Thirty-nine study participants (56%) experienced at least one WMSD at the elbow, forearm, and/or wrist, mainly with signs of epicondylitis and nerve entrapment at the medial elbow. The risk of grinders developing upper extremity WMSD was about 2.5-times higher and packers had an 8.6-fold higher risk of a clinically relevant DASH > 29 compared to the control group. However, these differences were not statistically significant. The groups were also proven to be clinically equivalent in terms of DASH score. Surgical device mechanics do not seem to have worse DASH values or be at higher risk of upper limb WMSDs compared to a control group. This is the first study to analyse and compare different workplaces in this industry that are also common in other industries.To assess the prevalence of upper extremity work-related musculoskeletal disorders (WMSDs) among surgical device mechanics compared to a control group, a total of 70 employees were included and assigned to three occupational groups . Personal factors, work exposure, manual skill, and complaints were assessed by two self-administered questionnaires and an industry test. WMSDs were diagnosed in a standardised clinical examination. The two-one-sided  Work-related musculoskeletal disorders (WMSDs) are pathologies in which the work environment and performance of work contribute significantly to the condition and/or the condition is made worse or persists longer due to work . These dUpper extremity pathologies related to work were first described in the 18th century by the Italian doctor and philosopher Bernardini Ramazzini, the father of occupational medicine. Today, the overall prevalence of upper extremity WMSDs ranges from 4% to 20% . It has A PubMed search using the search terms “musculoskeletal disorder” AND “work” AND “upper extremity” (date of search: 12 July 2019) returned 1504 hits; from these hits 262 articles were shortlisted. Of 178/262 (68%) original research articles found, 60/178 (34%) publications contained a clinical examination of the test subjects with or without structured questionnaires/interviews. Of these, 50 were publications with a cross-sectional study design, but only 11 articles contained a control group.Sorgaz described a repetitive strain injury model according to which highly frequent repetitive movements cause microlesions that accumulate in the affected musculoskeletal structures and eventually cause symptoms . EpidemiUpper extremity WMSDs have been shown to be related to numerous occupational situations and specific industries . The medThis study was conducted at the headquarters and main production site of Aesculap AG, Tuttlingen, Germany, which has approximately 3500 workers and employees. It is the world leading manufacturer of surgical instruments situated in a local area with more than 400 medical technology companies of varying sizes. Following an analysis of the workstations and work content, we defined three different study groups: group I = grinding and polishing characterised by repetitive and forceful exertions (subsequently referred to as “grinding”); group II = inspection and packaging characterised by repetitive exertions without force (subsequently referred to as “packaging”); and group III = all other white-collar and blue-collar employees working in manufacturing, warehouse, and office, representing a cross-section of the company not including groups I and II  as a control group (hereinafter referred to as “control”). A detailed description of the job tasks is listed in Control: The control group represents a cross-section of the company’s working population. All workplaces at the company were included, from light office work to heavy work with high physical strain.The study was approved by the Ethics Committee of the State Medical Council of Baden-Wuerttemberg, Jahnstrasse 40, 70,597 Stuttgart, Germany (project number F-2017-005). Random samples of active white-collar and blue-collar workers from the targeted groups were taken via randomisation lists between September 2017 and March 2018 and this sample population was asked to fill in two self-administered questionnaires after having agreed to enter the study and signed the informed consent form. No incentives were offered. The first standardised questionnaire obtained information about exclusion criteria (see below), demographic, and personal data, such as sex, handedness, secondary occupation, sporting and physical hobbies , age, height and weight (body mass index), volume of employment, and years of service (continuous parameters). Current subjective complaints in the upper extremities  were also recorded in this questionnaire. The validated Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure was used as a second questionnaire ,20. The Age <18 or >65 years.Employment in the respective workplace for less than 5 years.Currently on sick leave.Absence from work due to upper extremity pain for more than 2 weeks within the last 3 months.Cervical spine syndrome or herniated intervertebral disc.Shoulder pain radiating into the forearm.Debilitating congenital malformation of the upper extremity.Rheumatoid conditions including fibromyalgia.Previous upper extremity surgery due to nerve entrapment syndrome(s) and/or chronic musculoskeletal disorders, such as tennis elbow, golfer’s elbow, tenosynovitis of the flexor and/or extensor tendons, including trigger finger and de Quervain’s disease.More than three unanswered items in the DASH disability/symptom questionnaire.The following exclusion criteria were applied in this study: We applied the DASH to measure physical function and symptoms in patients with one or more musculoskeletal disorders in the upper limb . We chosThe participants were invited for a structured physical examination of the elbow, forearm, wrist, and hand. It consisted of active range of motion (ROM) manoeuvres of the wrist , grip strength by Jamar dynamometer (3 measurements per side), pain on a visual analogue scale (VAS) at rest and under strain, as well as a search for tender points for tenosynovitis. The examiner decided the diagnoses based on a standard set of criteria for pathognomonic clinical signs specific to upper extremity pathologies as proposed by Waris et al. . These iThe participants also underwent the Purdue Pegboard (PPB) Test, which is a neuropsychological test that involves different abilities: gross movements of arms, hands, and fingers, as well as fine motor extremity , and bimanual dexterity ,30. It wThere were only two different examiners  to optimise inter-rater reliability. The examiners were blinded to the questionnaire responses.t-test (TOST) procedure [t-test levels of 0.025 [All statistical analyses were performed using the SAS software version 9.4 . The primary analysis consisted of two parallel tests, which proved the hypothesis of equivalence of a respective test group and the reference group. This confirmatory analysis referred to the disability/symptom DASH score  and used the two-one-sided rocedure . Both thof 0.025 . The equof 0.025 . The 95%of 0.025 .For descriptive statistics with approximately normally distributed continuous data, the mean value and standard deviation  were calculated. For clearly non-normally distributed data, especially skewed continuous data, the median and interquartile ranges  were calculated . For catWhere statistical tests have been used for comparisons between groups, the two-sided p-values must be considered as measures of the effect size rather than as confirmatory values. t-tests in the TOST was set to 0.013. Assuming an expected group mean difference of 0 and a pooled standard deviation of 14.68, the study has a power of 80% to detect equivalence when the sample size is 26 per group [The sample size was calculated using nQuery Advisor 7.0 . The one-sided significance level used for individual er group . n = 20, packaging n = 24, and control n = 26) were included in the study. Six subjects were excluded, five for medical criteria and one because of absence from work due to upper extremity pain for more than two weeks within the last three months.Based on a basic population of about 3500 workers and employees, the total population after application of the inclusion criteria  consisted of 63 subjects in group I, 208 in group II, and 2501 in group III . A rando2), full volume of employment (91% (64/70)) and years of service at the company (16.1 (9 to 28) years) ) and right-handed (83% (55/70)). Very few had a secondary occupation (9% (6/70)) and 61% (43/70) reported having sporting or physical hobbies. The three groups had comparable demographic data with regard to age (42.1 (12.2) years), body mass index (BMI) (26.2 (5.0) kg/m) years) .The DASH scores for each of the three groups, including the optional sports/music and work modules, are shown in p-values < 0.0001). The mean score differences with corresponding 95% confidence limits are shown in The distribution of the values of the DASH score in the three groups is shown in The primary analysis proved that both grinding and packaging were equivalent to the control group. As the equivalence margins were set in respect to the minimal clinically important difference (MCID), these results support the evidence that the differences between the groups were not clinically relevant. Aside from the clinical relevance, the observed differences were proven to be statistically significant with 95% confidence intervals . As both 95% simultaneous confidence intervals for difference do contain zero, the significance of the observed differences at the 5% level can also be denied. Exploratively, we divided the DASH score in the individual groups according to gender. A clearly different structure in the distribution between men (homogeneous) and women (variable) was observed .Upper extremity pain  was reported in the questionnaire by 40% (8/20) of grinders, 58% (14/24) packers, and 42% (11/26) of the control group. Pathognomonic clinical signs for upper extremity WMSDs  at the elbow, forearm and/or wrist  were found in 56% (39/70) of the people examined. The frequency of one or more diagnoses was 60% (12/20) for grinders, 58% (14/24) for packers, and 50% (13/26) in the control group . BilaterThe sensitivity of the upper extremity pain (symptoms) to the gold standard of pathognomonic clinical signs (diagnoses) was 54% (21/39) whereas the specificity was 61% (19/31) . In our sample there were three packers with a DASH score >29, while in the control group there was no such case ). In the grinder group, 14 subjects were diagnosed with upper extremity WMSD, in the control group these were only 12 ). Further odds ratios are shown in Continuous clinical parameters are shown in The results of the Purdue Pegboard Test (PPB) are shown in Upper extremity WMSDs represent a range of disorders of the muscle, tendon, or nerve that also can occur in non-workplace settings with a similar or identical pathophysiology ,41. MuscWe conducted this prospective study at the headquarters and main production site of Aesculap AG, which is a leading manufacturer and global player in the surgical instrument industry, located in a medical technology cluster region ,43. AmonThe DASH outcome measure has proven to be a reliable and valid instrument to measure physical function and symptoms in upper extremity musculoskeletal complaints, including WMSDs ,45. It iAs in previous studies, it was observed that a non-clinical “normal” population does not have a zero value . Both grSurprisingly, it is not the grinders with their loading and repetitive activity tasks that have the highest (=worst) DASH score, but the packers whose work tasks are defined as repetitive with less loading and more variability in the movement sequences. This finding contrasts with a study which has shown significant differences in DASH scores between manually demanding and manually low-demanding jobs in favour of the latter . One reaThe average values of the three investigated groups correspond to those of a population not employed in manual work. A literature review showed that our scores are generally lower than in most studies that have analysed normative values in the general population outside clinical settings ,51,52,53Interestingly, the DASH showed a homogeneous distribution between the three groups in men, while women had a very inhomogeneous distribution. The influence of age (increasing DASH scores with increasing age) and gender (higher DASH scores in women) as well as further co-variates in this context will be topic of our future studies ,52.Active range of motion of the wrist and pain on the visual analogue scale (VAS) showed no abnormalities or relevant differences between the groups. The measured values for grip strength were partly below the published reference values, taking into account handedness, age, and sex ,48. In tThe design of our cross-sectional study with a control group, physical examination of the subjects, and the use of a questionnaire can be found in several studies related to different industries. Our literature research showed a prevalence of upper extremity pain  of between 21% and 71% in the study group and between 6% and 50% in the control group ,66,67,68In most studies, only the symptoms of musculoskeletal disorders of the upper extremity were described, instead of additionally identifying pathognomonic clinical signs . In the latter the prevalence has ranged from 21% to 56% compared to 5% to 22% in the control group ,61,62,64It has been shown that musculoskeletal disorders in different body regions are associated with different branches of industry. Lateral epicondylitis, wrist tendinitis and carpal tunnel syndrome are considered the most common diseases ,62,64,70We hypothesised that there would be no clinically relevant differences in the prevalence of upper extremity WMSDs between surgical device mechanics with specific repetitive work tasks, with and without forceful exertions, compared to other employees in the same industry. We were able to confirm this with surgical device mechanics not seeming to be at higher risk of upper limb WMSDs compared to the control group. Although grinders and packers had higher DASH values than the control group, this difference was of no clinical relevance and statistically not significant. However, there are partly contradictory statements in this regard from other sectors of industry ,14,15,76The diagnostic patterns observed in this investigation were, in general, consistent with medial epicondylitis and cubital tunnel syndrome in the elbow. Lateral epicondylitis, tenosynovitis in the wrist, and carpal tunnel syndrome were underrepresented. This can also be explained by the working positions at various workplaces, some of which were noticeable during our site inspections, with partially unpadded support of the elbows and proximal forearms on edges and surfaces . In addition to regular occupational health check-ups, the study company offers optional preventive medical check-ups for individual complaints. Furthermore, there are check-up programs for each employee on a voluntary basis to identify risk factors, preliminary stages of illness or diseases, and to be able to prevent or treat them in a targeted manner. In the latter case, a full-body profile is created including patient history, blood values, Electrocardiogram (ECG), lung function testing, visual and hearing tests, as well as a full body examination, including different organ systems. If particularities are identified during these examinations, further targeted measures may be taken. In the case of upper extremity WMSDs, hand therapeutic measures, ergonomic optimization of the workplace, and examinations by specialists  are usually initiated. Based on our study results, the response to the strikingly high rates of medial elbow pathologies should be an ergonomic sitting position and simple padding of the table edges. Longer periods of repetitive work, especially for packers, should be interrupted by other types of work, including job rotation as a preventive measure.There is a possible evaluation bias as it was not possible to blind clinical evaluators due to the participants’ clothing (blue collar vs. white collar workers). Thus, we believe that the bias is small, if present. A selection bias is also likely as persons with upper extremity complaints could be more motivated to volunteer. However, since this effect applies equally to the study groups and the control group, it would be cancelled out and at the same time increase the total number of complaints. This last effect may partly be compensated by the healthy worker effect, which often results in the working population being statistically shown to be healthier than is actually the case. People with pain and functional disorders might leave their work, and cross-sectional studies thus may underestimate the risk. The only validated test available for our series is the self-reported DASH outcome measure. However, the ability of subjects with musculoskeletal disorders cannot be assessed on the basis of questionnaires alone. As in every questionnaire, the translation of scores from the questionnaire to functional capacity for work can be questioned. Furthermore, our cross-sectional data has inherent limitations, including the inability to clearly distinguish clinically between the chronic, recurrent, and acute symptoms we observed. In addition to biomechanical constraints, psychosocial factors with difficult-to-define effects have been shown to play a role in the genesis of WMSDs ,80,81. WPlanning the current study, we assumed a normal distribution for the DASH score. The statistical analyses followed the a priori plan in order to maintain the significance level. The distribution analysis of the study data revealed an obvious ceiling effect, with 12 of 70 participants having the best score of 0 pts. Normal distribution-based statistical methods may lose sensitivity in terms of detecting differences between groups, with respect to the power to detect effects in such a situation. The ceiling is not unusual in studies using scores for outcome evaluation, particularly studies in orthopaedics, and should be taken into account when planning statistical analysis for future studies using DASH scores .The strengths of this study include the comparatively homogeneous study groups of healthy and physically active subjects as well as the above-average length of service of the employees with low job turnover, which should keep confounding to a minimum. In a lot of studies of WMSDs, the workplace data come from case series compiled from records of reportable injuries and illnesses kept by the employer’s liability insurance companies and the in-plant medical departments. Since these sources identify late-stage disorders that prompt workers to seek medical attention, the data probably identify an incomplete subset of cases and underestimate the true rates of disease. With regard to the study design of our investigation, the combination of self-administered questionnaire and specific face-to-face physical assessment has proven effective in obtaining a consistent study result. Thereby the criteria for specific and reliable assessment of the functional capacity of the forearm and hand according to Wind et al. were met . FurtherOur findings do not indicate that repetitive work with and without forceful exertions is associated with a higher risk of upper extremity WMSD in surgical device mechanics compared to a control group, but small effects cannot be ruled out. Although a high standard of occupational health and safety measures can be assumed within the study company, the pathologies frequently found in the medial elbow may be due to specific working practices. Based on the results of this study, targeted occupational health measures can be designed and implemented with the aim of both preventing and treating upper extremity musculoskeletal disorders . Once th


There are no prior publications or submissions with any overlapping information, including studies and patients. The study data have not been presented as an abstract or poster before the submission.Objectives: The study was conducted to analyze the changes of baroreflex sensitivity and heart rate variability from supine to upright standing in children and adolescents with orthostatic hypertension to explore whether and how the autonomic nerve regulation was involved in the development of pediatric orthostatic hypertension.Methods: This case-control study included twenty-five children with orthostatic hypertension (the patient group) and twenty-six healthy controls (the control group). All subjects underwent a standing test, during which their hemodynamic parameters were continuously monitored by a Finapres Medical System, and baroreflex sensitivity and heart rate variability were calculated.Results: The demographic characteristics, supine baroreflex sensitivity, and supine heart rate variability including time domain and frequency domain indices did not differ between the patients with orthostatic hypertension and healthy subjects (P > 0.05). However, a more obvious drop of baroreflex sensitivity and a greater increase of low frequency/high frequency ratio from supine to upright were observed in subjects with orthostatic hypertension compared with those in the healthy children . Changes of baroreflex sensitivity were negatively related to mean arterial pressure changes from supine to upright in all subjects (P < 0.01), and the increases in low frequency/high frequency ratio from supine to standing were positively correlated with those in mean arterial pressure in the study subjects (P < 0.001).Conclusion: Upright sympathetic overactivation is associated with pediatric orthostatic hypertension. Orthostatic hypertension (OHT) refers to a significant blood pressure (BP) elevation in the upright position compared to supine or sitting position, which reflects abnormal regulation of BP during postural changes. Streeten et al.  first puWhile, in adolescents and children, OHT has been recognized recently and it is now considered as an important cause of orthostatic intolerance (OI) –13. Our OHT stands for the hypertension occurring from supine to upright, and the autonomic nervous system regulates and maintains BP and heart rate (HR) during postural changes via baroreceptors . Hence, Therefore, this study was aimed to examine the possible changes in BRS and HRV indices from supine to upright in children and adolescents with OHT, and reveal the role of autonomic regulation in the development of pediatric OHT.Standing test); and exclusion of other diseases that cause OI symptoms (This case-control study enrolled 25 children with OHT (the OHT group) and 26 healthy children (the control group). The OHT group included 11 girls and 14 boys, from age 8 to 17 (12.5 ± 0.5) years old. All patients with OHT were admitted to the Department of Pediatrics at Peking University First Hospital from October 2015 to June 2019 with OI symptoms as their chief complaints and were diagnosed with OHT according to the published guidelines ≥ 20 mmHg and/or increased diastolic BP (DBP) ≥ 25 mmHg (in children 6–12 years old) or ≥ 20 mmHg (in adolescents 13–18 years old) from supine to upright standing; or during upright standing, BP ≥ 130/90 mmHg (in children 6–12 years old) or ≥ 140/90 mmHg (in adolescents 13–18 years old) , 20.During the standing test, HR, BP, and standard three-lead electrocardiograph were taken and recorded with a Dash 2000 Multi-lead Physiological Monitor . The last BP measured in supine position and the BP measured at 3 min after standing served as supine BP and upright BP, respectively. R-R interval (RRI) data obtained from electrocardiograph were visually reviewed, and five-min segments free of ectopic beats and artifacts severally in supine and upright position were used for further analysis.Meanwhile, the Finapres Medical System  was applied to continuously and non-invasively record beat-to-beat BP data during the standing test and calculating hemodynamic parameters and BRS afterwards. Using a finger plethysmogram, beat-to-beat BP measures of SBP, DBP, and pulse intervals were collected. Then, stroke volume (SV) was computed with the model flow method. HR was calculated as the inverse of the pulse interval, and cardiac output (CO) was calculated as HR multiplying SV. Mean arterial pressure (MAP) was computed as the true integral of the arterial pressure wave over one beat, and total peripheral vascular resistance (TPVR) was calculated from MAP divided by CO. Average CO and TPVR taken from the last 1 min of the supine period was regarded as the supine values, and the upright CO and TPVR were computed as a 1-min average in the third minute after standing. The reliability of beat-to-beat BP measurements was validated using a Finapres system .P < 0.01, the slope between SBP and interbeat interval was documented as one BRS value  and root mean square of successive differences (RMSSD) of RRI were analyzed. Original RRI series was altered to equidistantly sampled sequence by a cubic spline interpolation method. Fast Fourier transformation was then used to obtain power spectral density (PSD) functions with Welch's periodogram method. Total power (TP) in the frequency range from 0.0 to 0.4 Hz was composed of very low frequency , low frequency  and high frequency  bands. Powers of each band were computed as integrals under the respective PSD functions. The ratio between normalized LF power and HF power was calculated as LF/HF ratio.P < 0.05 (2-tailed) indicated a statistically significant difference. The independent t test was applied for the comparisons between groups in the same position, and the paired t test was utilized to compare the corresponding parameters before and at standing for the same person. The Chi-squared test was used to compare categorical variables. Covariance analysis was adopted to compare all autonomic measures (BRS and HRV) after adjusting for gender, age and body mass index (BMI). Pearson correlation analysis was used for linear correlations and partial correlation analysis was adopted to correct the influence of gender, age, and BMI.Statistical analyses were carried out with SPSS 20.0 software . All data are expressed as means ± SE, and P > 0.05, The sex ratio, age, height, weight, or BMI between the subjects in OHT and in control groups did not significantly differ . However, at 3 min of standing, the patients with OHT exhibited significantly higher SBP, DBP, and MAP than the control subjects . In addition, from supine to standing, OHT patients experienced an obvious decrease in CO (P < 0.01) and a marked increase in TPVR (P < 0.01), while the CO and TPVR of the control group did not show any significant changes upon standing (P > 0.05).As seen in P < 0.001), and the upright BRS in the OHT group was significantly lower than that in the control group after controlling for gender, age and BMI (P < 0.001). As for HRV indices, SDNN, RMSSD, TP, and HF power markedly decreased upon standing in all subjects, but at standing, SDNN, RMSSD, TP, LF power, or HF power did not significantly differ between the two groups. While, the elevation in LF/HF ratio from supine to upright was significantly greater in the OHT subjects compared with the healthy children, after controlling for gender, age and BMI (P < 0.01). Specific values in BRS and HRV changes from supine to upright are shown in P < 0.01, P < 0.001, Pearson correlation analysis showed that changes in BRS were negatively correlated with changes in MAP from supine to upright in all subjects  that we used for assessing the autonomic nervous function, due to the difficulties in the implementation of invasive methods in children, are not the most direct. Muscle sympathetic nerve activity (MSNA) detected by microneurography is another reliable way of evaluating sympathetic activity, which is more direct, but it is hard to conduct and not included in the present study due to the invasiveness of testing . The cohIn conclusion, our study provided new insight into the vital role of sympathetic hyper-activation upon standing in pediatric OHT. The data would greatly further the understanding of the mechanisms for OHT in children and adolescents.The datasets generated for this study are available on request to the corresponding author.The studies involving human participants were reviewed and approved by The Ethics Committee of Peking University First Hospital. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.JD, BH, and CTan contributed to the conception and design of the study, revise of the manuscript, and final approval of the version to be published. YH, YuW, YaW, YJ, ZH, CTao, CTan, and HL analyzed and interpretated the data, and drafted the article. YyW, BH, YaW, ZH, CTao, and HL undertook the test and acquired the data. JD, YJ, and CTan revised the manuscript critically for important intellectual content.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.


In addition, significant differences were detected in the National Institute of Health stroke scale score and activities of daily living score between the two groups. The present meta-analysis suggests that in China, compared to the usual care, psychological nursing is more effective for alleviating depressive symptoms, improving neurological rehabilitation, and recovering the ability of daily life.The present study aimed to evaluate the efficacy of psychological nursing of patients with stroke in China. The Embase, PubMed, Cochrane Library, CNKI, and Wanfang databases were searched from inception to February 1, 2020. Randomized controlled trials (RCTs) reporting the efficacy of psychological nursing of patients with stroke were included. Revman 5.3 and Stata 15.0 were used for data analysis. Twelve RCTs and 1,013 patients with stroke were included in this systematic review and meta-analysis. The results revealed a significant difference in the Hamilton depression score between the psychological nursing and usual care groups. The meta-analysis of three studies ( Social and psychological issues such as anxiety, depression, and cognitive impairment occur commonly after stroke in about 40% of the patients –3. MoreoNurses also face difficulty in coping with the fluctuating mood and uncooperative behavior of patients with stroke –9. Over Psychological nursing is the act of health professionals providing positive psychological interventions for patients after a medical event to help them acquire and maintain a good psychological state to ease rehabilitation and healthcare . PsycholPresently, psychological nursing of patients with stroke is gaining increasing attention in China. Some studies compared psychological nursing to the usual care for patients with stroke –27, albeThis systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria . The EmbThe following selection criteria were applied according to the PICOS principles. Participants (P): patients with stroke in China; Intervention (I): psychological nursing; Comparison (C): usual care; Outcomes (O): efficacy, which was evaluated using the Hamilton depression (HAMD) score, the National Institute of Health stroke scale (NINSS) score, and activities of daily living (ADL) score; Study design (S): random controlled trials (RCTs). Studies were excluded if they were published as reviews, editorials, letters, case reports, cell and animal studies, or expert opinions. Bingye Liao and Minni Liang independently and systematically screened the literature by titles and abstracts, and then read the full texts to determine the eligibility of the articles. If more than one article was from the same dataset, only the one with the largest sample size was included. Any disagreement in the literature search was resolved by the third author (Yuejiao Su).All data from the selected studies were extracted independently by two reviewers (Qiuyi Ouyang and Xiaojun Chen), and any disagreement was resolved by the third reviewer (Hongqin Song). The extracted data, including the study year, number of samples, male, mean age (years) of the participants, and follow-up duration were summarized into simple standard forms. Each study was independently screened by two reviewers. The risk of bias assessment was evaluated according to the Cochrane Handbook for Systematic Reviews , which iP-values or 95% CI were estimated if needed (I2) were used to assess heterogeneity . The publication bias was estimated using the Egger's test. P < 0.05 indicated statistical significance.The continuous variable data were expressed as mean differences (MD) with 95% confidence intervals (CI). Odds ratio (ORs) and the 95% CI were calculated to combine the categorical variable data. Next, the missing standard deviations (SD) such as f needed , 30. Amoogeneity . A fixedA total of 469 articles were screened after a combined search of Embase, PubMed, Cochrane Library, CNKI, and Wanfang for articles published until February 1, 2020. Subsequently, 217 potential articles were selected after removing the duplicates. Of these, 150 articles were excluded based on title and abstract review, and the full-text of the remaining 67 articles was reviewed. An additional 55 articles were excluded according to the inclusion and exclusion criteria. Finally, 12 studies , published from 2004 to 2019, were included in this meta-analysis –27. The The sample size of the included studies was 50–114 cases, and the duration of follow-up was 2–8 weeks. The baseline characteristics of the 12 studies are summarized in n = 526 patients) used the total HAMD scale as the outcome measurement, and the results of the meta-analysis showed a significant difference in the HAMD score between the psychological nursing and the usual care groups (standardized mean difference (SMD) = −0.92, 95% CI: −1.22 to −0.62, I2 = 63%, Pheterogeneity = 0.01) (P = 0.642), sample size (P = 0.633), and mean age (P = 0.175) of the intervention group did not have moderating effects. The meta-analysis of three studies (n = 235) that used a depressive symptom control of ≥25% as the outcome revealed a significant difference between the two groups  (Seven studies ( = 0.01) . Meta-re> 0.999) .n = 149 patients) used the NIHSS scale as the outcome. The results of the meta-analysis showed a significant difference in the NIHSS score between the psychological nursing and the usual care groups  (P = 0.46), sample size (P = 0.24), and mean age of the intervention group (P = 0.68) did not have moderating effects on the efficacy for improving neurological rehabilitation by the NIHSS scale.Two studies ( = 0.01) . The metn = 817 patients) used the ADL scale as the outcome. The meta-analysis showed a significant difference in the ADL score between the psychological nursing and the usual care groups , I2 = 0%, Pheterogeneity = 0.35) (Two studies ( = 0.35) .t = −1.14, 95% CI: −13.9 to 5.36, P = 0.305)  .This systematic review and meta-analysis identified 12 studies investigating the psychological nursing of patients with stroke in China. The analysis found that compared to the usual care, psychological nursing is more effective for alleviating depressive symptoms, improving neurological rehabilitation, and recovering the ADL.In the present meta-analysis, the HAMD, NIHSS, and ADL scores favored the psychological nursing group as compared to the usual care group. Nevertheless, all three scores examine different aspects. HAMD is a well-known and widely used questionnaire for depression and recovery . It examSeveral recent RCTs assessed the effects of psychological nursing of patients with stroke in China. These trials assessed the effects of psychological nursing on depressive symptoms, neurological rehabilitation, and the ADL. Li et al.  concludeThose effects of psychological nursing on scales of anxiety, depression, and stroke-related impairments are consistent with the core aim of psychological nursing, i.e., improving the quality of life of the patients by decreasing anxiety and depression through a continuous and ongoing psychological care process, which is opposite to classical psychological interventions such as cognitive-behavioral therapy, which requires the participation of the patients and specialized healthcare professionals , 12. DecNevertheless, the current study has some limitations. First, because of the differences between the healthcare systems in China and Western countries, a decision was made to include studies conducted only in China. Although this limits the generalizability, it improves the applicability of the results nationwide. Second, although all included studies were RCTs, the main limitation was the significant risk of reporting bias and selection, as well as the risk of bias evaluation. Third, the gray literature was not included. Fourth, the efficacy in long-term follow-up lacked evidence. Fifth, the majority of the included studies were from a single site using a small sample size, and hence, larger sample size and multicenter studies should be conducted. Finally, high heterogeneity was detected across some outcomes. This could be attributed to the articles with meta-analysis that investigated psychological nursing after stroke; however, the exact content of this psychological nursing varied across centers.In conclusion, this systematic review and meta-analysis demonstrated that psychological nursing might be more effective for alleviating depressive symptoms, improving neurological rehabilitation, and recovering the ADL than the usual care group in China. Thus, well-designed and larger studies are essential to characterize the efficacy of psychological nursing for patients with stroke. Nevertheless, the present meta-analysis suggested that psychological nursing improves the psychological outcomes of patients after stroke and that such programs should be implemented in centers caring for patients with stroke. This should be conducive to reduce the burden on the healthcare system.The original contributions presented in the study are included in the article/BL and ML conceived and supervised the study. QO and XC analyzed the data. BL, ML, and HS wrote the manuscript. YS and QO made manuscript revisions. All authors reviewed the results and approved the final version of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


This study was conducted to investigate the correlations between social–emotional competence (SEC) and academic achievement (AA) among nursing students and to compare students’ level of each core skill of SEC  and academic achievement . A cross-sectional design was adapted. Data were collected from 195 nursing students in the junior and senior years who had participated in clinical practicum from four universities in South Korea. General characteristics, levels of critical thinking disposition, self-directed learning, creativity, emotional intelligence, problem-solving, collaboration, and academic achievement were collected via self-reported questionnaire. Canonical correlation analysis was performed to evaluate the relationship between SEC and AA. The canonical correlation coefficient between SEC and AA was 0.762. Critical thinking disposition (Rs = 0.89), problem-solving (Rs = 0.86), and cooperation (Rs = 0.80) made the most important contributions to SEC. Clinical performance (Rs = 0.95) and subjective AA (Rs = 0.57) were correlated with AA. SEC should be addressed to improve the AA of nursing students. All core skills of SEC should be regularly promoted. It is particularly urgent for nursing students to improve their creativity. The highly anticipated fourth industrial revolution is expected to bring massive data and artificial intelligence-driven smart information technology to every corner of our lives . To secuThe 2016 World Economic Forum suggested that critical thinking, problem-solving, creativity, communication, and collaboration would be the core skills of the 21st century for dealing with complicated challenges. Curiosity, initiative, persistence/grit, adaptability, leadership, and social and cultural awareness were presented as the core character qualities that define how students approach their changing environment. SEC features many different skills and character components required in the 21st century that strengthen academic performance and professional readiness  and reduGiven these demands of the new era, the South Korean educational system has focused on motivating students to take initiative in their studies over the past decade . HoweverNursing students hone their nursing skills through education and training as they prepare to enter their profession. Clinical performance is one of the key elements used to evaluate the quality of nursing education. The academic accomplishments of undergraduate students are affected not only by individuals’ cognitive intelligence, but also by SEC . ClinicaAmong the 16 important SECs of 21st century education announced at the world economic forum, critical thinking, problem-solving, creativity, collaboration, and adaptability (the ability to process emotion) ,9, problExisting research on SEC among nursing students has explored partial correlations between some elements of SEC skills such as critical thinking ,9, problThe purpose of this study was to investigate the correlations between SEC and AA among nursing students. The more detailed goals were as follows: first, to gain an understanding of levels of SEC  and AA  among nursing students; second, to find correlations among critical thinking, problem-solving, creativity, emotional intelligence, collaboration, self-directed learning, clinical performance, and subjective AA among nursing students; and third, to establish canonical correlations between SEC variables and AA variables among nursing students.This research was a cross-sectional descriptive survey conducted to find correlations between SEC and AA among nursing students.The subjects of this study were junior and senior undergraduate nursing students who had experienced clinical training and voluntarily agreed to participate in the study. The sample size was calculated using G*Power 3.1.9.2 . The minimum sample size needed to analyze the relevant correlations was 191 when the effect size was medium (0.2), significance level was 0.05, and statistical power was 0.80. The recruitment goal was 200 subjects, considering the possibility of drop-out and withdrawal from participation, and the study ultimately included 195 subjects.The general characteristics of the participants were shown Social–emotional competence (SEC) was measured including critical thinking disposition, self-directed learning, creativity, emotional intelligence, problem-solving, and collaboration abilities.Critical thinking disposition. Critical thinking disposition was measured using Yoon’s Critical Thinking Disposition (YCTD) instrument for nursing students . The sevSelf-directed learning. Self-directed learning was measured using a tool for college students and adults developed by Lee et al. . The tooCreativity. Creativity was measured using an adapted version of Runco’s Ideational Behavior Scale (RIBS)  for collEmotional intelligence. Emotional intelligence was measured using the Wong and Law Emotional Intelligence Scale (WLEIS) adapted by Jung and Jung . The tooProblem-solving. Problem-solving was measured using a tool developed by Lee et al.  to measuCollaboration. Collaboration was measured using a tool developed by Chung . The tooClinical performance. Clinical performance was measured with a tool developed by Lee et al.  and reviSubjective academic achievement (AA). Subjective AA indicates the level of self-perceived AA. In this study, a visual analogue scale of 0 to 100 was used, allowing students to mark their own level of achievement. The higher the points were, the higher they perceived their AA.Academic achievement (AA) was measured from clinical performance and subjective academic achievement.The study was approved by the Daegu Catholic University Institutional Review Board (CUIRB-2018-0009) prior to data collection. Data collection was carried out after notifying participants that the data would be collected through an online survey. The researcher selected four nursing departments located in three urban cities and asked the deans for cooperation for data collection, providing information on the purpose and methods of research. One nursing student was selected as a research assistant for each university, and a research assistant was given instructions about the purpose of the research, data collection method, confidentiality and anonymity, the withdrawal policy, and possible benefits and disadvantages. The survey was conducted among nursing undergraduates who acknowledged that they understood the instructions and voluntarily agreed to participate in the research. Participants who completed the survey were rewarded with small gift.The frequency, percentage, average, standard deviation, internal consistency, and reliability (Cronbach’s α) of the participants’ general background information were analyzed using SPSS Statistics 25.0 . Pearson correlation analysis was used to analyze the correlations between the SEC variables  and the AA variables . Canonical correlations between the SEC variables and the AA variables were analyzed after standardizing the scores of each variable.The Helsinki Statement was fully observed for ethical considerations and to ensure that the research was ethical for the subjects. The survey was conducted after receiving approval from the college Institutional Review Board. Furthermore, all participants were provided instructions, including information on the purpose and methods of research, withdrawal from the survey, and ethical protections such as confidentiality and anonymity. The survey was administered among participants who agreed to the terms.The analyses of SEC and AA showed that the correlations ranged between r = 0.295 and r = 0.646 for all sub-variables other than creativity and subjective AA, indicating there was a moderate level of correlation .1 = critical thinking disposition, X2 = self-directed learning, X3 = creativity, X4 = emotional intelligence, X5 = problem-solving, and X6 = collaboration) and the Y variables represented AA . The two formulas presented below were derived through the canonical correlation analysis.For the canonical correlation analysis, the X variables represented SEC (XThese are equations:p < 0.001) and the canonical correlation coefficient was 0.762 (The X variables and Y variables were confirmed to represent SEC and AA, with percentages of 58.5% and 61.1%, respectively. The Wilks coefficient for the canonical correlation between the two variable groups proved meaningful at 0.394 (F = 15.332, as 0.762 , which iThis study was conducted to explore the correlation between SEC and AA among nursing undergraduates in the fourth industrial revolution and to understand the relative importance and level of the components of SEC and AA. The canonical correlation between SEC and AA was 0.762 in this study. This means that nursing students with high SEC have better clinical performance and subjective AA, which leads to a generally high AA. This result is in line with that of previous studies, which suggested that higher SEC leads to higher AA ,30. CritHowever, the fact that the curriculum for nursing students requires relatively little imagination and emotional sensitivity  suggestsAmong the six elements of SEC measured in this study, critical thinking disposition and problem-solving were most closely correlated with SEC among nursing students, while nursing students were found to have relatively low levels of critical thinking disposition and problem-solving. This indicates that the various educational strategies currently being utilized to nurture these important critical thinking abilities among nursing students are not playing a sufficient role. Given that critical thinking disposition and problem-solving are related to clinical performance ,9,10 andCollaboration is needed in any profession, but is particularly crucial for nurses . This stEmotional intelligence was the fourth most important factor of SEC among nursing students. Nurses with high emotional intelligence take care of patients proactively, treat them with a calm and confident attitude, communicate with precise language, and tactfully deal with and manage patients in various circumstances . EmotionSelf-directed learning was the fifth most relevant component of SEC among nursing students in this study, with a relatively low score of 67.6 out of 100. Korean nursing students have low self-directed learning, since their education is focused on rote learning and memorizing knowledge, as well as competition to get better grades , even thThis study found creativity to be the least important component of SEC, scoring 59.4 out of 100. Creativity is a required skill for nurses who need to take care of many different patients, are often faced with unexpected situations, and cannot satisfy the demands of diverse types of patients by simply performing daily practices. Therefore, creativity is a necessary skill for a nurse. Diversity learning ,40, freeClinical performance and subjective achievement explained 61.1% of AA among nursing students, and students with higher SEC were proven to have higher clinical performance and AA. However, in a clinical study environment focused on observing how others practice rather than on getting hands-on experience , opportuSubjective AA was proven to be an important factor for overall AA, scoring 63.5 out of 100. Students’ self-confidence was also a determining factor for AA , and motThis study is meaningful in that it demonstrated the canonical correlation between SEC and AA of nursing students, with comprehensive analyses that factored in the various elements of SEC. This study confirmed correlations among the six elements of SEC that have been reported to be the core skills of the fourth industrial revolution era, including critical thinking disposition, self-directed learning, creativity, emotional intelligence, problem-solving, and collaboration. The analysis also found a relative order of importance among the elements for nursing students, and that creativity was the most unmet skill relative to its importance. Subsequent steps should include designing a curriculum that prioritizes the development of key skills that are unmet based on the relative weights derived from the results of this study. Since this study measured AA using two criteria—clinical performance and subjective AA—the results should be interpreted with caution. Furthermore, since this study surveyed nursing students in some regions of Korea, it is difficult to generalize the results of this study. Further research is needed to improve our understanding of students’ actual competence, such as objective evaluations of clinical performance and grades.The study found correlations between SEC and AA among nursing students. Elements of SEC, including critical thinking disposition, problem-solving, collaboration, self-directed learning, creativity, and emotional intelligence, should be fostered to enhance the academic performance of nursing students, in that order. It is particularly urgent to nurture creativity among nursing students, given that it is one of the most crucial professional skills in the 21st century. Future studies should further explore the main factors of SEC and AA, as well as the immediate impact of nurturing the main factors of SEC on AA.


Glossolalia (“speaking in tongues”) is a rhythmic utterance of pseudo-words without consistent semantic meaning and syntactic regularities. Although glossolalia is a culturally embedded religious activity, its connection with psychopathology  is still a matter of debate. To elucidate this issue, we investigated 32 glossolalists, 32 matched control participants, and 32 patients with schizophrenia using the Animated Triangle Test (ATT) and the Reading the Mind in the Eyes Test (RMET). The ATT can detect hypo- and hypermentalization using animations of two moving triangles. Healthy adults describe these as random movements , willed actions , or they mentalize . We found that glossolalists provided more mentalizing descriptions in the ATT random and intentional movement animations relative to the control participants. They also recognized more mental states in the RMET than the controls. None of them had a diagnosis of mental disorders. In contrast, patients with schizophrenia hypermentalized only in the ATT random movement condition, whereas they showed hypomentalization in the ATT intentional movement condition and in the RMET relative the control subjects. Hypermentalization in the ATT positively correlated with intrinsic religiosity in the glossolalia group. In conclusion, our results demonstrated a substantial difference in the mentalizing ability of glossolalists  and patients with schizophrenia . The default cultural interpretation of this phenomenon delineates a “heavenly language of the spirit” accessible only to the gifted ones. Glossolalists often report an intentional or spontaneous suspension of will to convey divine messages and prophecies. They tend to perceive an external locus of control, a conviction that extrapersonal forces possess control over their life  , alteredHowever, social cognitive functions have not been compared in glossolalia and psychotic disorders. The assessment of theory of mind (ToM) and mentalization  is of particular relevance . ExperieConcerning the psychopathological model of glossolalia, it is notable that altered mentalization is a well-replicated feature of schizophrenia . Some paThe purpose of the present study was to compare mentalization in individuals with glossolalia and patients with schizophrenia by using the Animated Triangle Test (ATT) . This teWe hypothesized that individuals with glossolalia show hypermentalization in the absence of mental illness, depressive-anxious features, or enhanced schizotypal traits. In contrast, patients with schizophrenia are characterized by both hypo- and hypermentalization, together with a decreased accuracy in the description of the ATT animations , 2019. WWe recruited 32 glossolalists and 32 control volunteers who did not practice glossolalia from local Pentecostal and charismatic communities. The criteria of glossolalia were established according to The third group of participants consisted of 32 outpatients with schizophrenia who were demographically similar to the glossolalia and non-glossolalia group, including education, IQ, social-economic status, and religious activity . The patAll participants received the structured clinical interview for DSM-5  disorders to confirm the diagnosis of schizophrenia and to exclude mental disorders in the glossolalia and non-glossolalia group . None ofThe Oxford-Liverpool Inventory of Feelings and Experiences (O-LIFE) assesses schizotypal personality traits . The selThe modified DUREL is a self-report measure consisting of five items . The insZ = 4.9, p < 0.001; intentionality for non-random animations: κ = 0.81, Z = 9.6, p < 0.001; accuracy for random animations: κ = 0.78, Z = 4.8, p < 0.001; accuracy for non-random animations: κ = 0.82, Z = 9.5, p < 0.001).Participants viewed brief video clips on the computer screen depicting two triangles (Frith-Happé animations) , 2002. TParticipants saw 36 photographs depicting eye-regions of faces of actors and actresses. Each photograph appeared on separate slides. Eye-regions expressed complex social emotions and mental states . Without any time-pressure, participants choose which of four words (one target and three foils) best described the mental state of the actor or actress on the photographs. The dependent measure was the number of correct responses .ps > 0.2), we used parametric statistical tests. Behavioral measures were entered into analyses of variance (ANOVAs) to investigate the main effect of group , test conditions , and the interaction between the group and test conditions. The ANOVAs were followed by Tukey’s Honestly Significant Differences (HSD) post hoc tests. The IQ and SES were covariates in the ANOVAs. Pearson’s product moment correlation coefficients were calculated between the ATT/RMET data and the demographic and clinical parameters. Correlation analyses were also corrected for IQ and SES . Multiple regression analyses were conducted to determine the predictors of religiosity. Demographic parameters were compared with one-way ANOVAs, Student’s t-tests (two-tailed), and chi-square tests. The level of statistical significance was set at alpha <0.05 (corrected for multiple comparisons with the Benjamini–Hochberg method).We used STATISTICA 13.1  software package for data analysis. First, we conducted Kolmogorov–Smirnov and Levene’s tests to evaluate data distribution and the homogeneity of variance, respectively. Given that the data were normally distributed, and the variances were homogeneous  = 20.44, p < 0.001, η2 = 0.31], test condition , and a two-way interaction between group and test condition . Individuals practicing glossolalia detected more intentionality in the random and intentional animations than the non-glossolalia control subjects (ps < 0.05) (p < 0.05), but in the intentional movement animations, they achieved a lower score relative to the controls (p < 0.01). Finally, a head-to-head comparison between individuals with glossolalia and patients with schizophrenia indicated no significant difference in the random condition (p > 0.1), whereas, in the intentional movement animations, the patients performed worse than the glossolalia group (p < 0.001)  of glossolalists, patients with schizophrenia, and matched control subjects . The ANO < 0.05) . Patient< 0.001) . The aboF = 12.02, p < 0.001, η2 = 0.21] and test condition  . Tukey’s HSD tests revealed that glossolalists outperformed controls  and patients with schizophrenia  who were impaired relative to the control group (p < 0.001).Regarding mentalization related to the recognition of complex social emotions, the ANOVA performed on the RMET scores indicated a significant main effect of group . In the other two groups, we found no significant relationships between ATT and DUREL scores. There were no significant correlations between ATT and DUREL organized/personal religiosity scores in either group. The RMET did not correlate with the DUREL scores  in either group .In the glossolalia group, higher scores on the ATT random and intentional conditions were associated with higher DUREL intrinsic religiosity scores [Our results confirmed the hypothesis that glossolalists display hypermentalization. Specifically, they more frequently attributed intentions to randomly moving objects on the ATT as compared to non-glossolalists with similar demographic and religious features. In this respect, glossolalists and patients with schizophrenia were similar. However, individuals practicing glossolalia were also highly sensitive to intentionality when the animated objects interacted with each other to mimic social behavior in the ATT. Glossolalists also recognized more complex mental states in the RMET than the controls. General hypermentalization is a critical feature that distinguished glossolalists from patients with schizophrenia who achieved lower scores on the ATT intentional condition and the on RMET relative to the control volunteers. In other words, patients with schizophrenia showed hypomentalization in the ATT intentional condition and in the recognition of facial expression of complex mental states, whereas glossolalists hypermentalized in all test conditions.The hypermentalizing feature of schizophrenia was inadequate and possibly maladaptive because the patients exclusively interpreted random movements as if these were intentional: they detected social salience in a non-salient situation . In glosBeyond the characterization of mentalization, an important finding of our study is that individuals with glossolalia did not meet the criteria of DSM-5 disorders, and their depression, anxiety, and schizotypy scores did not differ from the values of the non-glossolalist volunteers. Therefore, our results are against the hypothesis that glossolalia is a consequence of psychopathology . HoweverFrom a broader perspective, our findings provide further evidence that enhanced mentalization is an essential component of religious and spiritual cognition. The leading cognitive theory of religion focuses on the concept of hyperactive agent detection device (HADD) as an evolutionary ancient mental faculty serving social cognition . AccordiThe present study is not without limitations, and our initial results on glossolalia and social cognition raise several questions for future studies. First, the sample size was small, and the study was underpowered. This limitation is explained by the uniqueness and rarity of the sample. Individuals with glossolalia are often reluctant to participate in research studies. Therefore, the study must be replicated and extended in a large and representative sample. Second, it is unclear how specific linguistic features are related to mentalization. This issue necessitates a multifaceted assessment of mental state attribution with both visual and verbal tests, together with the linguistic analysis of glossolalic speech. Third, we used only two tests to measure mentalization, which is a complex psychological construct comprising distinct components. Moreover, the impact of enhanced mentalization on daily functioning and quality of life should be elucidated. The ecological validity of these experimental procedures is not clearly understood . Forth, Furthermore, the issue of culture, gender, race, ethnicity, social-economic status, and other demographic measures are of prominent importance in glossolalia research. In this respect, the critical feature of the present study was that we assessed a culturally, racially, and ethnically homogeneous population. All participants were Caucasian with Hungarian origin. Therefore, our data do not add new information regarding the diversity of ethnocultural context of glossolalia.When interpreting the present results, a potential selection bias must be taken into consideration. Specifically, it seems to be evident that patients with schizophrenia, who experience a potentially deteriorating course of illness, display a poor performance on mentalization tasks as compared to glossolalists and controls without a mental disorder. However, we selected highly functioning outpatients who were not statistically different in education, IQ, social-economic status, and religiosity concerning the other two study groups. We observed mild negative symptoms in our schizophrenia sample . The patients/participants provided their written informed consent to participate in this study.SK coordinated data collection and measurements, and wrote the first draft of the manuscript. SK and KC analyzed the data. IK performed the revision of the manuscript. All authors designed the study, reviewed and edited the final version of the manuscript, and approved the manuscript for publication.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.


The multiple linear regression equation was significant . Metabolic equivalent values were used to predict PA levels of participants, which were −3818.582 + 272.535 (motivation) + 249.848  + 149.899 (interaction with the environment). The association of factors such as socio-economic status (SES) (p = 0.092) and grade point average (GPA)  were examined using Pearson’s product-moment correlation. Gender (p < 0.01) and body mass index (BMI) (p < 0.01) were also explored for their differences. Conclusions: Perceived PL and PA levels were significantly related. The association between PL and GPA was identical. GPA and BMI showed significant difference between each group. The study offers a path to explore the concept of PL and how it can affect the PA of Chinese undergraduates. Furthermore, on the basis of this study, more research could develop practical interventions for Chinese undergraduates to enhance their PL and engagement in a lifetime of PA.Aim: To examine the association between the perceived physical literacy (PL) and physical activity (PA) levels among Chinese undergraduates. Methods: Simplified Chinese version of the Perceived Physical Literacy Instrument and the International Physical Activity Questionnaire were used to measure 536 students’ perceived PL and PA levels. Pearson’s product-moment correlation and multiple linear regression were then used to examine the relationship between the perceived PL and PA levels. Additionally, standard regression analysis was conducted to test for the effects at different demographics. Results: The correlation between perceived PL and PA level was low but significant (r = 0.350,  The concept of physical literacy (PL) rapidly gained global attention and led to a research boom ,2. GivenDrawing from the current research on PL assessments, many researchers are looking for extensions and applications of PL in cross-sectional fields. Cairney and colleagues introduced a conceptual model that positions PL as a health determinant and concluded that PL can be measured . JefferiAlthough Mainland China announced a policy to develop PL among students , the emeCross-sectional study was utilized in this research. Participants’ perceived PL and PA level were calculated by PPLI-SC and a simplified Chinese version of the long version of the International Physical Activity Questionnaire (IPAQ-SC). Pearson’s product-moment correlation and multiple linear regression were then used to examine the relationship between the perceived PL and PA level. The demographic information  of participants were also collected for further correlation analysis. The ethical approval was obtained from the Medical Ethics Committee of the First Affiliated Hospital of Jinan University.Jinan University was chosen as the location for the research. The Ministry of Education of the People’s Republic of China expressed that all Mainland China universities must complete 144 h of PE courses within four years . In thisThe research assistant was responsible for distributing the questionnaire to each participant and for answering the participant’s questions during this period. Each participant was allowed to ask questions throughout the questionnaire. In addition, they were free to refuse answering the questionnaire and could withdraw at any time. To encourage participation, some simple gifts, such as pens and bookmarks, were given to them once they finished the survey. After the participants finished the questionnaire, all questionnaires were collected by the research assistant.Participants’ perceived PL was assessed by PPLI-SC, which was translated from PPLI. It is an eight-item instrument used to measure the perceived PL of Chinese undergraduates. It includes three dimensions, which are (1) motivation, (2) confidence and physical competence, and (3) interaction with the environment. To be specific, (1) physically literate individuals will maintain positive attitudes toward PA throughout their lives. (2) Physically literate people are able to move with confidence and poise in a variety of challenging situations. (3) Physically literate people can interact with the environment in the context of everyday living . All of p < 0.05) and validity was used for Spearman’s rank correlation established by Caltrac accelerometer . The results showed that the long version of IPAQ-SC had intraclass correlation coefficients above 0.7 for PA [Participants’ PA levels were measured by the long version of IPAQ-SC, which was translated from the long version of IPAQ. It involves five environment domains: work-related (unrelated in this study), transportation, housework, leisure time, and sedentary. These domains were used to record participants’ moderate and vigorous PA performed for at least 10 uninterrupted minutes in the previous 7 days (5 school days and 2 weekend days). The data were collected in minutes per week for each of the PA intensities. Then, minutes were calculated for metabolic equivalent (MET) values by using the MET-minutes computation formulation ,34. Qu N7 for PA .The demographic information of the participants, such as gender and BMI, was also collected in the questionnaire. GPA was a standard way to measure academic achievement; Jinan University used a 5-point GPA model. Students with a GPA of less than 3 were allocated a normal score, GPA between 3 and 4 meant a good score and GPA higher than 4 meant an excellent score . The SESt-test. Each type of BMI was valued in PL by using analysis of variance (ANOVA) and z-scores were calculated in the correlations to test the influence on the relationship between PA and PL.IBM SPSS 25 was used for data analysis. The correlation between perceived PL and PA level was derived from Pearson’s product-moment correlation. Before the regression analysis, the research team examined the normality, linearity, and multicollinearity of the data to ensure that no violations existed during the analysis. Multiple regression analysis was then used to detect the association between perceived PL and PA levels. In addition, multiple regression analysis was conducted separately for males and females. Measures, such as demographic information, GPA, and SES were also considered in the Pearson’s product-moment correlation and standard regression analysis in computing the correlation with PL. The difference of each gender’s PL was explored through student’s Before testing the relationship between PA and PL, demographic characteristics of participants were analyzed. A total of 622 undergraduates were recruited and 536 of them completed the questionnaires . The participants’ ages ranged from 18 to 21 years old. The average age of participants was 19.40 years old and standard deviation was 0.83, which were all consistent with the research subjects.Pearson’s product-moment correlation was used to test the correlation between each dimension of PA level and three attributes of perceived PL . The avep < 0.01). No significant correlation existed between sedentary domain of IPAQ-SC and any other attribute.The correlation (r) between participants’ perceived PL and PA levels was 0.35, which was significant at the 0.01 level (2-tailed). Although the correlations are not high, three dimensions of PPLI-SC, namely, intensities of PA  and three domains of IPAQ-SC  showed a high significance  and so did the dimensions of perceived PL. The predicted PA level of participants was −3818.582 + 272.535 (motivation) + 249.848  + 149.899 (interaction with the environment) MET value. The standardized coefficients of (1) motivation, (2) confidence and physical competence, and (3) interaction with the environment were 0.176, 0.184, and 0.087, respectively. Except for interaction with the environment, the probability values of the other two dimensions were all less than 0.05, which showed a positive relationship between perceived PL and PA level. The participants’ MET values would increase by 272.535, 249.848, and 149.899 for each dimension score of perceived PL. The results showed that two dimensions were significant predictors of PA level.Multiple linear regression was used to predict the PA levels of Chinese undergraduates on the basis of the three dimensions of perceived PL . The anap < 0.01, ΔR2 = 0.157) and females . For PL dimensions in males, only motivation showed significant probability value (p = 0.048). For females, the probability values of motivation and physical competence were both less than 0.05.Multiple linear regression was then used to examine males and females separately . The resp = 0.092) and GPA  factors also examined the association by using Pearson’s product-moment correlation. Except for physical competence , motivation  and interaction with environment  both showed significant correlation with GPA. p < 0.01) was explored by student’s t-test. Perceived PL of males  were higher than females . BMI  was classified into three types and analyzed giving their different PL through ANOVA. BMI was classified into three types, namely, low, medium, and high. The medium group showed significant differences with low (p = 0.001) and high (p = 0.015) groups. For further analysis, z-scores were calculated to explore the different influences of each group in the relationship between PL and PA  while females have two . This illustrated the role of the key factor of motivation in improving males PA and PL. Meanwhile, female students need both motivation and confidence to be more active in PA. This is partly because PA engagement for males is not affected by factors such as physical condition. Compared with males, females are more likely to be influenced by interest, self-confidence, and physical condition. More influential factors lead to the result that female students are more likely to give up PA when they lack encouragement in any of the related dimensions. Globally, males were more active than females, thus more women suffered with physical inactivity than men in nearly every country . WithoutBody management is considered one of the key factors that can affect individuals’ PL ,33,46. Ep = 0.022). For each 1 point score increase in GPA, a corresponding 0.857 enhancement in PL exists. Thus, the higher transcript a student has, the more he or she would be willing to participate in PA. However, when viewed in combination with the z-scores, there is a ceiling on the GPA. When students reached GPAs higher than 4, their PL would not be increased. For dimensions of PL, motivation  and interaction with environment  showed significant positive correlation with GPA. Thus, considering both enthusiasm for participating in PA and interaction with the environment will increase students’ academic performances, PE courses can start from these two points to build curriculum content that is conducive to all-round development of Chinese undergraduates. Different from other two dimensions, physical competence showed no significant correlation with GPA. This also raised a question for traditional PE courses, which in the past were focused on improving students’ physical competence rather than motivation. The SES of family is positively related to the PA of students [Academic achievements positively relate to PA level ,48,49. Cstudents ,51. Studstudents . Howeverstudents . Based oThis study contains certain limitations. First, because the participants of this research were randomly collected, female undergraduates accounted for a large portion, which may cause outcome deviations. Second, subjects of this research all are Chinese undergraduates (from 18–21 years old), further study could continue to explore the association in other age groups. Third, PL and PA in this study were all collected from subject data (questionnaires of PPLI and IPAQ), further research could use objective measures for accuracy. Fourth, this study did not collect information about student majors, which may show a possible correlation in PA and PL. Further study could continue to explore and discuss this field.This study aims to examine the relationship between perceived PL and PA levels among Chinese undergraduates through a cross-sectional study given the lack of research focused on the topic. Additionally, the research investigates the relationship between PL and related factors such as gender, BMI, GPA, and SES. The results showed that attributes of perceived PL and PA level were associated with most of domains of PA and factors of individual demographic. Hence, the concept of PL should not only be incorporated into PE courses, but also into their daily lives as a lifestyle. The research focuses on the subjects of university students, which is the last stage of the education process following on from primary school, high school, and college. We highlight the importance of association between PA and PL, which showed a way to explore the concept of PL and how it can affect the PA of Chinese undergraduates. Furthermore, based on this study, more research could develop practical interventions on Chinese undergraduates to enhance their PL to influence them to engage in a lifetime of PA for wellness and longevity.


Upon exposure to chronic stressors, how do individuals move from being in a healthy state to a burnout? Strikingly in literature, this has prevailed a categorical view rather than a dimensional one, thus the underlying process that explains the transition from one state to another remains unclear. The aims of the present study are (a) to examine intermediate states between work engagement and burnout using cluster analysis and (b) to examine cortisol differences across these states. Two-hundred and eighty-one Argentine workers completed self-report measures of work engagement and burnout. Salivary cortisol was measured at three time-points: immediately after awakening and 30 and 40min thereafter. Results showed four different states based on the scores in cynicism, exhaustion, vigor, and dedication: engaged, strained, cynical, and burned-out. Cortisol levels were found to be moderate in the engaged state, increased in the strained and cynical states, and decreased in the burned-out state. The increase/decrease in cortisol across the four stages reconciles apparent contradictory findings regarding hypercortisolism and hypocortisolism, and suggests that they may represent different phases in the transition from engagement to burnout. A phase model from engagement to burnout is proposed and future research aimed at evaluating this model is suggested. Workers account for half of the world’s population and represent the largest contributors to economic and social development . Over thBurnout is a work-related syndrome that emerges in response to chronic stress . EmpiricPast research has repeatedly shown cortisol to be associated with stress and it has hence been proposed as a biomarker of burnout. Despite the general consensus around this hormone and its role in mediating responses to stress, findings on the burnout-cortisol relationship have been inconsistent. For instance, high levels of cortisol have been positively associated with burnout , whereasThe focus on burnout has largely neglected research on positive experiences in the workplace, until recently. The shift to the positive side of people’s work experience was partly due to the increased recognition that reducing stress or discomfort is not equivalent to increasing well-being and health . As a coWork engagement has been linked with several positive outcomes, including organizational commitment, extra-role behavior, personal initiative, organizational performance, and quality of service . In addiWork engagement and burnout are conceptualized as each other’s opposite , most ofInvestigating the progression between engagement and burnout is in line with current efforts to improve the classification system of psychiatry and psychopathology. Over the past several years, a competing vision, namely, the Research Domain Criteria (RDoC) initiative launched by the National Institute of Mental Health, has emerged in response to accumulating anomalies within the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Statistical Classification of Diseases and Related Health Problems (ICD) system . The DSMThe present study builds on previous research and contributes to the literature in at least two ways. Firstly, we use cluster analysis to examine different patterns of combinations of exhaustion, cynicism, vigor, and dedication and postulate intermediate phases between work engagement and burnout. This method has been proposed not only as a powerful tool for detecting structure in data sets, but also for identifying the features underlying the progression from a healthy to an unhealthy state . FurtherGlucocorticoids and HPA axis involvement have been extensively described under acute stress, but their functioning throughout chronic stress and particularly in the workplace still requires clarification .Burnout has been defined as a work-related syndrome that emerges in response to chronic stress, and is characterized by the presence of (a) feelings of energy depletion or emotional and physical exhaustion and (b) increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job .Some studies indicate that in burnout, the HPA axis is under chronic and persistent activation . AccordiCynicism has been conceptualized as defensive coping resulting from exhaustion, involving emotional (negative affect) and cognitive-motivational components . Under cEngagement can be understood as a positive work-related affective-cognitive state of mind characterized by vigor and dedication. Rather than a specific, momentary state, engagement refers to a more persistent state that is not limited to a particular object, event or situation . Vigor rAlthough engagement represents a healthy and positive state of well-being , engagedM=36.44; SD=8.28). 44% of the participants worked in the public sector (work start time 9 a.m.) and 56% in private companies (work start time 8 a.m.).A self-selected sample of 281 workers  from Córdoba, Argentina, participated in the study. The sample comprised workers of both sex  aged between 20 and 60years , of both sexes, having signed the corresponding informed consent and being active workers with at least 2 months of seniority in the institution at the time of the sampling. All participants were asked to provide information regarding potential covariates that could affect cortisol levels and therefore to be considered as exclusion criteria, they should have had the use of systemic or topical steroids in the last 4 weeks, intense exercise prior to sampling, report of consumption of steroid-based anti-inflammatory drugs, oral injuries or diseases, alcoholism, chemotherapy, prolonged corticotherapy, autoimmune diseases, and infection.never) to 6 (daily). In order to avoid response bias, we randomly merged all burnout and work engagement items into one questionnaire.Exhaustion and cynicism were assessed with the Argentinean version  of the MSalivary cortisol was collected at three time-points to determine the cortisol awakening response (CAR): immediately after awakening and 30 and 45min thereafter . All samPersonal details were obtained in relation to sex, age, and type of sector in which participants worked.Employees were contacted via e-mail and invited to participate in a study of well-being at work. The response rate was high (86%). Those who agreed to participate signed a written consent and responded a paper-and-pencil questionnaire with all the scales and an accompanying letter explaining the objectives of the study. Then, participants were provided with three plastic tubes (Corning LS tubes of 15 mL) and detailed instructions on collecting saliva, emphasizing the need to strictly follow the time schedule and refrain from drinking, eating, and brushing their teeth before collecting each of the three saliva samples . Data wek-means cluster analysis. This technique enables the grouping of individuals based on the similarity of their responses to a set of variables by way of an iterative process , descriptive statistics and correlations among variables were computed. Secondly, we explored different intermediate states within the engagement-burnout continuum by means of non-hierarchical  process . In the  process . Typical process . Since sparisons . Hedge’sup sizes  as in thd, an SD of 0.2 is considered a small effect, 0.5 a medium effect and 0.8 a large effect  is characterized by employees with the lowest scores in exhaustion (Z=–0.90) and cynicism (Z=–0.57) and the highest scores in vigor (Z=0.25) and dedication (Z=0.48), therefore representing the engaged group. Cluster 2  is characterized by employees who display similar levels of cynicism (Z=−0.41), vigor (Z=0.34), and dedication (Z=0.46) to cluster 1. However, they also had notably higher levels of exhaustion (Z=0.82). Accordingly, we labeled this group as the strained group. Cluster 3  is characterized by employees with the highest level of cynicism (Z=1.44), moderate exhaustion (Z=0.64), slightly above-average scores on vigor (Z=0.18), and low scores on dedication (Z=–0.99), thus representing the cynical group. Cluster 4  is characterized by employees with the lowest levels of dedication (Z=–1.30) and vigor (Z = −1.87), moderate levels of exhaustion (Z=0.40) and higher levels of cynicism (Z=0.99), and represents the burned-out group.Three to six cluster solutions were examined, of which the four-solution one proved to be the more parsimonious and interpretable. e effect . Clusterg=0.37) and lower AUCg values (g=0.38) than the strained group. Engaged workers also exhibited significantly lower cortisol levels immediately after awakening (g=0.48), at +30min (g=0.56), and lower AUCg (g=0.53) and AUCi (g=0.39) values than the cynical group. The cynical group showed significantly higher cortisol at +45min (g=0.55) than the burned-out group. There were non-significant differences in cortisol between the burned-out and engaged groups, and between the strained and cynical groups.Differences in cortisol among groups are presented in A large body of research data supports the idea that most symptoms associated with mental disorders exist on spectrum, with many of them present to some degree even in the “normal” population . To bettEngagement and burnout have been conceived as polar opposites of occupational well-being. As stated by Four different groups emerged from our findings: engaged, strained, cynical, and burned-out. The engaged group displayed high vigor and dedication, and low exhaustion and cynicism; the burned-out group displayed the opposite pattern of scores in dedication, cynicism, exhaustion, and vigor. The strained and cynical groups revealed scores that were generally “in between” the scores of the engaged group on the one hand and the burned-out group on the other. The only exception was cynicism, which was highest in the cynical group. These patterns of results suggest that strained and cynicism may represent intermediate states between engagement and burnout. In addition, differences in cortisol and the HPA axis functioning across the groups suggest that there may be a temporal sequence between engagement, strained, cynicism, and burnout . In partengagement phase, AUCi levels indicate a moderate increase in cortisol levels upon awakening. These results are consistent with previous studies linking a moderate increase in cortisol level upon awakening with a healthy HPA axis response (In the response . Contrarresponse , our finresponse . Moreoveresponse .strained, is characterized by high levels of dedication and vigor, but also high exhaustion and increased levels of cortisol as reflected by AUCg values. Presumably, workers in this phase are exposed to increasing job demands (The second phase,  demands  but whic demands . Cortiso demands . It has  demands .cynicism, is characterized by the highest levels in cynicism, a marked dropdown in dedication and the highest AUCi and AUCg levels (The third phase, g levels . Unlike g levels . This ovg levels . It has g levels . A diminburnout, is characterized by the lowest level of vigor and dedication, moderate exhaustion, and high cynicism but somewhat lower than that in the cynicism phase. It seems likely that as the burnout symptomatology advances, GC does the same, but once a certain level of severity is reached in the upper range of burnout symptoms, HPA axis activity starts to decrease, displaying the transition from hyper- to hypocortisolism (see The fourth phase, lism see . Our resThere are certain limitations of the study that should be acknowledged. In particular, our proposed phase model posits that cynical and strained groups may represent intermediate phases in the trajectory from engagement to burnout. Since our study was cross-sectional, it is critical that future research longitudinally examine the intra-individual developmental paths from engagement to burnout. The use of longitudinal within-subject design and latent profile analysis would be particularly useful not only to empirically test the proposed phase model, but also to examine the patterns of stability and change over time and the factors that mediate the transition from one phase to another. For example, as mentioned previously, it has been suggested that under chronic stressors, perceived uncontrollability results in diminished HPA activity and that this decrease may lie behind the withdrawal behaviors that correspond to cynicism . As selfLiterature on the relationship between work engagement and burnout is largely descriptive. To date, no study has attempted to explain how employees transit from one state to another, particularly from a physiological approach. In this study, based on cluster analysis and examination of cortisol and HPA activity across the clusters identified, we propose a model with different phases involved in the transition from engagement to burnout. A longitudinal assessment of the proposed model along with cortisol measurement would be useful for confirming the present findings.The datasets generated for this study are available on request to the corresponding author.The studies involving human participants were reviewed and approved by the Ethics Committee of the Faculty of Medical Sciences, National University of Córdoba. The patients/participants provided their written informed consent to participate in this study.LPM and LAM conceived the study. JG and LPM participated in study design and acquisition of the data. MT made substantial contributions to the study design, and data analysis, MG critically revised the manuscript. All authors made substantial contributions to interpretation of the data, to drafting the manuscript or revising it critically for important intellectual content.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.