement stressors in refugee youth.Click here for additional data file.Supplemental material, SJP929833_Supplemental_material for Health-related quality of life in young Syrian refugees recently resettled in Norway by Cecilie R. Dangmann, Øivind Solberg, Anne K.M. Steffenak, Sevald Høye and Per N. Andersen in Scandinavian Journal of Public Health