Past research showed that social networking sites represent perfect platforms to satisfy narcissistic needs. The present study aimed to investigate how grandiose (GN) and vulnerable narcissism (VN) as well as social comparisons are associated with Facebook activity, which was measured with a self-report on three activity dimensions: Acting, Impressing, and Watching. In addition, the state self-esteem (SSE) was measured with respect to performance, social behavior, and appearance. One hundred and ten participants completed an online survey containing measures of SSE and Facebook activity and a priming procedure with three experimental conditions embedded in a social media context . Results indicated, as expected, that high VN was negatively associated with SSE on each subscale and the overall score. In addition, it was found that VN, but not GN, displayed positive associations with frequency of Facebook activities. Finally, it was proposed and confirmed that VN in interaction with the priming of downward comparisons negatively affected SSE. The conclusion drawn is that VN represents a key variable for the prediction of self-esteem as well as for the frequency of Facebook activity. In the following, the constructs Facebook activity, social comparison, and narcissism are described.Facebook is the most popular social networking site (SNS) in the world: It counted more than 2.6 billion monthly active users in the first quarter of 2020—a number even higher than the one reported in the year before .the need to belong, and (2) the need for self-presentation” (p. 3). These factors may be supplemented by adding a third need, namely, that of social comparison .https://shinyapps.org/apps/p-checker/; accessed on 1 March 2021).IBM SPSS 27 was used to analyze the data. To examine the hypotheses, bootstrapping regression models were employed, which are recommended if assumptions about the normal distribution of scores might be violated or if the number of participants is rather small. Additionally, correlations and partial correlations as well as Fisher Z-tests were calculated to check for significant deviations between correlation coefficients. To assess moderational effects, analyses of variance including the Johnson–Neyman technique were used. Finally, a test of excessive significance (TES)  was condSD = 8.149; range: 18–58). All participants were neurotypical German speakers. Most participants stated that their highest educational qualification was A level ; 27.3% had either achieved an academic degree (21.8%) or a successful state examination (5.5%); 10% had completed an apprenticeship; 4% had completed middle school; and one participant (0.9%) had completed secondary school. The majority of participants (65.5%) were currently studying; most of them (44.5%) were students of psychology. Most participants reported logging in on Facebook on at least a daily basis . Only three participants (2.7%) logged in less than once per month. Most of the participants displayed a moderate extent of weekly Facebook usage, i.e., they spent less than four hours per week on the SNS . However, nearly one third spent more than five hours on Facebook .The participants initially consisted of 118 adults. Most of them were either students graduating at the Ruhr University of Bochum and surrounding universities . The inclusion criteria were legal age, active Facebook membership, and private  usage of Facebook. As five participants did not own a Facebook profile, and three participants used Facebook only for commercial purposes, 110 participants were finally included in the statistical analyses. Eighty-two (74.5%) of them used Facebook for private purposes only, whereas 28 (25.5%) used Facebook for both private and commercial purposes. Twenty-three participants (20.9%) were male, 87 (79.1%) were female. Their mean age was 25.52 years  and especially Acting  subscales were rather low, in contrast to a rather high mean value on the Impressing FAQ subscale . Second, participants tended to achieve rather low NPI-15 sum scores . In addition, the Kolmogorov–Smirnov test indicated a significant difference from normally distributed data for the SSE Appearance subscale (p < 0.05), for which the histogram showed a bimodal distribution. Participants’ NPI-15 and FAQ Watching and Acting scores displayed a right-skewed distribution. Finally, NI-R and FAQ Acting scores displayed a leptokurtic distribution. Because root- as well as square transformations of the skewed data did not improve the shape of the distributions considerably, the level of significance was set at p < 0.01 for all hypotheses tests to counteract these limitations. Additionally, bootstrapping was employed for conducting regression analyses because of the resulting robustness of bootstrapping regression models against model violations.With respect to the priming procedure, all participants completed the ranking order task. The majority (30%) chose a satisfying relationship as their subjectively most important category. Success in achievement domains and social popularity were placed on the first rank by 16.4%, and by 7.3% of respondents, respectively. Participants mostly compared themselves with friends and relatives, followed by acquaintances, colleagues or fellow students, and spouses. Six participants assigned to the upward comparison condition, and one participant assigned to the downward comparison condition did not write down any comparison standards and also did not report their thoughts or feelings during a moment of inferiority or superiority. However, the priming results did not differ significantly as a function of whether the seven non-completers were included or not. Hence, results are subsequently reported including all 110 participants.r = 0.41, p < 0.001; controlled for VN: r = 0.44, p < 0.001), whereas VN was only negatively associated with SSE to a significant extent if GN was controlled for . Among the three SSE subscales, only the Social subscale was significantly correlated with GN. The correlation between GN and VN became significant when SSE was partialled out . Furthermore, the FAQ subscales were positively correlated with each other. The Acting subscale displayed the highest correlation with the total FAQ.Supporting previous results, GN and VN were correlated positively , indicatTotal, SSEPerformance, SSESocial, and SSEAppearance, constituting strong evidence for H1. In addition, the explained variance was substantial both for the total score and for each of the subscales. Furthermore, the second part of H1 received also some support from the data because the partial correlations of VN with SSETotal and SSESocial were significantly negative.In correspondence with the first hypothesis, the results of a partial correlation analysis indicate that grandiose narcissism is positively correlated with SSE (controlling for VN). This pattern of results was confirmed with respect to the NPI for SSETotal scores  = 5.77, p < 0.001), and the same was true for each model with, respectively, one of the three SSE subscale scores as criterion  = 4.35, p < 0.001; SSE Social: F  = 3.10, p < 0.01; SSE Appearance: F  = 4.01, p < 0.001). The entire model explained 31.4% of the variance in participants’ total SSE, and 25.6%, 19.7%, and 24.1% of the variance in the SSE Performance, Social, and Appearance subscales, respectively. As shown in p < 0.001), as well as all SSE subscales . Likewise, in all models—except the one with SSE Appearance as criterion, where no significant interaction effect was revealed—one significant interaction effect emerged: namely the downward comparison condition × NI-R interaction: In participants assigned to the downward comparison condition, SSE significantly decreased as NI-R values increased . Moreover, SSE scores of participants in the upward comparison condition displayed a, though non-significant, trend to decrease in response to an increase in NI-R scores . The same was true for the upward comparison condition × NPI-15 interaction effect, although that trend was much less pronounced here and never reached significance levels exceeding p = 0.14 . Post-hoc analyses by means of the Johnson-Neyman technique revealed two zones of NI-R scores, within which the conditional effects of downward comparisons on SSE Total became significant. One of them included NI-R scores of 1.12  and lower; the other included NI-R scores of 3.2  and higher. For the SSE Performance and Social subscales, one region of significance could be determined, respectively, which included NI-R scores of 3.62  and higher for SSE Performance, and of 3.27  and higher for SSE Social as criterion. In all cases, conditioned effects and corresponding significances strongly increased as NI-R scores increased .The regression analysis conducted to test whether VN moderates the influence of downward comparison direction on participants’ situational self-esteem (H2) revealed that VN significantly moderated the influence of downward comparison direction on participants’ SSE: The overall fit of the model comprising all eight predictors became significant in predicting SSE Hypothesis 3 referred to the associations of VN with different measures of Facebook activity. As shown in Hypothesis 4 assumed that GN displays a significant positive association with Facebook activity. An inspection of Z-test to compare the correlations between grandiose and vulnerable narcissism and the Facebook Activity Index including number of Facebook log-ins, hours online, and number of Facebook friends. The results are revealing. The overall score of the FAQ  as well as the FAQ-subscales correlated significantly higher with VN than with GN . The correlation difference was marginally significant for log-ins on Facebook  and significant for number of Facebook friends  and hours spent on Facebook . The latter difference indicates that number of Facebook friends was correlated higher with GN than with VN, reversing the general trend.Hypothesis 5 postulated that GN would not be linked with Facebook activity after control for VN. The correlations between GN and most measures of Facebook activity were non-significant, and this was true no matter whether VN was controlled for or not see . TherefoF  = 3.96, p < 0.001). The same was true for the models employed to predict participants’ FAQ Watching and Impressing subscales  = 3.70, p = 0.001; FAQ Impressing: F  = 2.17, p < 0.05). However, the model with FAQ Acting as criterion displayed a non-significant overall fit. Altogether, the eight predictors explained 23.9% of variance in FAQ Total scores, and 14.7% and 22.7% of the variance in the Watching and Impressing subscales, respectively. Only one significant main effect was revealed: NI-R scores significantly predicted FAQ scores , confirming once again H3. As shown in Impressing subscale. However, in the model predicting participants’ scores in the Watching subscale, a significant negative interaction between NPI-15 scores and exposure to upward comparisons was found .RQ 1 referred to in how far GN and VN might moderate the influence of upward social comparisons on Facebook activity. First, the ANOVA test for the overall fit of the model to predict participants’ FAQ scores became significant  and higher, as visualized in p < 0.05; CI [−1.69–−0.11]) for an NPI-15 score of 13.00. None of the other group × VN or group × GN interactions that were tested reached significance with respect to the prediction of FAQ total or any FAQ subscale scores.This result contains both theoretical and practical importance. Post-hoc analyses revealed that conditioned effects of upward comparisons on FAQ A test of excessive significance based on six hypotheses-oriented effects  was conducted. The calculations revealed a success rate of 0.8333, indicating that 83,33% of our hypotheses could be confirmed, and a median observed power of 0.964 was achieved. Above, the TES revealed a deflation  of −0.1306, indicating that less hypotheses than possible were confirmed with respect to the median observed power. Finally, R-Index = 1.0946, indicating that our findings can be  replicated in X*1.0946 follow-up studies. Concluding the results of the TES, the data does not seem to be biased, the power was sufficient despite the fact that the sample was quite small, and the findings seem to be generalizable.The major aim of the present study was to get deeper insights into how individuals who have been exposed to social comparisons and who display a high extent of narcissism use Facebook to self-regulate. Hypothesis 1 predicted that grandiose narcissism is positively related with state of self-esteem. This hypothesis was confirmed by the result across several measures of state of self-esteem. High grandiose narcissism was systematically associated with high self-esteem. This consistent result replicates the findings of earlier studies ,42,43. GPerformance, and the SSE Social subscale as criterion, respectively—the evidence for hypothesis 2 is quite strong: The higher the extent of VN, the lower participants’ SSE in response to having experienced a downward comparison situation. These results correspond with the proposal by Lockwood [The second hypothesis, which postulates that VN would moderate the influence of downward comparison direction on participants’ SSE, enters new territory by emphasizing the consequences of perceived own vulnerability on the repercussions of downward comparisons. More specifically, it was predicted that vulnerable narcissists would respond with reduced state self-esteem to downward comparisons. This hypothesis, which was mostly supported by the results of multiple regression analyses, enables a better understanding of the effects of downward comparisons on self-esteem. Because a significant interaction between VN and assignment to the downward comparison condition was discovered in three of the four regression models—namely, in the ones with the entire SSE scale, the SSE Lockwood  that parLockwood  correspoIn correspondence with their defensiveness, the lack of self-confidence and increased anxiety of vulnerable narcissists seem to accentuate the negative implications of poor results by others for themselves. Their slogan seems to be “That could happen to me too!”. That means that vulnerable narcissists seem to suffer negative repercussions on the basis of thinking about the negative fate of others. This is more or less reasonable, but the implications of this sensitivity for own vulnerability are self-threatening . The curIn their summary of more than sixty years of research on social comparison processes, Gerber and colleagues  come to Hypothesis 3 was mostly confirmed as VN displayed a significant positive relationship with measures of Facebook activity. In contradiction with H4, a lack of significant correlations between GN and Facebook activity emerged. The explanation for this result is that grandiose narcissists possess a number of personality traits, intra- and interpersonal strategies and interpersonal skills, which enable them to succeed pretty well in elevating their own self-esteem in the offline world. Hence, it is likely that they do not benefit from SNSs as much as people with difficulties in winning over their audience in the offline world do. However, two specific findings regarding H4 are especially noteworthy. First, the only measure of Facebook activity that was consistently correlated with GN was the number of Facebook friends. This is in correspondence with a number of previous studies ,61,62,63Z-tests revealed that the correlations of NI-R with FAQ are significantly higher than the correlations of NPI with FAQ. Clearly, the level of VN matters when it comes to Facebook use, but the level of GN not so much. The only exception to this rule seems to be number of Facebook friends.With respect to H5, which assumed that the association between VN and Facebook activity is stronger than the association between GN and Facebook activity, it is noteworthy that Fisher Taken together, the findings obtained in the current study contribute to a confirmation of the SOS-T . FacebooWatching scores, subsequent to the exposure to upward comparisons, was recorded. This result indicates that selective avoidance of online social comparisons via Facebook Watching by grandiose narcissists in response to the exposure to upward social comparison information occurs. It corresponds with the general trend observed by Gerber and colleagues [With respect to the research question (RQ 1), the interaction effects of (vulnerable or grandiose) narcissism with upward social comparison were generally weak. But a significant negative effect of GN on FAQ lleagues  that upwThe analyses in the present study were based on an online survey including self-report measures and a priming paradigm. The experimental approach is an advantage of our research design. This research, however, is not without limitations. First, the employment of self-reporting measures constitutes a point of concern, as they might prompt socially desirable responding. Although an experimental design was employed for testing hypothesis 2, most of the tests of the hypotheses on the links between narcissism and Facebook activity rest on a correlational design. Second, whereas our research focused on trait narcissism, it would be interesting to manipulate state narcissism experimentally  and to mThird, the participants do not represent the population of Facebook users in general because psychology students were overrepresented. Therefore, a replication study with more representative Facebook users would be desirable.Watching is meaningful from a theoretical point of view, indicating an avoidance effect of grandiose narcissists after exposure to the superiority of others.Fourth, to include a more sensitive measure of priming effects on Facebook use, the employment of assessments of intentions to use Facebook is recommended. The FAQ and the other Facebook use measures which were employed in this study refer to behavioral reports which might be quite resistant against short-term priming effects. Intentions instead of behavioral reports are more likely to be modified by priming manipulations. Nevertheless, the significant effect of exposure to upward comparisons in interaction with GN which was detected on FAQ


Objective: Fat distribution has increasingly been acknowledged as a more significant health parameter than general obesity, in terms of the risk of cardiovascular disease (CVD). We aimed to investigate the regional fat distribution pattern and general body fat characteristics of adults with cerebral palsy (CP), and we explored the risk of CVD in this population.Methods: People aged ≥20 years who were diagnosed with CP were recruited between February 2014 and November 2014. The subjects underwent a structured interview, laboratory studies, and physical examination. The amount and distribution of fat were determined directly by dual-energy X-ray absorptiometry. Laboratory analysis was performed to measure total cholesterol and triglyceride, high-density lipoprotein (HDL), low-density lipoprotein, and fasting plasma glucose levels. The Framingham risk score (FRS) was used to present the 10-year risk for having CVD, and predictors such as sex, age, total cholesterol, HDL, systolic blood pressure, treatment for hypertension, and smoking status were used to calculate the FRS.Results: Ninety-nine adults  with CP were included. The participants consisted of all five levels of the Gross Motor Function Classification System. The mean body mass index (BMI) was 22.52 ± 4.58 kg/m2. According to BMI criteria, 54.9% were overweight and 27.3% were obese. The fat mass index criteria revealed 10.1% excess fat and 7.6% obesity. In univariable regression analysis, age, the timing of physical function deterioration, and android fat percentage were associated with the FRS . In multiple regression analysis, the FRS was associated with age and android fat percentage, based on the following formula:Conclusions: Body fat distribution in the android area is significantly associated with future CVD risk in adults with CP. When people with cerebral palsy (CP) mature into adulthood, they frequently face various secondary conditions. Among the major challenges of this population, lack of physical activity, decreased physical fitness, and a sedentary lifestyle are often reported in adulthood , 2. TherPhysical inactivity in people with CP may increase the risk of obesity. At the same time, they have an increased risk of dysphagia and other gastrointestinal problems, which may lead to nutritional deficiency , 7, whilRecently, fat distribution has been proposed to be more closely associated with CVD risk than with the general measures of obesity, such as total fat mass or body fat percentage , 12. AndTherefore, we sought to identify the prevalence of obesity and the characteristics of body fat distribution in an adult population with CP, and we assessed their cardiovascular risks and the relationship thereof with body fat distribution in this population.Participants were recruited from the community, with the cooperation of nationwide organizations for persons with disabilities, and four hospitals in Gyeonggi and Seoul in South Korea. A total of 243 adults with CP were included in this study. Participants were excluded if they were not able to understand or answer the questionnaire despite receiving assistance from an interviewer, if they failed to complete dual-energy X-ray absorptiometry (DXA), or if they withdrew before data collection. Data were collected between February 1, 2014, and November 31, 2014.All study procedures were approved by the institutional review boards of the participating institutions, operating in compliance with the Guidelines for Good Clinical Practice. Written informed consent was obtained from all participants. After obtaining consent from the participants, questionnaire surveys on basic information, assessments, and measurements were conducted.A structured interview and physical examination were conducted by a physiatrist or a trained research nurse in order to complete the questionnaire regarding demographics and physical function. The questionnaire included questions on sex, age, current smoking status, and drinking habits. Current smoking was defined as any cigarette smoking within the previous month. Never cigarette smokers and ex-cigarette smokers were classified as non-smokers. Likewise, drinkers were classified as those with any alcohol consumption in the past previous month.Waist circumference and resting blood pressure were also measured. Waist circumference was measured in subjects in a standing position, at normal expiration. It was measured at the midpoint between the lower margin of the least palpable rib and the top of the iliac crest, using a stretch-resistant tape , once foThe types of CP and the areas affected were investigated. They were determined by a single physiatrist (SHJ) with more than 15 years of clinical experience in CP. The types of CP were classified as spastic, dystonic, dyskinetic, ataxic, or mixed . AffecteFor gross motor function, we used the Gross Motor Function Classification System (GMFCS). This is a five-level scale, where level I represents the least disability and level V the most, based on typical performance rather than the maximal capacity , 24. PeoThe age at deterioration of physical function was also examined. GMFCS levels in 10-year intervals were determined, and the age span of physical deterioration was defined as the period when there was a regression of GMFCS level. The participants were also categorized according to the GMFCS level: ambulatory  and non-ambulatory groups (GMFCS levels IV and V). History of fall and number of falls in the past year were recorded by interviewing the patients.The Short Physical Performance Battery (SPPB) was assessed by a trained physiotherapist. It is a group of measures that combines the results of gait speed, chair stand, and balance tests . It is a2) were as follows: overweight (BMI of 25.0–29.9), and class 1, 2, and 3 obesity  (2) was calculated as fat mass divided by the square of height. Cutoffs for FMI were as follows: fat deficit (<5%), normal (5%−9%), excess fat (>9%−13%), class I obesity (>13%−17%), and class II–III obesity (>17%)  . Fat masy (>17%) .For body composition assessment, DXA  was used. DXA provides a precise evaluation of body composition at a relatively low cost . DXA difA venous blood sample was obtained for laboratory analysis. The participants fasted for at least 8 hr before their blood was drawn. Blood composition analysis included total cholesterol and triglyceride (TG), high-density lipoprotein (HDL), low-density lipoprotein (LDL), and fasting plasma glucose (FPG) levels.http://cvdrisk.nhlbi.nih.gov). This tool was designed for adults aged 20 years and older. The FRS estimates the 10-year coronary heart disease risk based on predictors, such as sex, age, total cholesterol, HDL, SBP, treatment for hypertension, and smoking status  were calculated for continuous variables. The clinical characteristics were compared between groups using an independent retation .p <0.05 on univariable regression analysis were used for multiple regression analysis.Associations between the FRS and other factors were examined using univariable and multiple regression analyses. To determine the factors independently associated with the FRS, variables with p-values were calculated from two-tailed tests of statistical significance, with significance declared at the 5% level. All statistical analyses were conducted using the SPSS version 20.0 .All Ninety-nine adults with CP were enrolled; however, 79 adults were included in the analysis in this study. DXA could not be performed in 20 adults. In 17 adults, precise measurement was not possible because of deformities and abnormal postures. Two adults had dystonic-type CP and one adult had athetoid-type CP and could not remain still during the measurement. The mean age of the study population (45 men and 34 women) was 42.2 ± 8.5  years. The participant's characteristics, physical functions, and laboratory results are shown in p = 0.001, p = 0.003, p <0.001, respectively). The FMI was significantly higher in women than in men (p = 0.006). According to the FMI criteria, more men had a fat deficit than women (p = 0.002)  .p = 0.006) and a higher proportion of individuals with normal FMI in the ambulatory group (p = 0.036).There was no significant difference between the ambulatory and non-ambulatory groups in waist circumference, BMI, and body fat composition. However, there was a higher proportion of underweight individuals, by BMI criteria, in the non-ambulatory group (p <0.001). The FRS and 10-year risk of developing coronary heart disease did not differ between the ambulatory and non-ambulatory groups.The 10-year risk of developing coronary heart disease was higher in men than in women . In women, the android/gynoid fat ratio was positively associated with FRS (p = 0.047).Univariable regression analysis showed that FRS was positively associated with increasing age (p <0.001). R2 shows the percentage of variance in the outcome explained by all variables in the model.Multiple regression analysis of the FRS was performed with the factors (age and android fat percentage) that were significantly associated with FRS in univariable regression analysis. Multiple regression analysis showed that the FRS was associated with age and android fat percentage based on the formula below  reports released in 2012, the average overweight and obesity rate in South Korea was 35.1%. We found that Korean adults with CP in this study were not obese compared to the general Korean population. It has been debated whether adults with CP are more obese than the general population. Most studies have reported that adults with CP are more likely to be obese due to a lack of physical activity and a sedentary lifestyle –54. As wOn the other hand, the FRS scores in this population group were higher than those in the general Korean population. Park et al.  showed tThe discrepancy between BMI and FRS may underestimate the risk of metabolic disease in adults with CP who have normal or low BMI. The reason for the discordance may be explained by the body fat distribution, because age and android fat percentage were the factors that were associated with FRS, while factors such as BMI, GMFCS, or functional abilities were not found to be related to FRS.Due to altered body morphology and changes in lifestyle over a long period, the measures of overall adiposity, such as BMI, would not be appropriate for adults with CP. In adults with CP, higher excess adiposity can be detected despite a normal BMI when compared to neurologically intact adults. Therefore, it is important to evaluate fat distribution rather than general adiposity measures in this population. Peterson et al. assessed intermuscular adipose tissue and trunk adiposity using abdominal computed tomography (CT) . CT can In our study, it is notable that the ambulatory group had a higher proportion of individuals with a normal FMI. Moreover, both the fat-deficit and obese groups (according to FMI) were higher in the non-ambulatory group. On the other hand, the CVD risk by FRS was not significantly different between the non-ambulatory and ambulatory groups. The non-ambulatory group may be at risk of potential undernutrition caused by dysphagia and gastrointestinal problems, resulting in a fat deficit , 7. On tThis study had some limitations. First, this was a cross-sectional study. Therefore, we were unable to determine a cause-and-effect relationship. Second, a head-to-head comparison with the general population was not performed. Instead, we were only able to compare our data with the general population data from the OECD reports. Since the cohort represents a sample that is relatively small for determining prevalence in the CP population, a future study with a larger sample size would address this limitation. Third, other information, such as socioeconomic status or nutritional status, was not analyzed in this study. With these considerations, further detailed studies on body fat distribution and CVD risk in adults with CP could be performed.In conclusion, android body fat distribution and age are the two significant factors associated with 10-year CVD risk in adults with CP. Body fat distribution is more closely related to CVD risk than measures of general obesity in adults with CP.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Institutional Review Board at Seoul National University Boramae Medical Center. All subjects provided their written informed consent to participate in this study.SJ and HS: drafted the manuscript. SJ: conceived the study and critically revised the manuscript for important intellectual content. All authors have read and approved the manuscript and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.This research was supported by the Translational R&D Program on Smart Rehabilitation Exercises (#TRSRE-PS01), National Rehabilitation Center, Ministry of Health & Welfare, Korea.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.


Background: The prevalence of anxiety and depression in young students is associated with biosocial factors and scholastic stress. However, few studies have evaluated emotional-affective symptoms that are related to the immune system and antioxidant parameters in young individuals without diagnoses of affective disorders.Aim: This study aims to assess the relationship between emotional-affective symptoms and glutathione concentrations and CD4 and CD8 lymphocyte counts in college students.Methods: College students (n = 177) completed standardized psychometric instruments, including the Perceived Stress Scale, Hamilton Anxiety Scale, Beck Depression Inventory, Familiar Social and Friends Support Scale, and Rosenberg Scale. Blood samples were biochemically analyzed. Analyses of variance were conducted between four groups according to symptom severity.Results: A considerable prevalence of stress, anxiety, and depression symptoms was observed and negatively correlated with self-esteem and socio-familiar support. Perceived stress was sexually dimorphic. Although biochemical parameters were within reference ranges, glutathione, CD4, and CD8 tended to be lower in participants with anxiety and depression symptoms, which may be of predictive value.Conclusion: The relationship between antioxidant/immune parameters and socio-affective scores is latent in undiagnosed college students who might develop affective disorders. The findings suggest that during the initial development of affective disorders, stress management strategies should be implemented to help college students cope with the academic load and monitor negative changes in their physiological state. Research on the etiology of stress in college students who are studying health and engineering has gained importance in recent years because they are exposed to higher levels of stress than others , affectiHigh and chronic stress negatively affects physical health and promotes psychopathological symptoms . The preStress is well known to affect bodily functions, such as causing the inadequate neutralization of free radicals . OxidatiResearch on the scope of stress in college students has mainly analyzed psychosocial factors, cognitive processing, and personality characteristics of individuals, to detect anxiety or depression symptoms and to a lesser extent the association between stress and the immune system. Based on the importance of identifying biochemical correlates, this study investigated GSH levels, CD4 and CD8 lymphocyte counts, and their associations with perceived stress, anxiety and depression symptoms, self-esteem, and socio-familiar support in young adults without a prior clinical diagnosis. We hypothesized that less perceived support and lower concentrations of these antioxidant and immune parameters underlie symptoms of anxiety and depression in healthy young adults.A cross-sectional study was performed on male and female college students (≥18 years old) who were enrolled in the first semester (August–November 2018) of educational programs in chemical sciences.The sample size of 107 students was calculated based on a 95% confidence interval and 90% statistical power from previous studies that were conducted with Mexican young adults. The sample size was corrected according to the 1,283 students who were enrolled in the Faculty of Chemical Sciences and an expected non-response rate of 30%.The exclusion criteria included the identification of and previous treatment for psychiatric disorders. Diagnoses of psychiatric or affective disorders were determined by asking the following questions: “Do you have a psychiatric or affective diagnosis?” “Have you taken a pharmacological treatment or received psychological therapy?” Additionally, some medical conditions exceed the normal range of hematological parameter counts and antioxidant levels. Therefore, students with asthma, diabetes mellitus, anemia, autoimmune diseases, cancer, human immunodeficiency virus, and current infection were excluded from the study. These medical conditions were assessed by asking absence/presence questions. The exclusion criteria also included an incomplete questionnaire, the lack of a blood sample, and leukocyte counts or hemoglobin concentrations outside the reference range. Hemoglobin concentrations (sodium lauryl-sulfate reaction) and total leukocyte counts  were determined using a hematological analyzer .A total of 201 students were invited as the initial sample. The rate of response was 97.01% . Eleven students were excluded from the study because their hematological analyses were outside the reference range. The final sample size was 177.The project was approved by the Research Ethics Committee of the Institute of Health Sciences of the university . The latest Helsinki Code principles and Mexican Regulations on Health Research were followed. Students were invited to participate in the study in the school setting during a talk that provided information on the project and exclusion criteria. The participants provided written informed consent to participate in the study. Participation was voluntary and financial or school incentives were not provided for participation.A structured questionnaire was administered to ascertain general aspects , academic aspects, and stressors in school. The menstrual cycle phase was determined for women at the time of the study to avoid possible confounding effects on anxiety and depression symptoms. The menstrual cycle was recorded as regular or irregular and stratified into four phases according to the number of days after beginning menses: menstrual (1–6 days), follicular (7–14 days), luteal (15–24 days), and premenstrual  was used to evaluate depression symptoms, which assesses psychic, physical, and cognitive aspects, not including anxiety symptoms . It has The Rosenberg Scale was used to assess self-esteem . It is aThe Familiar Social and Friends Support Scale (FSFSS) was used to assess social and familiar support . It has The students were stratified into the following four groups to analyze self-esteem, socio-familiar support, GSH levels, and CD4 and CD8 lymphocyte counts according to PSS-10, Hamilton Anxiety Scale, and BDI-I scores: control group , stress (S) group (PSS-10 score ≥11), stress and anxiety (SA) group , and stress, anxiety, and depression (SAD) group . We generated four groups because the phenomenology of stress, anxiety, and depression share symptoms  and are Blood samples were collected by arm venipuncture 3–7 days after the students completed the questionnaire and scales. Phlebotomy was performed between 7:00 and 8:30 a.m. using the anticoagulant ethylenediaminetetraacetic acid . GSH levels and CD4 and CD8 lymphocyte counts were determined immediately after blood collection.Glutathione concentrations were quantified in 200 μl of whole blood using the Ellman reagent 5,5′-ditiobis (2-nitrobenzoic acid) (DTNB). The sulfhydryl group is soluble after placing the sample in a solution of trioxophosphate acid and EDTA. A 500 μl aliquot reacts with 250 μl DTNB to form a yellow chromophore that is read at 412 nm. The concentration of total GSH was calculated by interpolating the absorbance of the samples on a calibration curve with known concentrations of 0, 1, 5, 10, 15, 20, 40, and 50 μmol/L (prepared from a stock solution of 1 mM GSH). GSH levels were corrected according to hemoglobin concentration in each sample, expressed as GSHc.Lymphocyte subpopulations were detected by flow cytometry using an acoustic focus cytometer . Monoclonal antibodies  that were coupled to different fluorophores were used for each cell subset (anti-CD4-PE and anti-CD8-Alexa488). In 200 μl of whole blood, erythrocytes were lysed with ammonium-chloride-potassium solution, and then leukocytes were resuspended in phosphate saline solution. A 5 μl aliquot of CD4 antibody and 1.25 μl aliquot of CD8 antibody were added in a dark room and incubated at 4°C for 60 min. The samples were fixed with 1% paraformaldehyde and 0.02% sodium azide. A total of 50,000 events were evaluated per sample. Distribution graphs of cell populations were analyzed using . The results are expressed as a percentage of CD4 and CD8 lymphocytes and the CD4/CD8 ratio.2 tests were created to compare the distribution of categorical variables between groups. Data that followed a normal distribution were analyzed using parametric analysis of variance (ANOVA) and Student’s t-test as appropriate. Non-parametric data were analyzed using the Kruskal-Wallis test and Mann-Whitney U test. Significant effects in the Kruskal-Wallis test were followed by the Dunn post hoc test. Values of p ≤ 0.05 were considered statistically significant.The data were analyzed using  . The frequency and percentage of categorical variables are presented. Continuous data are presented as means and standard deviations and SEM. The Spearman test was used to analyze correlations. Contingency tables for exact Fischer and χ2 = 4.02, df = 1, p = 0.04). The substance with the highest frequency of consumption was alcohol, followed by tobacco and marijuana  than in women , exams (19.8%), the time to complete school work (19.2%), the short time to eat (14.5%), a fear of failure (11.3%), and peer acceptance (5.3%). Although PSS-10 scores reflected mild stress, no differences among these stressors were observed . No sex differences in anxiety  or depression  symptom scores were found. In women, PSS-10 scores were similar among the four phases of the menstrual cycle . Lower Hamilton Anxiety Scale scores  and lower BDI-I scores  were observed in the follicular phase compared with the premenstrual, menstrual, and luteal phases. Neither physical activity nor substance use was associated with emotional symptoms. p < 0.0001) and socio-familiar support .Perceived Stress Scale −10 scores were significantly higher in women than in men (n = 25), 14.7% were assigned to the S group (n = 26), 54.8% were assigned to the SA group (n = 97), and 16.4% were assigned to the SAD group (n = 29). The distribution of men and women was similar between groups . Significantly higher anxiety  and depression  symptoms were observed in the SAD group compared with the control and SA groups  expressed suicidal ideation. Among these participants, 7.9% were in the SAD group, and 3.4% were in the SA and S groups. Students in the S, SA, and SAD groups had lower self-esteem than students in the control group  or GSHc  levels among groups . GSHc levels were not influenced by substance use  or physical activity . GSHc levels were not different between men and women . GSHc levels did not differ between menstrual cycle phases .The statistical analysis did not show differences in GSH  and CD8  were found in the SAD group compared with the control and SA groups .Trends toward decreases in the percentage of CD4 (A groups . The CD4p = 0.0529) and between GSHc levels and anxiety symptom scores .Correlations between psychometric scores, GSH levels, and lymphocyte counts were not significant. A trend was observed between GSH levels and anxiety symptom scores  of students presented mild-intensity stress. This percentage was higher than in previous reports in the Mexican population, in which 65% of young people presented stress that derived from school activities . In otheIn this study, the students did not exhibit a significant increase in perceived stress according to the source of stress, but the perceived need for acceptance by peers was a notable stressor in this study. This aspect reflects social belonging and the process of adapting to a new school environment . When thThe 71.1% of the students who presented mild to moderate symptoms of anxiety was higher than in previous studies with similar college populations, in which the frequencies ranged from 19 to 41% , and higImportantly, 16.3% of the students in this study with mild to moderate depression symptoms reported stress and also symptoms of anxiety. This percentage was similar to the 16% prevalence of depression symptoms that was reported in students from the beginning to end of college , the sevThe prevalence of anxiety or depression is higher in women than in men . HoweverIn this study, socio-familiar support was high in the control group and negatively correlated with PSS-10 scores. Thus, an adequate level of socio-familiar support, combined with an optimal level of trust, is a mechanism of emotion regulation and a significant predictor of emotional health in students. This finding is similar to studies of American, Lithuanian, and Korean students . MoreoveLow motivation is related to health-risk behaviors, such as addiction, alcohol consumption, and poor eating habits . In thisThe control group in this study suggested that an optimum level of self-esteem that is higher than the normal range is an important factor to reduce unhealthy practices and psychiatric problems. Self-esteem fully mediated the development of depression symptoms, which is consistent with previous studies of students from Korea and the Republic of Cyprus . AlthougStudies have investigated the influence of school, social, and family environments on emotional responses to stress in students. Stress can also manifest physiologically. We evaluated antioxidant concentrations and immune system parameters, to associate them with the emotional and affective states of the students. During the stress response, the loss of negative feedback of the HPA axis intensifies glucocorticoid secretion, increases the production of reactive oxygen species , and proOther biological processes beyond oxidative stress and antioxidant function are related to mental disorders, such as inflammation, which can reduce the biosynthesis and availability of neurotransmitters and affect neuroplasticity . MarkersThis study has limitations. First, this study lacked a clinical screening or structured interview to corroborate the answers of the participants about a psychiatric or affective diagnosis. These findings suggest that most of the participants did not have an anxiety or depression disorder. Although the anxiety and depression symptom instruments that were used have been validated, they are self-report questionnaires and only evaluated symptom severity, and they do not necessarily have diagnostic value. Thus, the participants in this study self-reported that they do not have a psychiatric diagnosis, but some of them could be underdiagnosed. Future studies should incorporate clinical interviews to conduct comparisons with healthy students. Second, this study lacked a clinical evaluation to discard possible chronic diseases. The students reported the absence of any medical condition. Normal ranges of immune and hematological parameters are well accepted as basic screenings of a good immune system and health status. Future studies should conduct a thorough medical evaluation even when the target population is considered healthy. Third, there are few reports on serum GSH measurements in non-clinical individuals to make comparisons with our findings. GSH levels in the central nervous system that are assessed in psychiatric patients by spectroscopy techniques are not equivalent to serum concentrations. Nonetheless, the interpretation of central and peripheral GSH levels may be presumed to be in the same direction with regard to affective symptoms. Fourth, although the sample size achieved the necessary statistical power to support the results, future studies should include larger sample sizes to analyze cohorts and corroborate the directions of the present findings.Despite the above limitations, we found that a combination of psychiatric, cognitive, and social factors plays an important role in the mental health of college students, which is consistent with previous reports . TogetheThe relationship between antioxidant/immune parameters and socio-affective scores was latent in undiagnosed college students who might later develop affective disorders. Our findings on emotional health in college students could suggest incipient stages of affective disorders for which stress management strategies could be incorporated to cope with the stress of academic load and monitor negative changes in physiological state.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 Research Ethics Committee of the Institute of Health Sciences of the Universidad Veracruzana . The patients/participants provided their written informed consent to participate in this study.CB-V, BB-M, and OV performed conceptualization, methodology, formal analysis, writing the original draft, and funding acquisition. OV performed validation. CB-V, JV-H, and MX-G performed investigation and supervision. EG-M, JR-L, EH-H, and LV supported in finding resources and writing—review and editing. All authors fully reviewed and approved the submitted 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.


Treatment of tongue cancer caused oral morbidities such as oral dryness, and dysphagia. The purpose of this study is to examine the time course of oral function and QOL based on resected area for patients after tongue cancer resection. 31 patients who underwent tongue cancer resection at the Showa University Head and Neck Oncology Center. The participants were divided into two groups; 24 participants in partial/hemi glossectomy group (PG), and seven in subtotal/total glossectomy group (TG). Participants were evaluated swallowing function (FOIS and MASA-C), tongue pressure (TP: kPa), BMI, whole body muscle mass (kg), and QOL evaluation . Participants were measured at baseline , 1, 3, and 6 months after surgical treatment . At baseline, tongue pressure and FOIS score of PG were significant higher than that of TG. At 1M, TP, MASA-C, and FOIS score of PG were significant higher than that of TG. At 3M, TP, MASA-C, and FOIS score of PG were significant higher than that of TG. At 6M, TP and MASA-C were significantly higher than that of TG. QOL measurements did not noted any significant difference between groups before 6M. At 6M, Some QOL measurements of TG related tongue function  were significantly lower than PG. The resected area had significant effects on oral morbidities and feeding function. It is necessary to develop more effective rehabilitation methods to improve patients QOL who had functional impairment remained. Treatment of tongue cancer (TC) contributes significantly to oral dysfunction . Oral dysfunction is often long lasting, given that TC prevalence is increasing in younger patients and the survival rates are increasing . Previous studies have reported that the frequency of oral dysfunction, including difficulty in swallowing (dysphagia) and speech difficulty, caused by TC treatment depends on the resected area of the tongue . Dysphagia has been reported in over 76% of head and neck cancer (HNC) patients treated with concurrent chemotherapy. It decreases the patient’s quality of life (QOL) following HNC treatment . QOL is considered to be an important factor in both treatment decision and outcome evaluation . It is necessary for multidirectional analysis and for the appropriate evaluation of treatment results. The result of HNC treatment should be evaluated according to both QOL and post-treatment functional outcomes . However, only a few studies have conducted a multidirectional analysis that includes QOL by focusing on change over time, following HNC treatment. Further, a majority of previous studies have focused on HNC patients who received chemoradiation therapy . In contrast, a few studies have focused on the change in QOL for HNC patients who received surgical treatment . In HNC patients who received chemoradiation therapy, some studies have reported that the QOL returned to baseline a year after treatment . However, it has been reported that the QOL of HNC patients who received surgical treatment did not return to baseline after treatment . The longitudinal change in QOL in HNC patients who underwent surgery is still unclear. Moreover, the relationship between the resected area and decrease in oral function and QOL is also unclear. Thus, the purpose of this study was to examine the differences in oral function and QOL in patients after TC resection, based on the resected area.PatientsThis study included TC patients who were scheduled for surgical treatment at the Head and Neck Oncology Center, Showa University Hospital and were then referred to the Department of Special Needs Dentistry, Division of Oral Rehabilitation Medicine, Showa University Dental Hospital for rehabilitation. The participants were divided into two groups: partial glossectomy or hemi-glossectomy (PG) group and subtotal/total glossectomy (TG) group. The exclusion criteria were: (1) age<20 years, (2) inability to follow instructions, (3) other malignant tumors, (4) severe diseases that could influence the evaluation, (5) incomplete measurement data, and (6) provision of additional treatment  due to the recurrence of the cancer. Patients were examined at baseline , 1 month , 3 months , and 6 months . This study was approved by the Ethics Committee of Showa University School of Medicine , and all participants signed an approved informed consent form before participating in the study. All procedures were performed according to the World Medical Association Declaration of Helsinki .AssessmentsAll measurements were performed by dentists from the Department of Special Needs Dentistry, Division of Oral Rehabilitation Medicine, Showa University Dental Hospital. The primary tumor stage, TNM classification, method of surgical operation, use of a palatal augmentation prosthesis, and medical history were collected from the medical records. The patient’s weight, body mass index (BMI), whole body soft lean mass (SLM), and skeletal muscle mass (SMM) were evaluated as muscle mass-related measurements. Lip closure force (LC) and tongue pressure (TP) were evaluated as oral function measurements. Feeding function was evaluated using the Mann Assessment of Swallowing Ability–Cancer version (MASA-C) and Functional Oral Intake Scale (FOIS), while QOL was assessed using the European Organization for Research and Treatment of Cancer (EORTC) QOL Questionnaires QLQ-C30 and QLQ-H&N 35.Muscle mass-related measurementsSLM and SMM were measured using Inbody S20 , which can evaluate the patient’s SLM and SMM in a supine position. The patient was placed in a supine position on the examination table, with four electrodes on the first and third fingers and four points on the left and right ankles, eight contact-type electrodes in total . The patient’s weight was measured, and BMI was calculated at each time point .Oral function measurementsLC was measured five times using a lip force measuring device . The average score of the five measurements was calculated as the LC score .TP was evaluated using the JMS tongue pressure measuring device . A balloon-shaped intraoral probe was placed behind the upper front teeth. The patients were instructed to push the probe against the hard palate using the tongue with maximum force for five seconds, and changes in air pressure inside the probe were measured. The measurements were performed 10 times, and the average score was calculated as the final TP score . Between each trial, there was an interval of at least one minute to recover from fatigue.Feeding functionSwallowing function was evaluated using the MASA-C . MASA-C has been validated for use in the HNC population and demonstrates strong sensitivity, specificity, and positive predictive value for the identification of dysphagia. The total maximum score that can be obtained from MASA-C is 200 points. A cut-off score of 185 determines the presence of dysphagia in the HNC population.The FOIS was used as a measure of functional eating status . It is a valid and reliable tool used to document functional eating abilities. A 7-point ordinal scale describes the functional oral intake of patients with dysphagia.QOL measurementsQOL was assessed using the Japanese version of EORTC QLQ-C30 version 3.0 and QLQ-H&N35 questionnaires. The scores were calculated according to the EORTC scoring manual . The QLQ-C30 is composed of both multi-item scales and single-item measures, and includes five functional scales, three symptom scales, a global health status/QOL scale, and six single items. Each of the multi-item scales includes a different set of items; no item occurs in more than one scale. All of the scales and single-item measures range in score from 0 to 100. A high scale score represents a higher response level. Thus, a high score for a functional scale represents a high/healthy level of functioning, a high score for the global health status/QOL represents a high QOL, but a high score for a symptom scale/item represents a high level of symptomatology/problems. EORTC QLQ-H&N35 incorporates seven multi-item scales that assess pain, swallowing, senses (taste and smell), speech, social eating, social contact, and sexuality. It also includes 11 single items. All the scales and single-item measures range in score from 0 to 100. For all items and scales, high scores indicate more problems.RehabilitationAll patients enrolled in this study received indirect or direct training, as needed. After the pain in the surgical region had subsided, patients underwent rehabilitation such as massage for surgical scarring, oral motor exercise including lingual exercise, and direct training, according to their requirement. Moreover, some patients underwent swallowing rehabilitation and used a palatal augmentation prosthesis (PAP) to improve bolus transportation, pharyngeal swallowing pressure, and clearance of the oral and pharyngeal residue.Statistical analysisχ2 and Fisher’s exact tests were used to compare the two groups for age, gender, muscle mass-related measurements, oral function measurements, feeding function, and QOL measurements. Paired t-tests and the sign test were used to detect changes within groups from baseline to six months. Statistical analyses were performed using IBM SPSS version 25.0 . All p values were two-sided, and p<0.05 was considered significant.Bivariate analyses with t-tests, This study was approved by the Ethics Committee of Showa University School of Medicine , and all participants signed an approved informed consent form before participating in the study. All procedures were performed according to the World Medical Association Declaration of Helsinki (version 2002).PatientsA total of 31 patients (19 men and 12 women) were included in this study. The mean patient age was 62.90 years (standard deviation [SD]: 13.69 years). The participants were divided into PG and TG groups. The patients’ characteristics are described in detail in Muscle mass-related measurements2; TG- mean 24.44, SD = 4.07 kg/m2)   ].BMI: There was no significant difference in BMI between PG and TG groups at each time point .SMM: There was no significant difference in SMM score between PG and TG groups at each time point .Oral function measurementsLC: There was no significant difference in LC score between PG and TG groups at each time point  .TP: The mean TP score for the PG group was significantly higher than that for the TG group at all measurement points  .Feeding functionMASA-C: At BL, there was no significant difference in the MASA-C score between the PG  and TG  groups. At 1M, the mean MASA-C score of the PG group was significantly higher than that of the TG group . At 3M, the mean MASA-C score of the PG group was significantly higher than that of the TG group . At 6M, the mean MASA-C score of the PG group was significantly higher than that of the TG group  .FOIS: At BL, the mean FOIS score of the PG group  was significantly higher than that of the TG group . At 1M, the mean FOIS score of the PG group  was significantly higher than that of the TG group . At 3M, all the PG patients scored 7, and the mean FOIS score of the TG group  was significantly lower than that of the PG group (p<0.01). At 6M, all the PG patients scored 7, and there was no significant difference between the mean FOIS score of PG and TG groups  .QOL measurementsThe results of this study indicated that the area of the resected tongue had significant effects on tongue pressure (TP) and feeding function. In contrast, it did not indicate any effect on muscle mass-related measurements. QOL measurements did not demonstrate any significant difference before 6M. However, some QOL scores showed significant differences between PG and TG groups at 6M.In a previous study, it was reported that the reduction in TP depended on cancer stage, radiotherapy, and reconstruction . Patients who underwent minimal glossectomy, near-half partial glossectomy of the mobile tongue, and subtotal glossectomy demonstrated 6%, 59.6%, and 84.7% reduction in TP, respectively . In the present study, patients underwent subtotal/total glossectomy, indicating almost 80% reduction at 1M. However, it recovered to about 55% reduction from BL. In contrast, in patients who underwent partial glossectomy or hemi-glossectomy, TP levels almost similar to that at BL were noted. In this study, all patients received indirect and direct training, as needed. It has been reported that 9 weeks of oral motor exercise including lingual exercise increases lingual strength . This might be the cause of the recovery of TP in both groups.Before treatment, there was no significant difference in the MASA-C scores between the PG and TG groups. Only one patient demonstrated dysphagia (MASA-C score<185). This patient claimed an inability to eat a normal diet because of pain. However, after treatment, all TG patients indicated dysphagia. Thus, regardless of the size of the cancer, its presence causes dysphagia; however, no PG patients reported dysphagia. This suggested that patients with greater than half glossectomy had a higher incidence of dysphagia, with or without reconstruction. A previous study reported that the extent of tumor resection and lymph node metastasis affected swallowing in TC patients . Another study reported that patients with tongue resection greater than 50% and advanced tumor stage were at a high risk for aspiration . Dysphagia is among the most prevalent and debilitating symptoms resulting from HNC treatment. It has been reported that different mechanisms may contribute to the development and maintenance of dysphagia during HNC treatment . Studies have investigated the risk of aspiration in patients with tongue resection due to cancer. In this study, we used MASA-C to detect dysphagia. All TG patients reported dysphagia after treatment, regardless of the presence/absence of aspiration. Patients had undergone swallowing rehabilitation and used PAP, which resulted in improved bolus transportation, pharyngeal swallowing pressure, and clearance of the oral and pharyngeal residue . This could be why they were able to eat a normal diet despite dysphagia (FOIS score 7). A variety of assessment tools have been developed to measure the severity of dysphagia and the level of functional eating abilities are not the same .In this study, there were no significant differences between the QOL measurements of the two groups before 6M. However, the patient’s QOL dropped significantly after treatment. Some scales did not return to BL at 6M. Previous studies in HNC patients utilizing radiotherapy have also reported that the patient’s QOL did not return to baseline after treatment . However, a previous study reported that the QOL of HNC patients returned to baseline a year after treatment; in these patients, dysfunctional eating, diet, and speech persisted, but the changes were not statistically significant . The same tendency was noted in the present study at 6M. Some QOL measurements in the TG group related to tongue function  were significantly lower than that in the PG group. Before 6M, the effect of surgery on the healing period of the wound was evident in patients of both groups, and rehabilitation could improve the QOL in both groups. The patients enrolled in this study underwent swallowing rehabilitation, including direct/indirect training, and utilized PAP. This might have contributed to the prevention of the decline in QOL. In stroke patients also, swallowing rehabilitation is reported to affect QOL . By initiating rehabilitation at an early stage, tongue function and QOL measurements in the PG group recovered at 3M. However, the results of this study showed that patients who underwent surgical resection of a greater part such as subtotal/total glossectomy showed remnant functional impairment, indicated by a lower QOL score at 6M. This result suggested that it is necessary to develop more effective rehabilitation methods to improve the QOL of patients with residual functional impairment.It has been reported that neck dissection has a significant effect on swallowing function . If the pharyngeal branch of the vagus nerve is injured during neck dissection, the ability to clear the pharynx is reduced. In many cases of oral cancer, reconstruction of the pharynx results in a limitation of laryngeal elevation or a delay in the swallowing reflex, thereby causing aspiration. In this study, two PG patients and all TG patients underwent neck dissection. This might have had a significant effect on the result of MASA-C. The two PG patients who underwent neck dissection did not indicate dysphagia on MASA-C. This could be because the resected area of PG was small enough to preserve tongue function. In previous studies, patients with partial glossectomy did not show dysphagia because their tongue function was preserved even after treatment . It was thought that tongue function could have masked the effects of cervical dissection in PG. However, tongue function in TG was not enough to mask the effects of cervical dissection.Study limitationThis prospective cohort study was limited to a small sample size with further reduction in cases due to subject withdrawal during the course of the study. Patient drop-out during a prospective HNC study because of the recurrence of cancer, change of residence, etc. is not unusual . However, it may introduce a degree of subject bias into the overall results. Furthermore, additional variables such as the type, amount, and duration of medications  may provide an insight into the observed results. Thus, to better clarify the changes in QOL reported in the current study, future studies should incorporate larger samples, follow patients for a longer post-treatment interval, and consider additional variables that have the potential to affect the patients’ QOL.In conclusion, the size of resection had significant effects on oral morbidities. However, significant effects on the participant’s QOL were not demonstrated before 6M. At 6M, some QOL measurements in the TG group related to tongue function  were significantly lower than that in the PG group. The results of this study suggested that appropriate rehabilitation might help to improve the patients’ QOL. However, it is necessary to develop more effective rehabilitation methods to improve the QOL in patients with residual functional impairment.Yoshiaki Ihara; research planning, paper writing. Yuichi Tashimo, Shinji NOzue, Yoshiki Iizumi, Yuma Hukunishi, Yoshiro Saito; data collection. Toshikazu Shimane, Koji Takahashi; study design.


Obesity Surgery was the most prolific journal in this field. Prof. Schauer Philip R., Prof. Buchwald H. and Prof. Sjostrom L. were the most renowned experts in this aspect. The top cited references discussed the status of metabolic surgery for the treatment of T2DM worldwide and the importance of regular evaluation. The extracted keywords mainly formed three clusters: (1) research on the selection of different metabolic surgery methods; (2) possible mechanisms; (3) improvement of T2DM complications by metabolic surgery. Our study makes a comprehensive and objective analysis of metabolic surgery in obese patients with T2DM, providing valuable information for further clinical application and related scientific research. Researchers can quickly locate research hotspots in a large number of relevant literature.Metabolic surgery has become a powerful treatment for obese type 2 diabetes (T2DM). Experts have been devoting to the research of metabolic surgery in the treatment of T2DM. The debate continues, and there is no comprehensive statistical and intuitive analysis for it. To explore the current research status, the latest hotspots and the changing trend in this field, we conducted a bibliometric analysis. This paper made a bibliometric analysis based on the data source from Science Core Collection Network (WoSCC). Vosviewer v.1.6.10 software is used to construct a knowledge map. From 2011 to 2020, 1424 peer-reviewed papers on metabolic surgery for T2DM were retrieved. The United States contributed the most publications and gained global impact with the most citations.  The prevalence of type 2 diabetes (T2DM) and obesity is increasing across all age groups at alarming rates  T2DM andBibliometric analysis can be used to evaluate the research hotspots of a certain topic and find the direction of the field that has not been studied . ResearcAt present, thousands of original articles and comments on metabolic surgery for type 2 diabetes have been published, there is no comprehensive statistical and intuitive analysis for it. Our study bridges this gap using bibliometrics analysis and provides a comprehensive perspective on metabolic surgery for T2DM. Based on the advantages of the bibliometric analysis software Vosviewer, publications related to metabolic surgery of T2DM was statistically analyzed to reveal the core research, hotspots evolution and future development trends of related research on this topic. For this study, we assessed the annual publications growth, international collaborations, author productivity, source journals, and keyword co-occurrence analysis in relation to studies on metabolic surgery for T2DM.https://www.webofknowledge.com). We set the search criteria as follows: search topics, “metabolic surgery AND type 2 diabetes”; document type, “article”; year range, “from 2011 to 2020”; and no limit on language was set. The annual numbers of publications and the top discipline categories will be automatically generated after retrieval. VOSviewer 1.6.11, which was developed by Van Eck and Waltman of Leiden University, has the advantages of conducting accurate statistical analysis, clustering large-scale data, generating density visualization, and locating scientific research hotspots. In this study, we selected citation and co-authorship analysis to report and categorize top countries, institutions, authors, and source journals. Then, the research results are mapped from the perspective of network to illustrate the advantages of core research and reveal the collaborative relationship between them.The data used for bibliometric analysis were downloaded from the Web of Science Core Collection (WoSCC) database .Based on our search results, articles on metabolic surgery for T2DM were published in 49 journals. Table The research hotspots for treatment of metabolic surgery for T2DM were identified by high-frequency keyword co-occurrence analysis. The minimum co-occurrence of the keyword was set to 20. Of the 4185 keywords extracted for metabolic surgery for T2DM, 118 keywords reached the threshold, and those keywords with similarities were clustered based on the network. The three main clusters were represented by red, green, and blue, respectively  includes keywords representing different metabolic surgical procedures. As shown in Table Researchers have tried to explore the best biological and clinical predictors of postoperative remission of T2DM, including BMI, age, islet function, preoperative application of hypoglycemic drugs and surgical types et al. Some of the studies are case study and some are retrospective study and cohort study. Geltrude Mingrone et al.  considerIf we can elucidate the predictors of long-term remission of T2DM and determine which groups of people respond poorly to metabolic surgery, we can inform patients preoperatively of the likelihood of a suboptimal outcome. Doctors can be more specific for the surgical population, and patients can make more rational decisions about surgery.The development of minimally invasive laparoscopic techniques has led to an overall increase in the safety of metabolic surgery. It also reduces the risk of operative mortality. However, the side effects such as trace element deficiency and anemia cannot be avoided. In addition, there is a certain contradictory relationship between weight loss and cardiovascular disease after metabolic surgery. Some studies shown that trimethylamine nitric oxide (TMAO) increases after RyGB both in animal and human , 13. HowCluster 2 (green colored) represents keywords related to the mechanism of metabolic surgery for T2DM. As shown in Table Studies have shown that metabolic surgery has a profound impact on intestinal microflora. Maria Carlota Dao et al. 20 (citation no. 3) reported that Akkermansia muciniphila is a kind of mucin-degrading bacteria. Akkermansia muciniphila increases with bariatric surgery in both humans and mice, and is thought to help reduce body fat mass, glucose homeostasis, reduce adipose tissue inflammation, and increase intestinal integrity. The gut bacteria could be considered therapeutic targets. Therefore, further investigation may make it a therapeutic option, for example, to select suitable bacteria for intestinal flora transplantation.The mechanism of AMP-activated protein kinase (AMPK) has also attracted extensive attention. Neil B. Ruderman et al.  (citatioCluster 3 (blue colored) represents keywords related to outcomes, association, risk factors, mortality of metabolic surgery for T2DM research Table . AccordiSjostrom et al.  (co-citaAccording to our results, most authors focused on the study of metabolic surgery and macroangiopathy. Studies on metabolic surgery and microvascular lesions are limited. Buchwald et al.  (co-citaObesity on cardiovascular effects not limited to adults, also affects children and adolescents. Kelly et al.  reportedDespite these advantages, some limitations should also be considered. First, papers extracted from WoSCC from 2011 to 2020 may not cover all topics of metabolic surgery in T2DM research. WoSCC is a more suitable database for citation analysis. Second, most of the publications of WoSCC are in English, which may lead to linguistic bias. In addition, cooperative network analysis can show the co-occurrence and co-authorship of the institution, but VOSviewer cannot generate geographic map of co-author in the output file. Therefore, it is not possible to generate the visualization of geographical location and co-author, nor to calculate an understanding of their relationships.In conclusion, through the bibliometric analysis and visualization method, the current study provides a new perspective to analyze the application of metabolic surgery in the treatment of T2DM. This metabolic surgery treatment is a promising direction globally, with great potential for improving T2DM therapies. Our study makes a comprehensive and objective analysis of metabolic surgery in obese patients with T2DM. We expect this work may provide valuable information for further clinical application and related scientific research.


Gastric ulcers and colic of intestinal aetiology (CIE) are highly prevalent diseases in domestic horses, with a negative impact on equine sport and breeding life. Therefore, the studies investigating possible biomarkers for their diagnosis or clarifying their pathophysiology are of high interest. Oxidative status changes have been reported in both diseases, but only in the blood. However, saliva may be a relevant source of oxidative status biomarkers not yet assessed in horses with interesting advantages, owing to its non-invasive collection. Hence, this study aimed to validate in both saliva and serum automated assays for the measurement of oxidative status biomarkers and assess them in horses suffering gastric ulcer diseases (squamous and/or glandular) and CIE, studying their possible relationship with their inflammatory and immunity status. It was found that horses with glandular mucosa ulcers showed higher levels of some antioxidant and oxidative biomarkers in saliva correlating with a marker of the immune system such as salivary adenosine deaminase. Horses suffering from CIE had increases in serum uric acid associated with their systemic inflammatory response and outcome of the disease. In conclusion, some oxidative status analytes can be automatically measured in horses’ saliva and serum and may potentially be assessed as biomarkers of gastric ulcers and CIE.Changes in the oxidative status of the blood of horses suffering from gastric ulcers and colic of intestinal aetiology (CIE) have been reported. However, saliva can also be a source of biomarkers of oxidative status. Therefore, this study aims to validate automated assays for the measurement of oxidative status biomarkers  in the saliva and serum of horses, to assess their changes in the different ulcer gastric diseases (squamous—ESGD and glandular—EGGD) and CIE, and to evaluate their relationship with serum amyloid A (SAA), adenosine deaminase (ADA), and the systemic inflammatory response syndrome (SIRS) status. The assays showed a low imprecision and good linearity with enough sensitivity in both fluids. In EGGD, higher levels of FRAS, uric acid, and AOPP in saliva were observed compared to the healthy group, correlating with the salivary ADA levels. Horses with CIE showed increases in uric acid concentrations in serum associated with their SIRS status and outcome of the disease. In conclusion, analytes related to the oxidative status can be measured in the saliva and serum from horses by automated assays, and some of them can potentially be assessed as biomarkers in horses with gastric ulcers and CIE. Blood is the sample most frequently used for biomarker assessment in human and veterinary medicine . HoweverEquine Gastric Ulcer Syndrome (EGUS) and colic of intestinal aetiology (CIE) are diseases with a significant impact in equine sport and breeding due to their prevalence and costly treatment ,9. In thTherefore, this study aims: (1) to validate assays for the measurement of selected biomarkers of oxidative status in saliva and, for comparative purposes, serum of horses; (2) to assess the possible differences in these analytes if suffering from EGSG, EGGD, or CIE; (3) to evaluate the possible relationship of these analytes in serum and saliva with the inflammation status assessed by the serum amyloid A (SAA) ,17 or thThe horse population enrolled in this study originated from the Large Animal Teaching Hospital at the University of Copenhagen and the Veterinary Teaching Hospital of the University of Extremadura. Samples were collected from February 2020 to May 2021. The horses’ age, sex, and breed were recorded.The diseased population were diagnosed at those hospitals by certified internists .Horses suspected of EGUS   were ref9/L), and rectal temperature (outside the range of 37.0–38.5 °C). When performed, necropsy diagnoses were recorded.Colic of intestinal aetiology was diagnosed in both centres based on history, physical examination , haematology, plasma biochemistry, examination per rectum, transabdominal ultrasonography, gastric reflux, abdominocentesis results, exploratory laparotomy, and/or response to treatment. Whether each suffered a systemic inflammatory response syndrome (SIRS) was evaluated by the SIRS score (4 point-score) proposed by Roy et al. . AccordiThe healthy population was selected from privately owned horses admitted at the hospitals for routine health checks without any signs of illness to confirm their health status, in which a gastroscopy study, as previously described, was performed to discount EGUS . At the hospital, they showed normal findings on a physical examination  and no haematological or biochemical abnormalities.g for 10 min at 4 °C within 30 min of sampling. Saliva and serum were then transferred into Eppendorf tubes and stored at −80 °C until analysis. Horses that yielded serum samples with visual gross haemolysis or blood-contaminated saliva samples were excluded from the study.The saliva was obtained as previously reported ,22. The The samplings in the EGUS and healthy population were performed before intravenous sedation and gastroscopy but immediately after the horses were placed in the examination stand. In the CIE group, the samples were obtained after the arrival at the hospital, immediately after horses were placed in the examination room.The TAC analytes  and the biomarker of oxidant status AOPP were measured by assays previously adapted to automated analysers and used for measurements in saliva and serum of different veterinary species such as pigs, sheep, or cows ,24,25. TThe ADA enzyme in saliva and serum , ADA isoenzyme 1 (ADA1), and isoenzyme 2 (ADA2)) was determined by a commercially available spectrophotometric automated assay  previously reported and validated in horses (lower limit of detection (LLOD) = 0.07 IU/L) . ADA2 waThe salivary and serum analytical validation for the FRAS/FRAP, CUPRAC, TEAC, uric acid, and AOPP analytical assays was determined assessing the following characteristics:Imprecision. Calculated as the intra-assay precision by the within-run coefficient of variation . For this purpose, three pools of saliva and serum samples with high, medium, and low levels of each of the above analytes  were use2 were calculated.Accuracy. Indirectly estimated by linearity under dilution. It was calculated by serially diluting  two pools of saliva/serum obtained as described above  with deiSensitivity. Determined by the LLOD and the lower limit of quantification (LLOQ). The LLOD is defined as the lowest values of the analyte that could be distinguished from a specimen of zero value. It was calculated as a mean value plus 3 standard deviations of 13 replicate determinations of the zero standard (deionized water). The LLOQ is the lowest level of the analyte that can be measured above the limit of detection with a CV < 20%, and it was calculated from a pool of saliva/serum obtained as above described serially diluted with deionized water  and each dilution was analysed in five replicates in the same run. CVs for each dilution were estimated for the intra-assay precision.Data were checked for normality using the Shapiro–Wilk normality test. Arithmetic means and 95% confidence interval (CI) if data showed normal distribution or medians and interquartile range (IQR) if not normally distributed, standard deviation (s.d.), CVs, and linear regression analysis for the linearity under dilution test were calculated using an Excel 2000 h spreadsheet and Graph Pad Software Inc. .p ≤ 0.05 were selected to indicate significance in all analyses).The possible differences in the salivary and serum oxidative stress profile, ADAt in saliva and serum, and ADA isoenzymes in saliva between the healthy population and the horses suffering ESGD, EGGD, ESGD + EGGD, or CIE, and between the healthy population and those horses which survived CIE vs. those that did not (non-survivors), were evaluated by a one-way ANOVA test with Tukey’s adjustment for multiple comparisons or by the Kruskal–Wallis test followed by Dunn’s multiple comparisons test, depending on whether the data were normally or abnormally distributed, respectively. A stand-alone power program for statistical testing (G-Power)  was empln = 6, average age = 11.0 ± 5.0 years), EGGD , ESGD+EGGD , CIE , and healthy populations  are provided in A total of 23 horses with EGUS and 22 horses with CIE were enrolled in this study. Details of ESGD , uric acid in saliva in the healthy population (n = 2), horses with ESGD+EGGD (n = 1), and uric acid in serum in the healthy population (n = 4), ESGD (n = 1), EGGD (n = 2), ESGD+EGGD (n = 1), and CIE (n = 2 and n = 1) populations, respectively. In these cases, the LLOQ was used for statistical purposes.The LLOD and LLOQ of the oxidative status profile evaluated are shown in p = 0.009, β error = 0.02), ADA1 , and ADA 2  than the healthy horses . The non-survivors in the CIE population had higher levels in saliva of ADA1  and ADA2  than the healthy horses.Horses with CIE had higher salivary levels of ADA2 than the healthy population , uric acid , and AOPP  in saliva, and the ratio AOPP/albumin  in serum were higher in the horses with EGGD than in the healthy group.The levels of FRAS , uric acid , and the AOPP/albumin ratio  than in the healthy horses. The CUPRAC level in serum was lower  in horses suffering from CIE than in the healthy group.In serum, horses with CIE showed increased levels of FRAP (p = 0.005 and p = 0.005) and non-survivors (p = 0.002 and p = 0.031) showed increased levels of FRAP (β error = 0.06) and AOPP/albumin ratio (β error = 0.04) compared with the healthy group. TEAC and uric acid levels in serum were higher (β error = 0.65 and β error = 0.01) in the non-survivor horses compared to both the healthy (p = 0.02 and p = 0.001) and survivors (p = 0.02 and p = 0.001) horses, respectively.In horses with CIE , both thp = 0.014, p = 0.018, and p = 0.006), CUPRAC , and TEAC  with ADAt, ADA1, and ADA2 values, respectively, and in the horses suffering EGGD between FRAS (p < 0.001), CUPRAC (p = 0.001), and uric acid (p = 0.023) with ADA2. In serum, a high correlation in horses with ESGD was observed between TEAC and SAA levels (p = 0.003).The correlations’ results are listed in p = 0.016) was observed between the SIRS score and the serum levels of uric acid.In the horses diagnosed with CIE, a moderate correlation  . They alChanges in biomarkers of oxidative stress were observed in horses with EGGD and CIE. Horses suffering from EGGD showed increased values of the oxidant biomarker AOPP and the antioxidant biomarkers FRAS and uric acid in saliva, whereas changes were not observed in horses suffering from ESGD. The pathophysiology of ESGD has been related to factors that increase the exposure of the squamous mucosa to acid, whereas the EGGD pathophysiology has not been totally elucidated . It is hThe fact that only horses with EGGD showed significant increases in the saliva of ADA and its isoenzymes, which are biomarkers of the immune system activation, could indicate an involvement of the immune system in EGGD. This would be in line with recent reports that relate an immune-mediated involvement in the pathophysiology of gastroduodenal disease, ulcerogenesis, and the healing process in horses ,9,11,20.In horses with CIE, the oxidative status changes were reflected in the serum, with changes in the antioxidant biomarkers FRAP, CUPRAC, and uric acid, and in the oxidative biomarker AOPP. The ratio of AOPP/albumin increasing in horses with CIE could reflect a disturbance in the oxidative status as previously described in horses with impactions . TherefoThis report has some limitations and, therefore, should be considered as a pilot study. It is important to point out that the possible stressful situation of being in a new place could influence our results, mainly in the CIE group since they were sampled immediately after their arrival. Additionally, a gastroscopy was not performed in horses from the CIE group. Therefore, possible gastric ulceration could not be ruled out in these horses. In addition, although most of the analytes showed adequate statistical power, these results should be considered preliminaries. Therefore, further studies with a larger population of horses with ESGD, EGGD, and CIE with a stricter inclusion criterion to separate out their differences and causes should be performed to confirm our findings and to evaluate the ability of the analytes of this report for its clinical use, not only in the diagnosis but also to evaluate disease progression and monitoring of treatment. In addition, further studies should be performed to evaluate whether these oxidative status changes in horse saliva and serum are only observed in gastrointestinal diseases or other types of diseases not related to the gastrointestinal tract.Based on this study, a panel of analytes related to oxidative status  can be measured with sufficient reliability and sensitivity in both saliva and serum from horses using automated assays, being the first study that analytically validates them in horse saliva to the best of the authors’ knowledge. In addition, changes in the saliva FRAS, uric acid, and AOPP levels and serum ratio of AOPP/albumin from horses with gastric ulcers in the glandular mucosa, and in the serum FRAP, CUPRAC, uric acid levels, and the ratio of AOPP/albumin from horses suffering from CIE, were observed. These redox biomarkers’ changes in horses suffering from EGGD are correlated with the ADA activity in saliva, a biomarker related to the immune system. Overall, this report indicates, for the first time, that analytes related to redox status can be measured in the saliva of horses and can have potential use as biomarkers in this species. The evaluation of these analytes has advantages associated with the use of saliva, such as easy, non-painful, and non-invasive collection, and the possibility to be obtained in field conditions, with repeated sampling, producing minimum discomfort and anxiety.