The multiparous women presented greater (p > 0.05) IRD at rest and during ADIM compared to the primiparous women. Regarding abdominopelvic muscle function, differences were only significant (p < 0.05) between the nulliparous with primiparous women in prone and supine conditions. These findings suggest that parity influences IRD: women at 6 months postpartum present greater IRD compared to nulliparous women; multiparous women present greater IRD at rest and during the activation of deep abdominal muscles than primiparous women; and primiparous women exhibit worse abdominopelvic muscle function than nulliparous women.Widening of the inter-rectus distance (IRD) is highly prevalent among postpartum women and can lead to dysfunction of abdominopelvic muscles. The aim of this study was to evaluate the differences in IRD and abdominopelvic function between nulliparous, primiparous and multiparous women. A cross-sectional study was conducted on 75 women . The participants underwent ultrasound assessment under three conditions  and curl-up) at two locations (2 cm above and 2 cm below the umbilicus). Furthermore, abdominopelvic muscle function was determined by prone, supine and side bridge tests. In all conditions and locations, the IRD were significantly higher ( Inter-rectus distance (IRD) refers to the separation between the two bellies of the rectus abdominis muscle along the linea alba ,2. The aThe presence and severity of DRA is based on two important aspects: (1) the abdominal values of the IRD and (2) the alteration of the linea alba’s tensile properties and its ability to transfer the force ,10. In aRegarding DRA effects, scientific research confirmed heterogeneous conclusions. On the one hand, a recent systematic review  found thSeveral methods are used for the assessment of the IRD, such as measurement with callipers, tape measure, and the traditional ‘finger width‘ method . Some auTo date, several authors ,27,28 haThis was a cross-sectional observational study that conformed to the Declaration of Helsinki  and was A sample of nulliparous, primiparous, and multiparous women were recruited in Valencia, Spain, from November 2018 to January 2021, using flyers in obstetricians’ and other health care settings, as well as through prenatal education and prenatal fitness centers.To be included in the study, the participants had to be aged between 23 and 43 years old  to calculate the sample size. With the study design, assuming a medium/large effect size f = 0.40 (d = 0.80), α = 0.05, and β = 0.15, a minimum sample size of 72 subjects was required.All the women attended a single assessment session. Two physical therapists with 10 years of clinical experience in women’s health (L.F.-A) and in rehabilitative ultrasound imaging (S.P.-A.) performed all the measurements. Firstly, L.F.-A. explained the procedure in detail to the participants. The same researcher performed an exhaustive anamnesis, in which all the women provided information about the following sociodemographic and clinical data: age, birth, baby weight, weight gain during pregnancy, soft tissue damage, profession, exercise before and during pregnancy, and routine. Weight, height, and waist circumference were measured using standard procedures. Profession was categorized according to the Daily Physical by Occupational Classification of the National Health and Nutrition Examination Survey . CurrentThe IRD was assessed by ultrasound imaging. A SAMSUNG HS30 device  interfaced with a two-dimensional, high-frequency linear transducer (LN 5-12) was used in B-mode for all the imaging.The ultrasound transducer was placed transversely along the linea alba in order to register IRD at two locations: 2 cm above the superior border of the umbilicus and 2 cm bellow the inferior border of the umbilicus . Good inThree still images were obtained at the two locations under three different conditions: resting in the supine position with a slight knee and hip flexion maintained by placing a pillow under the knees and with arms along the body, abdominal draw-in maneuver (ADIM) and abdominal curl-up . For theAbdominopelvic muscle function was assessed by prone and supine bridge test and side bridge test (right and left) .For the prone bridge test a, the woThe supine bridge test b consistFor the side bridge test c,d, the The subjects raised their pelvis from the floor, while maintaining their body alignment by supporting themselves only on one forearm and their feet. Their contralateral arm was placed across the chest with the hand on the opposite shoulder. The test was then repeated on the other side.All the tests were performed on a mat. During all the tests, the subjects were reminded to maintain the position for as long as possible . Each po2).The statistical analyses were performed using the IBM SPSS Statistics software for Windows . The Shapiro–Wilk test was used to evaluate the normality of the data. The results are shown as mean (SD) or frequencies, as appropriate. The subjects’ demographic variables were compared using one-factor analysis of variance (ANOVA), Kruskall Wallis or chi-square (χp2 = 0.01), medium , and large . Statistical significance was set at p < 0.05.To determine significant differences among the groups , the conditions  and locations (2 cm above and 2 cm below the umbilicus) in the IRD variable, three-factor ANOVA with repeated measures in factor condition and location were used. Differences among the groups in abdominopelvic muscle function were analysed using one-factor ANOVA. When the ANOVA models indicated significant differences in the main effects, Bonferroni correction was applied to avoid type I error in the multiple comparisons. The effect size was interpreted as small , with a mean age of 34.15 ± 3.84 years. All the included subjects completed socio-demographic data collection as well as ultrasound assessment and abdominopelvic test sessions .p > 0.05) in age, weight, body mass index (BMI), height, waist circumference, profession physical activity classification, or in abdominal and low back pain. However, it was observed that the number of participants who performed physical exercise were significantly higher (p = 0.001) in the nulliparous than in the primiparous and multiparous groups. Furthermore, the nulliparous women registered higher exercise intensity (p = 0.007) than the multiparous women. Regarding the postpartum variables, both the primiparous and the multiparous women presented similar values, except for the rates of exercise during pregnancy. In this comparison, the primiparous group showed a significantly greater (p = 0.01) number of participants performing exercise than the multiparous group.The participant’s demographic and clinical characteristics are presented in p < 0.05) in the primiparous and multiparous women than in nulliparous women. In all cases, the effect size was large. With regards to the comparison between the postpartum women, the multiparous women showed higher IRD than the primiparous women, with significant differences (p < 0.05) in the rest condition (only 2 cm above the umbilicus) and in the ADIM condition (at both locations).p < 0.05) in the comparison between the nulliparous and primiparous women in prone and supine conditions. Finally, no significant differences were found in the time values between the primiparous and multiparous women.Regarding the outcomes related to abdominopelvic muscle function, the nulliparous women showed better time values  than the primiparous and multiparous women in the four conditions . However, differences were only significant  or superficial (curl-up) abdominal muscles, compared to the nulliparous women. No studies have previously investigated IRD values comparing between nulliparous, primiparous and multiparous women. More specifically, the primiparous and multiparous women participating in our study showed an IRD at rest of 1.99 and 2.60 cm at 2 cm above the umbilicus, and 1.32 and 1.43 cm at 2 cm below, respectively. Previous studies have also reported IRD values at rest but considering women with heterogeneous parity  and measurement locations along the linea alba. For instance, Liaw et al. , in a saAll these differences in IRD behavior between postpartum and nulliparous women confirm the morphological and functional changes in abdominopelvic muscles that have been reported in postpartum women in comparison to nulliparous women, mainly related to the elongation and thickness decrease of the abdominal muscles .Moreover, our findings suggest that multiparous women present higher IRD values compared to primiparous, in both at rest and ADIM. However, while these differences were observed at 2 cm both above and below the umbilicus during ADIM, they were only detected 2 cm above the umbilicus at rest. These results again be explained by the greater IRD values in the supraumbilical region in postpartum women .Regarding abdominopelvic muscle function, in our study, only the primiparous women demonstrated statistically significant differences when compared with the nulliparous women, showing worse abdominopelvic muscle function in the performance of the prone and supine bridge tests. These results are in line with those of other authors, who have confirmed changes in abdominopelvic function, such as lower strength and higher fatigability of both trunk and lumbopelvic stabilizing muscles in postpartum women, which could explain our findings ,44,45. SConsidering all the above-mentioned findings, it is important to highlight that, although the multiparous women showed higher IRD than the primiparous women in some conditions , no differences in abdominopelvic muscle function were detected between the primiparous and multiparous women. Thus, it seems that although IRD is influenced by parity, this does not necessary indicate a negative effect on the global function of the abdominopelvic region. This is in accordance with other studies ,10 whichIn this study, there are some methodological issues that should be considered. First, the main weakness of this review is the small sample size and the performance of physical activity. These two aspects may have limited the generalizability of our results in postpartum women. Second, no information regarding breastfeeding was collected, which could be a factor influencing the natural course of the IRD and the abdominopelvic function during the postpartum period. Moreover, although exercise habits were registered (frequency and intensity), this study did not consider the effect of exercise on IRD and abdominopelvic muscle function. In future studies, it could be interesting to investigate this point by comparing groups performing different exercise modalities and/or intensities. Furthermore, the women in our sample exhibited relatively low BMI. Additionally, since this was a cross-sectional study, only data at 6 months postpartum were collected. Further research in this topic, including additional follow-up measurements throughout postpartum, is warranted to investigate the natural course of the IRD and the abdominopelvic muscle function in the longer term. In conclusion, parity influences IRD at 6 months postpartum, as both primiparous and multiparous women present greater IRD at rest as well as during the activation of the abdominal muscles compared to nulliparous women. Moreover, multiparous women present greater IRD at rest and during the activation of the deep abdominal muscles compared to primiparous women. Nevertheless, in our sample, weaker abdominopelvic muscle function was only observed in primiparous compared to nulliparous women. These findings may contribute to the understanding of the natural evolution of the IRD in postpartum women.


We evaluated the effects of long-term/recurrent use of antibiotics in childhood on developing cognitive impairment in middle and old age from UK Biobank Database.UK Biobank recruited participants aged 37–73 years. Cognitive impairment was ascertained by fluid intelligence questionnaire. Primary outcome was the occurrence of cognitive impairment in middle and old age. Multivariate logistic regression models were used to explore the relationship between long-term/recurrent use of antibiotics and cognitive impairment.p < 0.01). The effect of long-term/recurrent use of antibiotics in childhood on cognitive impairment was homogeneous across different categories of various subgroup variables such as sex, age, APOE4, ethnic groups, income before tax, smoking status, alcohol status, BMI, hypertension and diabetes but the effect of long-term/recurrent use of antibiotics in childhood was modified by the educational qualification .Over 3.8–10.8 years’ follow-up, 4,781 of the 35,921 participants developed cognitive impairment. The odds of cognitive impairment in middle and old age among long-term/recurrent use of antibiotics in childhood were increased by 18% compared with their counterparts (adjusted odd ratio 1.18, 95% confidence interval 1.08–1.29, Long-term/recurrent use of antibiotics in childhood may increase the risk of cognitive impairment in middle and old age. Cognitive impairment is the nomenclature of one or more cognitive impairment areas, ranging from complete cognition to mild cognitive impairment and finally dementia . CognitiAdolescence is a critical period of development, marking the transition from childhood to adulthood. It is in the last stage of development before adulthood that the brain is highly responsive to certain environmental cues . CompareAntibiotics are usually used to remove or prevent bacterial colonization in the human body, and not to target specific types of bacteria . StudiesWe used the UK Biobank Database to perform the population-based retrospective cohort study with a representative sample of 502,505 participants. The cohorts, with subjects aged 37–73 years, were established from 2006 to 2010 across England, Scotland and Wales. At baseline (between 2006 and 2010), a detailed assessment of their characteristics and a completed cognitive testing were made. The participants were followed until 2014–2015. The study was approved by the North-West Multi-center Research Ethics Committee. The research was carried out in accordance with the Declaration of Helsinki of the World Medical Association, and participants gave informed consent. The data were anonymized and no additional ethical approval was required for the present analyses.Fluid intelligence (FI) is defined as the ability to reason and to solve new problems independently of previously acquired knowledge, and is related to working memory , attentiLong-term/recurrent use of antibiotics as child or teenager was recorded as “During childhood or as a teenager did you receive long-term or recurrent courses (3 or more per year) of antibiotics (for example for tonsillitis or acne)?” The above information was collected in 2017–2018.To control for confounding factors, we included the following baseline variables (2006–2010) as covariates in the analysis: age, sex, educational qualification, apoe4, ethnicity, income before tax, smoking status, alcohol status, Body Mass Index . History of hypertension was originated from the question: “Has a doctor ever told you that you have had any of the following conditions?” And answers were: 1. Heart attack, 2. Angina, 3. Stroke, 4. High blood pressure, −7. None of the above, −3. “Prefer not to answer.” History of diabetes was derived from the question “Has a doctor ever told you that you have diabetes?”Using the analysis of Chi-square tests or Fisher’s exact test, we compared the proportion of cognitive impairment by sociodemographic factors , and clinical conditions and medical histories . Using multivariate logistic regression models, we calculated adjusted odds ratios (ORs) and 95% confidence intervals (CIs) between LRUAC and non- LRUAC controlling for gender, age, qualification, apoe4, ethnicity, income level, smoking history, drinking history, BMI, history of hypertension, history of diabetes.P-values less than 0.05 were considered statistically significant. Missing data in covariates were imputed using multiple imputation method . Sensitivity analysis was performed based on the complete cases without multiple imputation for missing values in covariates. Analyses were conducted with RStudio .A total of 502,505 consecutive cases from UK Biobank were evaluated. 466,584 participants were excluded from the analysis because they had no cognitive assessment, they had cognitive impairment at baseline, they were lost to follow-up at the next wave or the antibiotic data were missing. After exclusions, a total of 35,921 participants without cognitive impairment remained in the study, which included 30,859 participants without long-term recurrent antibiotics as child or teenager. During an average 5.2 years’ follow-up , 741 (14.7%) participants with LRUAC and 4040 (13.1%) participants without LRUAC were identified cognitive impairment. p-value for interaction <0.05, We also evaluated the risk of cognitive impairment after LRUAC in each variable subgroup and found that the effect of long-term/recurrent use of antibiotics in childhood on cognitive impairment was homogeneous across different categories of subgroup variables such as sex, age, APOE4, ethnic groups, income before tax, smoking status, alcohol status, BMI, hypertension and diabetes but the effect of LRUAC was modified by higher qualification , history of hypertension, and history of diabetes.Antibiotics changed the world and saved the lives of many patients who would have died of infection . In factAlthough no direct clinical studies prove that antibiotics are associated with cognition impairment, there are several cohort studies reveal effects of antibiotics on central nervous system diseases. Antibiotic exposure in the first 2 years of life increase risk of attention-deficit/hyperactivity disorder (ADHD) with average 8.8 years follow-up . Even prThere are some animal studies exhibiting the effects of antibiotics on cognition and the mechanics in the brain. Lach’s study shows that microbiota depletion with antibiotic treatment during the adolescent period cause enduring neurobehavioral disfunction, with obvious change of gene expression in the amygdala . Study bHowever, controversial results have been obtained in some clinical and animal trials. Studies have shown that antibiotics also have beneficial effects on Alzheimer’s disease. Through the triple eradication of antibiotics  to eliminate Helicobacter pylori and other pathogens, the cognitive function parameters of patients with AD were positively improved . The posThe strengths of this study are the large sample size, the cohort study with long follow-up time, and the robust result for the effect of LRUAC on cognitive impairment. Also, the study has some limitations. Firstly, the records of LRUAC were collected during 2017–2018, which may be subject to recall bias. The cognition normal participants were more likely to recall they did not expose to LRUAC, which might exaggerate the effect of LRUAC. Secondly, the FI score was collected from different ways: basic collection in UK Biobank Assessment Centre during 2006–2010 and follow-up collection online remotely during 2014–2015, which would cause measurement bias toward the score. Lastly, this was an observational study and the observed results may still be subject to possible unobserved confounding factors.In this population-based retrospective cohort study, we observed the impact of the LRUAC on the development of the cognitive impairment. We hope that our results could provide useful clues for assessing the lifelong effects of inappropriate use of antibiotics.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.The studies involving human participants were reviewed and approved by the North-West Multi-center Research Ethics Committee. The patients/participants provided their written informed consent to participate in this study.ZLiu: full access to the UK Biobank data and statistical analysis. HZ and DW: concept and design. ZLiu, SW, XC, and LL: drafting of the manuscript. All authors acquisition, analysis, or interpretation of data and critical revision of the manuscript for important intellectual contentThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Background: Sudden infant death syndrome (SIDS) is the sudden, unexplained death of infants <1 year old. SIDS remains a leading cause of death in US infants. We aim to identify associations between SIDS and race/ethnicity, birth weight/gestational age, and socioeconomic/environmental factors in North Carolina (NC) to help identify infants at risk for SIDS.Methods and Results: In this IRB-approved study, infant mortality 2007–2016 and death certificate-linked natality 2007–2014 were obtained from the NC Department of Health and Human Services. General, NC natality statistics 2007–2016 were obtained from CDC Wonder. Association between SIDS/total infant death and covariates (below) were calculated. Total infant mortality decreased 2007–2016 by an average of 14 deaths/100,000 live births per year, while SIDS incidence remained constant. Risk ratios of SIDS/total infant deaths, standardized to Non-Hispanic White, were 1.76/2.41 for Non-Hispanic Black and 0.49/0.97 for Hispanic infants. Increased SIDS risk was significantly and independently associated with male infant sex, Non-Hispanic Black maternal race/ethnicity, young maternal age, low prenatal care, gestational age <39 weeks, birthweight <2500 g, low maternal education, and maternal tobacco use (p < 0.01). Maternal previous children now deceased also trended toward association with increased SIDS risk.Conclusions: A thorough SIDS risk assessment should include maternal, socioeconomic, and environmental risk factors as these are associated with SIDS in our population. Hispanic ethnicity is a protective factor.Sudden infant death syndrome, or SIDS, is the sudden unexplained death of an apparently healthy infant <1 year old with no clear cause of death after evaluation, traditional autopsy, and review of clinical history . SIDS reWhile total infant death has decreased across the United States, SIDS incidence has plateaued . This isIn this study, we evaluate a population-based cohort of deaths in North Carolina to identify associations between SIDS death and race/ethnicity, gestational age, birth weight, maternal level of education, tobacco use, and history of previous maternal child death (from any cause).This study was approved by the Duke University Health System Institutional Review Board. Infant mortality data were obtained from the North Carolina Department of Health and Human Services (NCDHHS). Data were abstracted from NC vital records from January 2007–July 2016. Data from 2016 were annualized in year-over-year analyses. The cohort of SIDS deaths had the following inclusion criteria: (1) NC death certificates from January 2007–July 2016, (2) age at death <1 year and not missing, and (3) underlying cause of death ICD10 code of R95 (“Sudden infant death syndrome”) or R99 . Exclusion criteria included patients missing birth or death certificates. Death certificates from the latter part of 2016 were not received from NCDHHS and thus were not included in analyses. Demographic data from death records were identified using maternal, self-identified race and ethnicity. Birth certificate data from all NC births 2007–2014 were also obtained from NCDHHS. Birth certificates 2015–2016 were not included in analyses due to lack of availability of this data to investigators. Though the temporal range of death certificates included exceeded that of the birth certificates, only incidence by race/ethnicity over time was analyzed on death certificates. SIDS death records were linked with corresponding birth certificates by sex, date of birth, and full name. Partial matches, defined as any birth and death certificate with matching sex, date of birth, and a full name off by a single letter, were all included in the data set. Death records missing a matched birth certificate were excluded from analyses of covariates of SIDS risk.NC natality statistics were obtained from the CDC Wonder database 2007–2016 . Births SIDS and total infant death incidences per 100,000 live births were calculated for race/ethnicity by year. As all data are from a complete population, inference testing was not performed. Change in incidence per year over the study period for SIDS and total infant death were calculated using a linear model. Mean differences between races/ethnicities by year over the study period for SIDS and total infant deaths, as well as related risk ratios were calculated. Risk ratios were standardized to Non-Hispanic White Incidence. Hispanic White and Hispanic Black are combined in the Hispanic group as >95% of all Hispanic births in the state of NC during the study period were Hispanic White.We selected potential covariates associated with SIDS risk from birth certificate data for analysis. This included sex of the baby, maternal race/ethnicity, maternal age at the time of birth , Kotelchuck prenatal care index (categorized by sufficiency), obstetrician estimate of gestational age <39 weeks (compared with ≥39 weeks), birthweight <2500 g (compared with ≥2500 g), maternal education of 0–8 years or 9–12 years (compared with any college), any tobacco use during or in the year prior to pregnancy (compared with no tobacco use), and mother with at least one previous birth now dead (compared with mothers with no previous births now dead). Our cutoffs of gestational age, birthweight, and prenatal care are based on the typical designation of a full-term vs. preterm, low- vs. normal-birthweight infants, and sufficient prenatal care respectively –17. DiviThe odds ratios of these covariates in SIDS infants vs. non-SIDS infants were calculated via univariate analysis and adjusted using a multivariable logistic regression model, including all mentioned covariates. All ORs were calculated for births 2007-−2014. All analyses were performed using RStudio V1.3 and SAS V9.4.To determine the relationship between race/ethnicity and the incidence of SIDS, we analyzed NC death records and natality data 2007–2016. A total of 1,170,505 babies were born to mothers residing in the state of NC over the study period. There were 8,691 total infant deaths and 1,209 SIDS deaths, comprising 14% of total infant deaths . A detaiTo determine the influence of race, ethnicity, and total infant death in SIDS, we first stratified population data by race and ethnicity. The overall incidence of total infant death was 763/100,000 live births with an average decrease of 14 deaths/100,000 live births per year  decreased with female sex (OR 0.80), non-Hispanic White or Hispanic race/ethnicity compared with non-Hispanic Black , maternal age of 25–29, 30–34, and ≥35 compared with ≤19 , Kotelchuck prenatal care index of intermediate, adequate, and adequate plus sufficiency , and increased with gestational age <39 weeks (OR 1.33), birthweight <2500 g (OR 1.72), maternal education of 0–8 years or 9–12 years , and any tobacco use during or in the three months prior to pregnancy relative to non-SIDS infants (OR 3.13). The odds of developing SIDS trended toward a decrease with maternal age 20–24 years compared with ≤19 years , or other race/ethnicity compared with Non-Hispanic Black , and an increase when infant's mother had at least one previous birth now dead . All adjusted ORs are summarized in To determine the relationship between SIDS incidence and covariates of sex of the baby, maternal race/ethnicity, maternal age at the time of birth, Kotelchuck prenatal care index, gestational age, birthweight, maternal education, tobacco use, and mother with at least one previous birth now dead, we performed a multivariable logistic regression comparing births resulting in a SIDS death vs. all other births, yielding adjusted odds ratios (ORs). A table of SIDS and non-SIDS infant proportions by covariate is included in In 1992, the American Academy of Pediatrics debuted the Back to Sleep Campaign recommending that babies be put to sleep in the non-prone position, which led to a decrease in total SIDS deaths by 40%. Unfortunately, in the past two decades, there has been a stable number of SIDS deaths in the United States , 18. We Other studies have attempted to explain the racial disparity in SIDS. For example, it has been described that racial discrimination affecting Black women is a risk factor for poor pregnancy outcomes, which seems to be related to chronic stress leading to enhanced inflammatory response, compromised fetal development and adverse pregnancy outcomes , 23. ExaWhile we did not directly examine the pathways underlying biological or environmental associations with SIDS, we can generate hypotheses for explanatory mechanisms for directly analyzed covariates based on previous literature. Explanations for the association between prematurity and/or low birthweight and SIDS relate to problems of underdevelopment of respiratory control. For example, a 1998 study proposed a link between lung underdevelopment, known as apnea of prematurity, and SIDS . FurtherOne potential factor influencing SIDS risk that we did not directly measure due to data constraint is insurance status, as this influences access to healthcare and health education resources and has been associated with many health outcomes. Mothers in NC, along with newborn infants, have a mix of insurance types, private and public. In NC, all infants born to mothers with Medicaid are automatically guaranteed enrollment in Medicaid until they turn 1 year of age. Medicaid is also available to qualifying mothers while pregnant and for 60 days post-partum . Of noteAs we have observed, SIDS is multifactorial and complex. Improved understanding of risk factors and health disparities can improve our care for these populations and, hopefully, lead to a decrease in SIDS.This study is retrospective and observational in nature. Additionally, not all birth certificates were available for the entire SIDS death population, and birth certificates were not available to us after 2014, meaning that the cohort for racial/ethnic associations was somewhat different from that involved in calculation of other variable associations.In our study of NC deaths 2007–2016, we find that the incidence of total infant death has decreased over time while SIDS incidence has remained constant, with a higher SIDS risk in Non-Hispanic Black infants, and a lower SIDS risk in Hispanic infants compared to Non-Hispanic White infants. Additional observed variables associated with SIDS include male sex, low prenatal care, prematurity, low birthweight, low maternal education, maternal smoking, and having a previous child die. The considerable differences in SIDS incidence related to biological and environmental conditions highlight the need for SIDS risk assessment, along with a concentration of effort into reducing health disparities in pregnancy and early life.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Duke University Health System Institutional Review Board. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements. Written informed consent was not obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.This manuscript was previously presented as a poster at the Duke University School of Medicine Department of Pediatrics Retreat and the American Academy of Pediatrics Conference 2021.MY, MR, CO, MM, JL, and AL: planned the study, interpreted the findings, drafted the manuscript and/or revised the manuscript. NF: provided data. KC, AD'O, and TS: provided data support, analysis, and statistical analysis. JL and AL: provided study oversight. All authors contributed to the article and approved the submitted version.This study received funding from Pfizer Foundation grant (MR training fellowship) and the Duke Clinical Translational Science Institute (MR training fellowship). These funders were not involved in the study design, collection, analysis, interpretation of data, and the writing of the article or the decision to submit for publications. This study also received funding from the Centers for Disease Control and Prevention (NU50DD004933-03-00). JL is supported by grants from NCATS, CDC, and AHA. AL is supported by grants from the NIH, CDC, American Sudden Infant Death Syndrome Institute, and the Duke Children's Health and Discovery Initiative.MR received a consulting fee from Nabla Bio for an unrelated project. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


N = 64), an investigator-initiated registration-directed clinical trial at three hospitals (N = 142), and an exploratory clinical trial examining different stimulation parameters (N = 22). The primary efficacy endpoint  was extracted for each patient group with pain in the face, upper limb, or lower limb, and a meta-analysis of the efficacy of active rTMS against sham stimulation was performed. Standardized mean difference (SMD) with 95% confidence interval (CI) was calculated for pain change using a random-effects model. The analgesic effect of rTMS for upper limb pain was favorable . In contrast, rTMS did not produce significant pain relief on lower limb pain  or face . In conclusion, these findings suggest that rTMS provides analgesic effects in patients with neuropathic pain in the upper limb, but not in the lower limb or face, under the conditions of previous clinical trials. Owing to the main limitation of small number of studies included, many aspects should be clarified by further research and high-quality studies in these patients.High-frequency repetitive transcranial magnetic stimulation (rTMS) of the primary motor cortex for neuropathic pain has been shown to be effective, according to systematic reviews and therapeutic guidelines. However, our large, rigorous, investigator-initiated, registration-directed clinical trial failed to show a positive primary outcome, and its subgroup analysis suggested that the analgesic effect varied according to the site of pain. The aim of this study was to investigate the differences in analgesic effects of rTMS for neuropathic pain between different pain sites by reviewing our previous clinical trials. We included three clinical trials in this mini meta-analysis: a multicenter randomized controlled trial at seven hospitals ( In some systematic reviews and therapeutic guidelines, high-frequency rTMS of the M1 for neuropathic pain has been shown to be effective . MoreoveP-value) is clearly provided, but the amount or rate of the decrease in pain intensity is not, and there is a lack of data available for meta-analysis by pain site. Therefore, we defined this study as a mini meta-analysis, because only our previous trials were extracted and analyzed. We extracted randomized controlled trials (RCTs) of rTMS using the figure-of-8 coil for neuropathic pain, conducted at Osaka University Hospital as the main study institution, because this was the first attempt to review the analgesic effects at different pain sites. We included three of our previous clinical trials in this meta-analysis . Standardized mean difference (SMD) with 95% confidence interval (CI) was calculated for pain change using a random-effects model. This analysis was performed using the Cochrane Collaboration’s software program Review Manager (RevMan) version 5.4.1. software .Changes in pain scale  were extracted as a primary efficacy endpoint from each trial, and a mini meta-analysis of the efficacy of active rTMS against sham stimulation was performed. Next, the efficacy of rTMS was analyzed for each patient group with pain in the face and upper or lower limbs. The chi-squared test and IThe relationship between resting motor threshold (RMT) and pain site was examined in an investigator-initiated registration-directed clinical trial , in whicn = 15; lower limb pain, n = 8; facial pain, n = 5). The etiologies of neuropathic pain were as follows: cerebral lesion in 21 patients, spinal lesion in 4, peripheral nerve injury in 1, phantom limb in 1, and root avulsion in 1 patient. In group B of n = 20; lower limb pain, n = 14; facial pain, n = 1). The etiologies of neuropathic pain were as follows: cerebral lesion, 30 patients; spinal lesion, 3 patients; and phantom limb, 2 patients. In n = 67; lower limb pain, n = 59; facial pain, n = 16). The etiologies of neuropathic pain were as follows: cerebral lesion, 54 patients; postherpetic neuralgia, 12 patients; spinal lesion, 9 patients; root avulsion, 9 patients; complex regional pain syndrome, 4 patients; phantom limb, 2 patients; and other lesions, 52 patients. In n = 10; lower limb pain, n = 10; facial pain, n = 2). The etiologies of neuropathic pain were as follows: cerebral lesion in 15 patients, complex regional pain syndrome in 3, peripheral nerve injury in 2, spinal lesion in 1, and root avulsion in 1 patient.A total of 228 patients from three clinical trials were included in the analysis . In grouP = 0.06, I2 = 59%), and the analysis of the pooled analgesic outcome showed that the effect size was not statistically significant −0.33 . In the analysis of the group of upper limb pain, heterogeneity was low , and the analysis of the pooled analgesic outcome showed a significant effect size of −0.45   and moderate , respectively. The effect size for pain change was 0.04  for lower limb pain and −0.24  for facial pain ( < 0.01) . This suial pain , 4. rTMSP < 0.01) (According to  < 0.01) .This study investigated the differences in analgesic effects of rTMS over the M1 using a figure-of-8 coil for neuropathic pain between pain sites. The findings from the three extracted clinical trials showed that rTMS for patients with neuropathic pain in the upper limb was particularly effective. Meanwhile, rTMS for patients with neuropathic pain in the lower limb and face was not confirmed to be effective.N = 226) had a different effect on pain relief at the pain site. There have been many studies on the pain relief effects of rTMS for neuropathic pain, but to the best of our knowledge, there are few reports on the differences in pain relief effects by pain site  (N = 14) than in upper and lower limb pain  (N = 249) was −0.38 (−0.49 to −0.27), and that for the whole population in this study was −0.33 (−0.70 to 0.04). Furthermore, the SMD (95% CI) for upper limbs pain in this study was −0.45 (−0.77 to −0.13). The SMDs (95% CI) of the two meta-analyses did not seem to be significantly different. Therefore, the results of the current study suggest that rTMS is clearly effective for upper limb pain and less effective for lower limb pain, as far as our previous studies are concerned.Our main finding showed that high-frequency rTMS treatment using a figure-of-8 coil for neuropathic pain (ain site . Ayache ctively) . Lefauchctively) . The parctively) , 2020 waWe need to consider the factors that contribute to the difference in pain relief effects of rTMS for upper and lower limb pain. First, we showed that the RMT of the hand was clearly lower than that of the lower limb . PreviouIn this meta-analysis, we focused on differences in the analgesic effects of rTMS over M1 at different pain sites. To date, some RCTs have been conducted in many centers to investigate various conditions. For example, trials have examined the pain-relieving effects of rTMS at different frequencies, different stimulation sites, and in single or multiple sessions, as well as trials examining the efficacy of rTMS for various neuropathic pain conditions, such as spinal cord injury , phantomN = 16) because the number of patients was too small compared to the analysis of upper limb pain (N = 76) and lower limb pain (N = 65). Because this study has been analyzed with a small number of patients, with only our previously generated results, it is necessary to take sufficient care while interpreting these results.Our study has a few limitations. First, the main limitation of this study is the small sample size and the small number of studies included, which made the sensitivity analyses difficult. Second, as a methodological consideration of this analysis, the procedure of meta-analysis must be considered. Although a meta-analysis should be conducted according to a predetermined procedure , we extrIn conclusion, this study suggests differences in the analgesic effects of high-frequency rTMS over the M1 using the figure-of-8 coil for neuropathic pain between pain sites. More importantly, rTMS for upper limb pain was clearly effective in relieving pain. Meanwhile, rTMS for lower limb pain and facial pain did not produce an analgesic effect under the conditions of previous clinical trials. However, considering the small number of included studies, our findings should be considered tentative.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Ethics Committee of Osaka University Hospital. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.KH and NM contributed to trial design and conducted experiments and data collection. YS, SO, and HK supervised the study. All authors contributed to the data interpretation. NM drafted the manuscript. KH edited the manuscript. NM and KH conducted statistical analyses. All authors reviewed and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The turnover intention of healthcare workers is a threat to the competence of health services, especially during COVID-19 time. This study aimed to investigate the association between stress and turnover intention among healthcare workers in Saudi Arabia and whether social support could affect this association. In this cross-sectional study, healthcare workers in primary healthcare centers in Saudi Arabia responded to an online questionnaire assessing their sociodemographic and occupational history, stress levels using the Perceived Stress Scale-10 (PSS-10), social support using the Multidimensional Scale of Perceived Social Support (MSPSS), and turnover intention within the next few months. Path analysis was conducted to assess the mediating effect of social support on the association between stress and turnover intention. A total of 1101 healthcare workers  participated in this study. The path between stress and support had a significant standardized regression weight . The path between support and turnover had a significant standardized regression weight . The standardized total effect of stress on turnover without the impact of support was significant . The direct effect of stress on turnover with the presence of support was significant . The indirect effect of stress on turnover with the presence of support was significant . Thus, there is evidence to show that support mediates the relationship between stress and support. Stress is associated with turnover intention among healthcare workers in Saudi Arabia. Social support had a mitigating effect on the relationship between stress and turnover intention. The World Health Organization declared coronavirus disease-19 (COVID-19) a pandemic. The pandemic has affected more than 100 countries since it started –6.Studies have shown that healthcare workers managing COVID-19 have been experiencing worse psychological issues such as stress than the public because they are more likely to get infected and transmit the infection to their relatives and friends –9. One oA few studies conducted during the COVID-19 pandemic have indicated high turnover intention among healthcare workers, yet none of them studied the possible role of stress in enhancing turnover intention. One study conducted on 261 nurses in the Philippines revealed that the fear of COVID-19 was associated with job dissatisfaction and increased turnover intention . In EgypA similar study conducted on 117 nurses managing patients with COVID‐19 in Pakistan displayed that anxiety and the perceived threat of COVID-19 resulted in nurses’ turnover intention . AnotherRecent studies have demonstrated several associations between the pandemic and stress among healthcare workers managing COVID-19. Social support was the major contributor to stress levels among healthcare workers in Egypt and Saudi Arabia during the COVID-19 . AnotherIndeed, the pandemic was inversely associated with stress among healthcare workers , 15, 16.Because of the social distancing measures in Saudi Arabia, this cross-sectional study was conducted using an online questionnaire. The study population included healthcare workers aged 18 years or more and working at different primary healthcare centers in Saudi Arabia. The term healthcare workers included physicians, nurses, paramedics, and administrative workers.To access a representative sample of healthcare workers, Saudi Arabia was divided geographically into five regions: Northern, Western, Southern, Eastern, and Central regions. The Saudi Ministry of Health is represented in the five regions. It is composed of health directorates, and each health directorate supervises a number of primary healthcare centers within its geographical region. In this study, six primary healthcare centers were randomly selected from every health directorate. Then, e-mails including links to the online questionnaire were sent to all healthcare workers in the selected primary healthcare centers on September 27, 2020, before reminders were sent a week later. A time span of three weeks was given to healthcare workers to complete their questionnaires, and the response rate was 73.4%.The least sample size was estimated using the Epi- Info version 7 StatCalc designed by the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO). In order to enhance statistical power and avoid an unpredicted low response rate, the least required sample size was more than doubled. Eventually, 1500 Healthcare workers were invited to participate in this study. Also, G*Power software, version 3.1.9.7, was used to calculate the power of this study, and this sample size (1101) has around 99% power (1-Beta error) at an alpha of 0.05, with two predictors and one criterion, to detect even a small effect size of 0.02 . Linear The online questionnaire was composed of four sections. The first section showed in detail the steps and aims of the study and ended with a question asking the respondents whether they agreed to participate. The second section included questions about participants’ age (years), sex , marital status (married or unmarried), citizenship (Saudi or non-Saudi), educational level (university degree and higher or high school level), smoking history (current smoker or non-current smoker), working hours per day and working days, and job title . The third section included two scales; the Arabic versions of the Perceived Stress Scale-10 (PSS-10) and the Multidimensional Scale of Perceived Social Support (MSPSS).PSS-10 is a reliable and valid scale to assess perceived global stress. This scale is composed of ten statements. Respondents have to express how much they agree with these statements on a Likert scale from zero (never) to four (very often), with higher scores indicating higher stress levels , 20. TheMSPSS a valid tool was to assess perceived social support from the following support resources, family, friends, and others. The scale is composed of seven statements, and respondents select a choice on a Likert scale ranging between one (very strongly disagree) and seven (very strongly agree), with higher scores indicating higher social support levels . This stThe Central Institutional Review Board of the Ministry of Health in Saudi Arabia approved the study protocol. All participating Healthcare workers were asked to select "accept to participate" on the first page and "submit answers" on the last page of the online questionnaire. The study was performed per the principles of the Declaration of Helsinki.The Statistical Package for Social Science (SPSS) version 23 was used for analysis, including AMOS. Descriptive analysis, including mean, standard deviation, frequencies, and percentage, was used to describe the study sample. Also, a chi-square test between the turnover and the demographic variables was used in order to advance understanding of the sample. The included variables in the chi-square test were age, sex, marital status, smoking, education, nationality, and job. Finally, path analysis using AMOS was conducted in order to evaluate how social support mediate the relationship between stress and turnover among the study sample.According to The result of chi-square test of independence showed that there was no significant association between turnover and the following variables: age, nationality, marital status, education level, and smoke.A chi-square test of independence showed that there was a significant association between gender and turnover, X2 = 10.89, p < .01. Of the male participants, 173 (28.0%) were wanting to leave the work, and 444 (72.0%) were not wanting to leave the work. Of the female participants, 181 (37.4%) were wanting to leave the work, and 303 (62.6%) were not wanting to leave the work .A chi-square test of independence showed that there was a significant association between job type and turnover, X2 = 17.64, p < .01. Of the physicians, 84 (34.7%) were wanting to leave the work, and 158 (65.3%) were not wanting to leave the work. Of the nurses, 134 (39.4%) were wanting to leave the work, and 206 (60.6%) were not wanting to leave the work. Of the paramedical staff, 84 (27.1%) were wanting to leave the work, and 226 (72.9%) were not wanting to leave the work. Of the administrative staff, 52 (24.9%) were wanting to leave the work, and 157 (75.1%) were not wanting to leave the work .A path analysis was run to look at the mediating effect of support on the relationship between stress and turnover. The path between stress and support had a significant standardized regression weight . The path between support and turnover had a significant standardized regression weight . The standardized total effect of stress on turnover without the impact of support was significant . The direct effect of stress on the turnover with support was significant . The indirect effect of stress on the turnover with support was significant . Thus, there is evidence to show that support mediates the relationship between stress and support .Stress level was found high among the healthcare workers in the primary health care centers. This result is supported by a systematic review study that found stress is a common problem among healthcare workers . Also, aThis study had several strengths. First, it is the first study, to the best of my knowledge, to assess the relationship between stress and turnover among healthcare workers in Saudi Arabia during the COVID-19 pandemic. Secondly, the study used a multi-stage random sampling approach to recruit a large cohort of healthcare workers in primary healthcare centers in Saudi Arabia. Thirdly, this research employed validated scales to assess stress and other covariates. Fourth, the results were controlled for several sociodemographic and potential occupational confounders.This study had several limitations. First, the cross-sectional design of this study did not imply causality. Second, due to the social distancing regulations related to the COVID-19 pandemic, healthcare workers were recruited by e-mails, and online surveys collected data. Online surveys, in general, are vulnerable to non-response bias since non-respondents might carry different sociodemographic and occupational characteristics compared to respondents , 23. ThiIn conclusion, this study indicated that high stress among healthcare workers in Saudi Arabia might be associated with increased turnover intention during the COVID-19 pandemic. However, social support can mediate the association and weaken the impact of stress on turnover intention. Different types of support can be used to reduce psychological stress and consequently decrease turnover intention. As a result, the health care workers should be provided with the available resources in the community which can satisfy their needs. Social support can be used as a coping strategy to reduce stress, as supported by psychological stress theory  which caS1 File(PDF)Click here for additional data file.S1 Data(SAV)Click here for additional data file.


Background and Objectives: Considering atherosclerosis as one of the more challenging threats to healthcare worldwide, any novel therapy that counteracts the risks for developing it, provides new opportunities for the management of this process. Material and methods: We performed an experimental research in which we induced a hypercholesterolemia via a cholesterol-rich diet. Our aim was to demonstrate the antiatherogenic potential of two essential amino acids . The experimental study was carried out over a period of 60 days. Male Wistar rats weighing between 250–280 g were used and divided into 4 groups, each group including 8 animals. Group I—control was fed with a standard diet. Group II received cholesterol, group III cholesterol and valine and group IV cholesterol and leucine. Blood samples were collected from the retro-orbital plexus, under anesthesia with 75 mg/kg of intraperitoneal ketamine, in three different moments  in order to measure the levels of triglycerides. Results: In R0, there were no significant differences between the average levels of triglycerides across all the groups (p < 0.05). Compared to the group I, in R1 and R2, the average levels of triglycerides were significantly higher in all groups (p < 0.001). Also, in R1 and R2, the average triglycerides in group II receiving cholesterol (C) were significantly higher than those in group III receiving valine (C + V) as well as in group IV receiving leucine (C + L) . In R2, the average triglycerides in group III were significantly lower than in group IV (p < 0.001). Conclusions: Our data provides evidence that valine and leucine have a direct impact on the lipid metabolism parameters by lowering the level of triglycerides. The comparison of the two essential amino acids indicates that valine acts more promptly and rapidly than leucine. Atherosclerotic cardiovascular disease represents nowadays a leading cause of death worldwide ,2. SurveRecent epidemiological data support the idea that hypertriglyceridemia is a prevalent risk factor for cardiovascular diseases, and plays an important role in the pathogenesis of atherosclerosis. Consequently, current perspectives of how dyslipidemia is treated should be renewed to also target the normalization of triglyceride levels . Upon coThe fact that triglycerides stimulate the production of inflammatory cytokines, of fibrinogen, and coagulation factors, thus affecting fibrinolysis, is another confirmation of its role in the atherosclerotic process . The invIn previous studies, we investigated the anti-atherogenic potential of valine and leucine, two non-polar amino acids, in the context of hypercholesterolemia induced by a cholesterol-rich diet, and we followed their effects on lipid metabolism -cholesterol, LDL-cholesterol) and oxidative stress parameters ,14,15,16In this paper, we focus on our results regarding the study of triglycerides levels, agreeing that hypertriglyceridemia could become an important therapeutic target in the management of atherosclerosis.The experimental study carried out over a period of 60 days. Male Wistar rats weighing 250–280 g were obtained from the animal farm of the “Grigore T. Popa” University of Medicine and Pharmacy, Iași. All animal protocols were carried out in accordance with the instructions of the Guide regarding animal care and scientific use, in strict accordance to international ethical regulations ,18.n = 8): Fed with a regular diet composed of agricultural byproducts.Control group I (n = 8): Received regular diet supplemented with 0.4 g/kg/day cholesterol.Group II—C (n = 8): Received regular diet supplemented with 0.4 g/kg/day cholesterol and 62.5 mg/kg/day valine powder for animal nutrition.Group III—C + V (n = 8): Received regular diet supplemented with 0.4 g/kg/day cholesterol and 69.985 mg/kg/day leucine powder for animal nutrition.Group IV—C + L  Guide for the Care and the Use of Laboratory Animals. Prior to the beginning of the study, the protocol received ethical approval from the ethics committee of the University of Medicine and Pharmacy “Grigore T. Popa”, Iaşi, Ethics Committee approval number 15186/2008.The data were centralized in Excel and SPSS databases and processed with their respective suitable statistical. Statistical confidence intervals with a 95% significance level were used. In order to evaluate the statistically significance between our groups we used ANOVA test (including repeated measures ANOVA). The threshold for statistical significance is the maximum level of probability which affords an error. A significance level of 0.05% points to sufficient precision in practice, and 95% probability indicates reliability.For each group, triglycerides were measured in R0, R1 and R2. The highest individual levels of triglycerides were found in group II corresponding to the rats who received cholesterol only .N = 32)  was conducted to evaluate the null hypothesis that there is no change in the triglycerides values in different subgroups measured in R0, R1 and R2 (N = 32) . The resp < 0.01. There was a significant increase of values over time . Compared to the control group, the average levels of triglycerides were significantly higher in all groups in R1 and R2 (p < 0.001).In R0, there were no significant differences between the average levels of triglycerides in groups II, III and IV and neither between these and the control group .Also, in R1 and R2 measurements, the average triglycerides in group II receiving cholesterol only (C) were significantly higher than those in group III receiving valine (C + V) as well as in group IV receiving leucine (C + L) (p < 0.001) (At the end of the experiment (R2), the average triglycerides in group III were significantly lower than in the case of rats who received leucine (< 0.001) .p < 0.001) [As described before, in previous studies, we evaluated the anti-atherogenic potential of valine and leucine in the context of hypercholesterolemia induced by a cholesterol-rich diet, following their effects on lipid metabolism  and oxidative stress parameters ,14,15,16According to our results, the two amino acids proved their antioxidant abilities, which could improve the endothelial damage related to atherosclerosis .The literature mentions that the appearance of atheroma plaque in the vessel’s intima in rats subjected to a hypercholesterolemic diet occurs in approximately 8 months. In our study, we did not obtain atherosclerotic plaques because the length of the experiment was 60 days, which is not long enough to produce severe lesions. Instead, at the biochemical level, we found changes in the parameters of lipid metabolism and oxidative stress that characterize atherosclerosis in the pre-lesional phases. In addition, according to our results, valine and leucine added to this diet have a direct influence on the lipid metabolism parameters by lowering the level of triglycerides, total cholesterol and LDL-cholesterol. Comparing the two essential amino acids, we noted that valine acts more promptly and rapidly than leucine. Therefore, we assume a possible hypolipemiant action and a consequently anti-atherogenic action of the two compounds.Triglycerides are present in the lipoprotein particles known as chylomicrons, which contain the largest amount of lipids absorbed in the intestines as well as in the very-low-density lipoproteins (VLDL) containing triglycerides synthesized in the liver. An increased amount of any of these two leads to elevated levels of serum triglycerides and to hypertriglyceridemia as a clinical condition, which is a heterogeneous ensemble of features, each of them contributing to a certain degree in the increase of the total cardiovascular risk .In the present experimental model, we aimed to study the antiatherogenic potential of 2 amino acids , based on the physiopathological mechanisms of atherosclerosis, in conditions of induced hypercholesterolemia via a cholesterol-rich diet. We analyzed many animal models discussed in the literature  and we cAmino acids are essential precursors for the synthesis of numerous molecules playing a major role in homeostasis ,24. LeucIn a study performed in 2018, we assessed the role of valine, leucine and isoleucine on the occurrence and progression of atherosclerosis in rats receiving hypercholesterolic diet. The comparative study of the three essential amino acids revealed that valine induced a faster response than leucine and isoleucine on the improvement of biochemical parameters, but no significant differences between the three amino acids in terms of their protective ability, according to the histopathological lesion assessment . Still, In the last years, numerous theories have been issued with regard to the role of essential amino acids in the modulation of atherosclerotic pathophysiology. However, the exact impact and timing of these amino acids intervention are not fully elucidated, as research has so far yielded contradictory results .At present, researchers are engaged in a discussion about both, a possible proatherogenic effect and a potential antiatherogenic role of branched-chain amino acids .Unlike our results, Bhattacharya et al. presented the idea in 2013 that branched-chain amino acids are responsible for increasing cardiovascular-related mortality, being associated with extreme forms of ischemic heart disease. They were able to demonstrate that the relationship is there even after the more traditionally accepted risk factors, such as diabetes mellitus or insulin resistance have been corrected .In a study from 2016, Ruiz-Canela hypothesized that elevated serum levels of branched-chain amino acids as valine, leucine and isoleucine correlate with increased global cardiovascular risk which may not be altered by dieting . In addiBased on the results of a prospective cohort study over a period of 18.6 years, Tobias et al., were able to conclude that the connection between branched-chain amino acids and cardiovascular disease is similar to the causal relationship between plasma levels of LDL cholesterol and cardiac mortality .On the other hand, numerous published studies support the beneficial effects of branched-chain amino acids in regulating lipid metabolism and functional cardiac parameters.Similar to our results, Noguchi et al. in 2006, highlighted the role that valine and leucine play in counteracting the impact of abnormal lipid concentration, directly involved in the production of atherosclerotic lesions .Terakura et al. demonstrated that supplementing the diet with branched-chain amino acids decreases the hepatic triglycerides accumulation and the chronic inflammatory process associated with obesity, most likely by inhibiting interleukin-6 (IL-6), Tumour Necrosis Factor-alpha  and monocyte chemoattractant protein-1 (MCP-1) expression. Also, in mice fed with branched-chain amino acids, their average adiposity was lower, probably mediated by peroxisome proliferator-activated receptor gamma (PPAR-gamma) .In 2012, Chen et al. shared their results regarding the influence of leucine on body weight and blood lipids. They witnessed a regulation of carbohydrate and lipid metabolism regardless of how the amino acid was administered  .Pedroso et al. showed that in rats with metabolic syndrome, restricting their caloric intake concurrent with adding leucine to their diet facilitates an improved protein anabolism, as well as an increase in the levels of leptin and IL-6. The study drew attention to the fact that supplementing the diet with branched-chain amino acids modifies the hepatic metabolism by influencing the metabolism of fatty acids and cholesterol .Another study confirming the role of leucine in lowering the levels of triglycerides and LDL and in raising HDL-cholesterol in diabetic rats to which food was supplemented with this amino acid was published by Sadri in 2017 . HoweverTherefore, research results are contradictory and different views are being presented. Some point to the effects of branched-chain amino acids with regard to an increasing in the global cardiovascular risk, while numerous studies highlight the benefits of supplementing the diet with leucine, valine and isoleucine in order to lower the lipid metabolism parameters. Our study evidently supports the latter by showing that leucine and valine lower the level of plasma triglycerides, thus having a positive effect on lipid balance and, consequently, on the integrity of the vascular wall.By comparing the measured triglyceride values across different groups according to the experimental design, the biochemical analysis revealed the fact that essential amino acids such as valine and leucine lower the level of triglyceride. Consequently, the vascular endothelium is protected and the risk of endothelial dysfunction diminished.The comparison of the two essential amino acids indicated that valine acts more promptly and rapidly than leucine. The results of this experiment support the idea that valine and leucine play a distinct and specific role in the evolution of induced atherosclerosis. How these two amino acids behave affords several subsequent research avenues in terms of therapeutic goals, and our study is an attempt to highlight a potential novel therapeutic strategy.


Until recently, many countries’ policies were motivated by economic growth; however, few strategies were developed to prevent environmental deterioration including reducing the ecological footprint. In this context, the purpose of this study was to analyze the role of natural resource rents, technological innovation, and financial development on the ecological footprint in 90 Belt and Road Initiative (BRI) economies. This research divided the BRI economies into high income, middle-income, and low-income levels to capture income differences. This research used the second-generation panel unit root, cointegration, and augmented mean group estimators to calculate the robust and reliable outcomes. Based on the annual data from 1991 to 2018, the findings show that natural resource rents drastically damage the quality of the environment, whereas technological innovations are helpful in reducing ecological footprint. Moreover, the outcome of the interaction term  negatively impacts the ecological footprint. Interestingly, these findings were similar in the three income groups. In addition, financial development improved environmental quality in the middle-income BRI economies, but reduced it in high-income, low-income, and full sample countries. Furthermore, the Environmental Kuznets Curve (EKC) concept has been validated across all BRI economies. Policymakers in BRI countries should move resources away from resource-rich sectors of industries/manufacturing sectors to enhance/promote economic growth and use these NRRs efficiently for a progressive, sustainable environment. Based on these findings, several efficient policy suggestions are proposed. However, this indicator has been criticized by several scholars as CO2 emissions are accountable for a minor portion of the whole environment and do not fully encapsulate environmental pollution. Nathaniel and Khan [2 emissions do not anticipate the stocks of resources . Therefore, it is necessary to use an inclusive proxy for environmental sustainability that removes the limitation links with CO2 emissions and offer suitable insights to policymakers/regular authorities related to the environmental quality. For this situation, the ecological footprint (EF) is a widely recognized proxy for environmental quality that can manage and assess NRRs [In recent years, environmental conditions such as pollution, substandard sanitation, and significant loss of natural resource rents (NRRs) and forest reserves have been key concerns for many countries. Meager environmental conditions jeopardize human health and economic well-being. These elements are vulnerable to climate change including health, natural and physical capital, and access to water, food, and land . These eand Khan  claim thess NRRs . Hence, ess NRRs ,5,6,7.The NRR has an essential element of the global economy, specifically most of the BRI economies that depend on extricating them for a significant portion of their economic growth . The NRRFurthermore, the state of the financial system within an economy is also asserted as a major contributor to its environmental well-being. Usually, although likely to boost economic growth, an underdeveloped financial system could be harmful to the quality of the environment. For example, the less-developed financial systems within the BRI countries can be expected to provide finance for pollution-intensive industries whereby the borrowed funds can be invested in environmentally unfriendly production processes. Consequently, the prospect of achieving environmental sustainability can be largely compromised. Conversely, a developed financial system could be beneficial for extending green finance, which can provide credit to firms keen to invest in energy-efficient production processes ,18. Furt2 emissions and a 2 °C increase in global temperature (excluding China). Therefore, assuming development proceeds as projected, CO2 emissions will increase by 66% until 2050 [There are several compelling reasons why we chose to undertake this study in BRI economies. From the start of the BRI in 2013 through to the end of 2019, China invested USD 760 billion, with 39 percent going into the energy industry, roughly 26 percent going into transportation, and 7 percent to metals . In termtil 2050 . Becausetil 2050 . All thetil 2050 . The gretil 2050 . This juThis work contributes to the current literature in the following ways. First, this research examines the effect of NRR, FD, and TI on the EF from 1991–2018 for 90 BRI countries. Furthermore, this study divided the BRI countries into three income levels  to examine the influence of these potential indicators on EF to assess potential disparity in the association between NRR extraction and EF due to their income differences. Second, the present study used the moderating effect of NRR with TI in reducing the EF. It would be helpful to examine whether NRR indicated with TI reduces the overall level of EF in the BRI countries. This moderating effect may help to improve NRR efficiency through TI . Third, The rest of the paper is structured as follows. Global warming and climate change as well as increased awareness of these problems have increased the importance of understanding environmental quality and its elements. We divided the literature into four sections to elaborate on the relationships between the study’s variables and EF. The first section describes the nexus between NRR-environment; the second section addresses TI-environment; the third section discusses FD-environment; and the fourth section elaborates the relationship between economic growth and environment.Recently, environmental sustainability and NRRs have received more attention among policymakers and researchers. For example, Ahmad et al.  analyzedBalsalobre-Lorente et al.  analyzedH1. NRR has an ambiguous effect on the EF in BRI economies.According to endogenous growth theory, research and development (R&D) expenditures can boost economic productivity and NRR utilization, however, the involvement of TI in environmental sustainability, especially EF, is uncertain . Chen anLikewise, Ke et al.  studied H2. TI has a negative effect on EF in BRI economies.The existing literature has documented mixed environmental impacts associated with FD. Among the studies that have claimed FD to be detrimental to environmental well-being, Yasin et al.  concludeH3. The effect of FD on EF is ambiguous in BRI economies.Since the pioneering work of Grossman and Krueger , investiH4. There is an inverted U-shape relationship between economic growth and EF in BRI economies.Therefore, after summarizing the relevant studies in the existing literature, the following gaps in the empirical literature can be identified: (a) it is clear that not many research articles have applied the EF for environmental quality assessment purposes in the context of large samples of BRI economies; (b) the literature concerning panel studies on the TI–EF nexus in the context of BRI economies is limited as the existing studies are mostly country-specific or have used short panels; (c) the previous studies have primarily discovered the individual (isolated) impacts of NRR, and TI on EF, while the joint (interactive) impacts of these variables have not been analyzed much in the previous studies; and (d) it is evident that the existing studies have conventionally used panel data estimators. Against this milieu, this study aims to bridge these above-mentioned gaps in the literature using longitudinal/panel data from 1991 to 2018 of 90 BRI economies.From a theoretical perspective, we looked at the association between NRR, TI, FD, and the EF on the treadmill production theory, endogenous growth theory, and ecological modernization theory. The treadmill theory of the product claims that environmental pollution directly affects NRR and economic growth . EndogenThe EKC hypothesis is widely employed in the existing literature to examine environmental sustainability due to economic growth. It is assumed that the three different channels of GDP growth that affect environmental sustainability are scale effect, composition effect, and technique effect . Accordi2) to test the EKC hypothesis’s validity. The EKC hypothesis in its extended form is presented as follows.The variables in the research were transformed into a natural logarithm. Following the pioneer study, Manning  recommenIn Equation (2), EF indicates the total ecological footprint, NRR denotes natural resource rents, TI presents the technological innovation, FD demonstrates the financial development, GDP displays the economic growth per capita; and i and t signify the 90 BRI economies and given time dimension (1991–2018), respectively. Therefore, this study aims that NRR, and, aside from its direct influence, TI may play a moderating role on the EF in 90 BRI economies. Thus, this study explored the moderation effects between NRR and TI by focusing on this problem. Therefore, in Equation (3), we included a moderation effect term, which is written as follows:This study explored the long-run association among NRR, TI, FD, and EF in 90 BRI economies using longitudinal data from 1991 to 2018. The name of the sample economies is provided in the This study adopted the following advanced econometrics methods: (i) We confirmed the cross-sectional dependence (CD) by employing the Pesaran CD method; (ii) augmented cross-sectional IPS (CIPS) panel unit root methods were employed to verify the stationary level of candidate variables; (iii) the study used the Westerlund cointegration method for the detection of log-run relationships among variables; and (iv) this research applied the AMG to examine the long-run elasticities of the variables.The possible CD occurs due to externalities, geographical and financial globalization, spatial effects, economic integration, and individual-specific effects ,62,63,64After evaluating the CD, the next step is to look at the slope homogeneity between the cross-sections. The issue of heterogeneity is critical due to differences in the BRI countries’ demographic and economic structures. The consistency of panel estimators may be affected by variation in slope parameters. Because of this, this study employed the slope homogeneity approach proposed by Pesaran and Yamagata . The tesThe next phase in the econometric approach is to check the stationary/integration level of all involved variables after testing the CD of data. The first-generation unit root approaches such as Levin-Lin and Chu, I’m, Pesaran, and Shin (IPS) cannot solve the CD’s problem . As a reThe next phase in the econometric process is to assess the long-run association between the variables. Westerlund  developeIn Equation (9), In Equation (9), the parameter for error correction Following this, we examined the long association between the NRR and EF in the existence of TI, FD, and economic growth. Economists suggest a number of methodologies for analyzing panel data. However, previous research used first-generation cointegration approaches , which might lead to biased outcomes in the existence of CD and heterogeneity. Thus, the AMG technique was used in the study by Eberhardt . This meFirst, the group-specific regression model was reformed with an model .0) of no CD between the variables are given in The first econometric step of empirical analysis scrutinizes the existence of CD among the variables. The results of the CD tests of the null hypothesis  of no cointegration for Ga. In contrast, the outcomes for Gt, Pt, and Pa provide an appropriate indication to reject the H0 with corresponding probability levels that are significant. Therefore, it shows that all variables comprise a long-run cointegration.In order to verify the long-run equilibrium between the variables, we used the second-generation test, namely, the Westerlund . Table 4We can assess the long-run relationship via the AMG method after completing the cointegration examination between the variables. The results of the AMG test are demonstrated in 2 positive and negative values with EF indicate the EKC hypothesis’s validity with an inverted U-shape. Specifically, a 1% upsurge in GDP enhances the EF by 0.776%, while a 1% rise in GDP2 lessens the EF by 0.028%. These findings align with [The coefficient of FD has a positive impact on the EF, so the 0.043% change in the EF is due to FD. Therefore, the policymakers should encourage foreign direct investment (FDI) to encourage investors to develop eco-friendly technologies and pollution-free industries. These findings coincide with those in . Furtherign with ,20. AccoFollowing Model 1 of high income BRI economies, the coefficient of NRR has a significant positive impact on EF at a 1% significance level, indicating that a 1% increase in NRR results in a 0.422 percent rise in EF. Since 2000, overall energy demand has grown by more than 83%, and the share of this development has been happening by a doubling consumption of fossil fuel utilization in BRI economies. Oil is also the primary source of power generation/energy demand in this region, leading to worse quality of the environment. This subset of results was discovered similarly in ,13. Alte2 elasticity were 0.837 and −0.025, respectively; this supports the EKC hypothesis with a U-shape. It was found that a 1% rise in GDP corresponded to a 0.837 percent surge in EF, while a 1% rise in GDP2 decreased EF by −0.025%. This means that pollution level increases during the early stages of economic growth. However, after arriving at a specific point, the pollution level will decrease. This result is congruent with the findings of [Additionally, a 1% rise in FD will result in a 0.037 percent decrease in the quality of the environment in the long-run. This empirical evidence indicates that FD enhanced the EF because most BRI countries rely on fossil fuels. These findings are in accordance with ,77,78. Cdings of . MoreoveIt was noted that a 1% upsurge in NRR* TI led to a 0.033% reduction in EF. In this regard, the result of NRR in middle income BRI economies had a significant and positive effect on the EF in Model 1. Specifically, at the 1% significance level, a 1% rise in NRR enhanced the EF by 0.222 percent in the long-run. This finding backs up the hypothesis that NRR is the primary source of environmental damage. The outcome supports the hypothesis that NRR is the primary source of environmental damage in the region. The positive impact of NRR can be supported by the fact that middle-income countries have the greatest number of oil-producing economies. These countries are placing immense pressure on their NRR to meet their energy needs, causing environmental damage. The findings of the present empirical evidence are consistent with those of .Furthermore, the TI coefficient has a negative and significant effect on EF, revealing that a 1% rise in TI reduced the EF by −0.055%. Thus, the TI outcomes minimized the EF through eco-friendly technologies and supported the existing findings Wang et al. ,80, in c2 on EF in middle income BRI countries. The findings are consistent with those of [Likewise, the validity of the EKC hypothesis is expressed by the positive and negative values of GDP and GDPthose of ,83. Morethose of  contende2 coefficients with EF. It is worth noting that a 1% increase in GDP results in a 0.520% rise in EF, whereas a 1% upsurge in GDP2 results in a 0.020% decline in EF. These results are comparable with [Considering Model 1 of low income BRI economies, the NRR coefficient affected EF positively and significantly. It is worth noting that a 1 percent increase in NRR outcomes led to a 0.188 percent rise in EF. The low income BRI economies hold almost 20% of the world’s proven oil reserves and put massive pressure on their NRR assets to accomplish their energy demand, decreasing environmental quality . These rble with ,85. AccoThe robustness of the results above-mentioned was tested using the alternative measure of EF with GHG as a dependent variable and an alternative estimator  . AccordiFor the past couple of decades, a sustainable environment has been a desired state worldwide. Environmental pollution can occur as a result of a variety of economic activities. Various socio-economic issues have a positive or negative impact on the environment. Many earlier studies have resulted in efficient input allocation as an environmentally beneficial component. This research explored the impact of NRR, TI, and FD with the interaction term (NRR* TI) on the EF from 1991–2018 in BRI countries in the EKC hypothesis framework. Furthermore, to capture the effect of income differences, this study divided the samples of the BRI countries into three income groups. The EF, a complete proxy , quantifies environmental quality in the current study. The Pesaran CD technique was used to check the CD. The stationary level was investigated using the CIPS panel unit root technique. The cointegration method, developed by Westerlund , determiAccording to the findings, this research recommends the following policy implications for stakeholders, governments, and policymakers in general, and specifically to BRI economies for environmental sustainability. Policymakers in BRI countries should move resources away from resource-rich sectors of industries/manufacturing sectors to enhance/promote economic growth and use these NRRs efficiently for a progressive, sustainable environment. TI should be massively utilized to use energy and NRR efficiently.The FD process should not be ignored in the policy framework for a sustainable environment in BRI economies. A balance should be struck between the economic benefits of FD and environmental quality. Furthermore, the policymakers should encourage clean and green foreign investment and welcome these investments, which carry technical skills, environmentally friendly technologies, and carbon-free methods in the BRI economies. These countries should change their dirty energy strategies into renewable energy sources. The government of these countries should focus on trade promotion with advanced technology by supplying eco-friendly technology and sources of renewable energy including hydropower, solar, wind, biomass, geothermal heat, waste-based energy, and employ environmental regulation policies such as imposing carbon tax/quota system on emission-intensive products, which could help to maximize environmental quality. Environmentally friendly technologies will preserve the BRI countries’ international capacities while ensuring a long-term environmentally sustainable economy.The enormous increase in EF and the economic performance of various economies continue to pique the interest of academics and practitioners. Concerns about global warming and its impact on human and animal health, hence on sustainable development, are also growing. As a result, policymakers and academics must examine the critical significance of absorptive capacity in promoting sustainable development.This research has some shortcomings that should be addressed in future research. Because our analytical approach does not take into account crucial cultural and social aspects, future researchers could expand on this research by investigating the interaction role of institutional quality and NRR in the pollution haven or halo hypothesis framework, making a significant contribution to the literature and will ultimately help to curb environmental pollution.


Many risk factors, including nutritional ones, contribute to cardiovascular diseases (CVDs). Increased fructose consumption, for example, can lead to an increase in CVD risk factors, i.e. an increase in blood lipids and the development of insulin resistance.  In the present study, Sprague Dawley rats were divided into two groups: control group (free access to tap drinking water for seven weeks), and a group that received fructose 10% in drinking water for seven weeks, (n═8 per each group). In all groups, before starting the test period and seven weeks after it, electrocardiogram was recorded by Power lab system. Unpaired t-test and two-way ANOVA were used for data analysis. Also, oxidative stress parameters were measured.  In the group received high doses of fructose, a significant reduction (P <0.05) was observed in the PR interval (P<0.001) and a significant increase (P<0.05) in the QTc interval. However, there was no significant change in the RR interval and the voltage of the QRS complex. A significant decrease in catalase, superoxide dismutase and glutathione peroxidase (P<0.05) and a significant increase (P<0.05) in malondialdehyde and lactate dehydrogenase were observed in the group that received fructose in comparison with the control group at the end of the experiment.  According to our results, the chance of arrhythmias in the rats receiving high doses of fructose was possibly due to the increased oxidative stress in the healthy rats. Diabetee stress . AccordiMDA, SOD, CAT and GPx kits were purchased from Zell Bio GmbH Co. (Germany). Xylazine (2%) and ketamine HCl (10%) were obtained from Alfasan Co. (Netherlands). LDH kit was purchased from Parsazmun (Iran).Sprague-Dawley rats were divided into two groups: the control group received free access to tap drinking water for seven weeks and the group received fructose 10% in drinking water for seven weeks, (n ═ 8 in each group). Before and seven weeks after starting the experiment period, ECG was recorded by Power lab system in all groups. The rats were kept at temperature 22 ± 2 °C, 50% humidity, 12-hour dark-light cycle and had free access to tap water and standard rat chow diet . They were treated according to the guidelines of the animal care and use of the Ethics Committee of Abadan School of Medical Sciences, Abadan, Iran (code: IR.ABADANUMS.REC.1395.86).The ECG was recorded before starting the test period and seven weeks after it, by Power lab system .Fifteen minutes after induction of anesthesia, limb lead II electrocardiogram was recorded to find out voltage of QRS , P-R interval and QT interval , and heart rate and RR interval . The formula to correct QT (QTc) is bazzet’s formula: .Seven weeks after the start of the test period, blood sample accumulated from the right atrium of the heart in the anesthetized rats was transported into EDTA containing tubes. After centrifuging at 4000 g for 10 min, the plasma was reserved at -80 °C for biochemical analysis. LDH, antioxidant enzymes  and MDA were measured by commercial kitsData were analyzed by GraphPad Prism6 and expressed as mean ± SEM. Comparisons between groups were performed using unpaired t-test. Two-way ANOVA was used for multiple comparison tests, followed by LSD. P-value <0.05 was considered statistically significant.) did not confirm a significant change on the first day of research. There was a significant decrease in PR interval (P<0.001) and a significant increase in QTc (P<0.05) of the fructose group in comparison with the control group on the last day of research. However, in the RR interval and voltage of QRS, no significant change was observed , RR interval (chronotropic parameters) and voltage of QRS  occurred in the group that received fructose in comparison with the control group on the last day .MDA showed a significant increase (P<0.05) in the fructose group in comparison with the control group on the last day .LDH showed a significant increase (P<0.05) in the fructose group in comparison with the control group on last day .et al., the high-fructose consumption resulted in significantly enlarged hearts. In isolated perfused hearts, the baseline values for ±dP/dt were higher in the high-fructose group compared with controls, and heart rates were lower in the high-fructose group compared with control group in the isolated hearts, but higher in in vivo study, suggestive of an increased sympathetic tone in the high-fructose group [et al., the effects of diabetes-induced oxidative stress and the role of lipid peroxidation was demonstrated [The aim of our study was to evaluate the effects of high doses of fructose on ECG parameters, an antioxidant enzyme, cardiac marker (LDH) and a marker of lipid peroxidation (MDA) in normal rats. In our study, we observed a significant increase in QTc and a significant decrease in PR interval in fructose group, but in RR interval and voltage of QRS, no significant changes were found. Utilization of sugar-sweetened beverages has been shown to be associated with the development of cardiovascular diseases . Concentse group . In Ghosnstrated . Our resThe results of our study showed that the high consumption of fructose has harmful effects on the heart and can be due to its effect on increasing oxidative stress. The high doses of fructose with decreased PR and increased QTc can increase the likelihood of arrhythmia in healthy rats.Authors gratefully acknowledge the help and financial support of the Abadan School of Medical Sciences, Abadan, Iran, with grant number: IR.ABADANUMS.REC.1395.86.The authors declare no conflicts of interest.