Background: Learning disabilities in children are a major public health concern worldwide, having a prevalence of 8%. They are associated with lost social, educational, and ultimately, professional opportunities for individuals. These disabilities are also very costly to governments and raise the issue of the appropriate means of screening. Unfortunately, validated tools for preliminary appraisal of learning and cognitive function in struggling children are presently restricted to specific age ranges and cognitive domains. This study sought to validate a first-line battery for assessment of academic skills and cognitive functions.Materials and Methods: The computerized Adaptable Test Battery, or BMT-i, includes a panel of tests for the first-line assessment of children's academic skills and cognitive functions. The tests reflect expected abilities for the age group in question, exploring academic skills  and cognitive domains . The authors relied on the results of these tests for a sample of 1,074 Francophone children representative of the mainland French school-age population . Thirteen speech-language pathologists and neuropsychologists individually administered the tests.Results: The psychometric characteristics of the empirical data obtained showed acceptable to good test homogeneity, internal consistency , test-retest reliability (intraclass correlation coefficients: ~0.80), and consistency with reference test batteries (r: 0.44–0.96).Conclusion: The BMT-i was validated in a large sample of children in mainstream French schools, paving the way for its use in first-line screening of learning disabilities among children with complaints, whether their learning difficulties have been flagged by their parents or by their teachers. In the last 50 years, authors have developed integrative models considering (i) academic skills, (ii) underlying cognitive skills, and (iii) neurobiological correlates, including familial forms and environmental factors .There is a growing consensus in support of early identification of LD by standardized tests and appropriate pedagogical interventions –10. Phasi) is a panel of tests for the first-line assessment of children's academic skills and cognitive functions, from kindergarten (age 4) to seventh grade (age 13). Designed as an adaptable set of tests suitable for a comprehensive evaluation, the BMT-i succeeds the Battery for Rapid Evaluation of Cognitive Functions  originally designed to provide health professionals with a quick clinical tool for screening acquired and developmental cognitive deficits in children ages 4–8 , mathematical cognition , and three cognitive domains . BMT-i tests assess the skills expected to be acquired by children in their respective age groups, between the ages of 4 and 13. They are meant to be simple to administer, short , and easy to score, and they can be taken at school or during an appointment with a health professional. Their purpose is rapid identification of children in the general population who require specialized assessments for precise diagnosis of LD, as recommended by France's Haute Autorité de Santé (HAS)  . Standarté (HAS) .i using a sample of over a thousand French-speaking children—without prior complaints or previously identified LDs—representative of the mainland French school-age population.Here we report psychometric data on the validity of the BMT-i has proceeded in several steps since 2010. Over the last 5 years, it has been gradually implemented, stratified by age groups and cognitive functions, and finally computerized. BMT-i tests apply neuropsychological models for a separate first-line examination of each of the five major domains of academic skills—i.e., (i) written language   oral language  . While the academic aptitude tests are adapted to each grade level, most of the cognitive function tests are identical across a given group, i.e., “youngest” (kindergarten through first grade), “intermediate” (second through fourth grade), or “oldest” (fifth through seventh grade). Scores are instantly and automatically converted into normed results that are summarized in a report. The BMT-i is intended for use by trained health professionals and their teams, including pediatricians, child psychiatrists, school doctors, general practitioners, psychologists, specialized professionals such as speech therapists, psychomotor therapists and occupational therapists. The published versions of the BMT-i tests (Design of the BMT-pelling) —and cogn skills) , (iv) no skills) . For thi-i tests  are desci corresponded to a classical approach in a descriptive study for obtaining an estimation of a prevalence p with both a specified precision (0.05) and a chosen degree of confidence (0.95). The children were exposed to an adapted testing corresponding to their grade, categorized into three levels depending on their age . The rational for the sample size for BMT-This prospective study included 1,074 children aged 4–13 (522 boys and 552 girls) from 12 mainstream public or private schools across France . The 12 schools voluntarily participated and represented the diversity of their geographic  and socioeconomic environments. After approval was granted by their respective regional education authorities and 99% of parents gave informed consent, teachers agreed that children in their classrooms would be tested in alphabetical order. All children were tested except those (i) severely handicapped, (ii) having no parent who spoke French, or (iii) whose parents did not consent to the tests , who began testing in February.The tests were administered in a single session (average duration: 45 min) for kindergartners; two sessions for elementary-school students ; and because of the greater number of mathematical cognition tests for their age group, three sessions for middle-school students .The job category of each parent was recorded, using the nomenclature of the French National Institute of Statistics and Economic Studies (INSEE) . The mosTests were individually administered by an examiner from a group of eight speech-language pathologists and five neuropsychologists, who had received two sessions of collective training. The testing took place in a designated room of each school on a Microsoft Surface Pro 3 convertible laptop running Windows 8. Instructions for each test were displayed on the screen, and the examiner also provided explanations to children, especially the youngest. For the sake of consistency, items that had to be read to the children were recorded in advance, and the recordings were played back by the application. The only exceptions were dictation and reading questions, for which the child's pace had to be considered. Because the tests were computerized, response times could be recorded by the computer. This is particularly important in the assessment of attention and executive functions, where response times are measured to the nearest mils. Children's responses were recorded automatically, when touchscreen input was possible, or manually by the examiner, for oral responses or when more complicated, explicit scoring was required. Scores were instantly and automatically converted into normed results.Examiners participated in semimonthly review meetings led by the authors, and frequently asked questions were regularly published to address potential scoring ambiguities. A clinical research assistant verified inclusion conditions (stratification), observance of the protocol, and thoroughness of tests. After anonymized data were exported, three of the neuropsychologist examiners performed double scoring of study logs under the authors' supervision.The scoring of most tests was objective and unbiased as responses were either automatically recorded or had clear answers . For scoring of participants' reproductions of simple or complex figures (463 children) and of handwriting (342 children), grade-specific inter-rater reliability coefficients were calculated using a random sample .The 10th child on each class list of students was scheduled to be retested for the entire battery and by the same examiner 3 weeks later under strictly identical conditions. At the request of the teachers, the planned retest could only be conducted among kindergarten and elementary school children assessed in the third quarter of the school year in three schools. Therefore, the retested subsample consisted of 22 children (10 boys and 12 girls) aged 4.8–11.3 years and belonging to one of the three groups of classes: (i) kindergarten through first grade, (ii) second through fourth grades, and (iii) fifth grade .i with standardized reference test batteries commonly used in clinical practice   .The inter-rater reliability coefficients for drawing and handwriting assessment were calculated and evaluated using correlation and linear regression coefficients.Test-retest reliability was measured using the intraclass correlation coefficient, which considers school level to be a fixed covariate measure . An intrTest item homogeneity was analyzed using DIMTEST  for dichIn addition, the quality of fit between the theoretical model and the empirical data was estimated through confirmatory factor analysis using the Root Mean Square of Error Approximation (RMSEA). RMSEA values of <0.08 are deemed acceptable . Analyse-i and reference tests scores were categorized as very low (7th percentile or lower), low (7th through 20th percentile), or normal (>20th percentile).Statistical analysis of the test battery comparison included correlation of raw scores (correlation and linear regression coefficients). Degree of agreement was determined by calculating Cohen's kappa: values in the range of 0.21–0.40 indicate fair agreement; 0.41–0.60, moderate; 0.61–0.80, substantial; and 0.81–1.00, almost perfect . For theAnalyses were carried out using JMP software  and the p < 0.001). The overall proportion of underprivileged families (29%) was similar to that reported in a recent French perinatal survey (28%) (ey (28%) . It was ey (28%) , which mey (28%) . In 6% or: 0.77–0.97) and handwriting (r: 0.76–0.84) assessments. Correlations and regression coefficients were significant for all grades  were uni-dimensional. For children in kindergarten and elementary school, due to the limited number of mathematical test items, composite scores were assigned.i scores, and i scores for reading time, reading accuracy, and dictations were significantly correlated with reference test battery scores at both the middle-school and third-grade levels (r ≥ 0.78). For reading comprehension, the correlation between BMT-i and reference tests scores was high at the third-grade level (r = 0.78) and average for the two BMT-i's texts at middle-school (text 1: r = 0.47 and text 2 r = 0.57). There is an average correlation between BMT-i pattern completion test scores and the WISC-V Matrix Reasoning subtest (r = 0.57) and Fluid Reasoning Index (r = 0.44), respectively. i and reference test battery scores into three groups . Cohen's kappa values were moderate (0.39–0.68) for all tests except middle-school reading comprehension (0.25 and 0.30) and pattern completion (0.24), for which they were acceptable. All Cohen's kappa values were significant, with p-values ranging from < 0.0001 to < 0.01.i. This single screening tool includes diverse tasks aimed at identifying the different aspects of LDs, as internationally recommended  allows for dependable interpretation of scores as indicators of children's aptitudes for reading, spelling, math, and various cognitive functions . The coefficients of internal consistency, describing test score reliability, are generally satisfactory, but scores on some tests, including for quality of drawing, were very unstable. Time to completion offers additional information about a child's skills, as long as it is carefully considered in the light of the quality score.To verify the consistency of score data with the theoretical model and determine whether the five cognitive domains were accurately represented, confirmatory factor analyses were performed. These indicated that test scores were significantly related to the cognitive skills they theoretically represented. Hence, the results reported are aligned with the generally recognized theoretical structures associated with the five domains of academic skills and cognitive function , 6, 10. i and reference tests revealed high levels of correlation in all areas of written language, except reading comprehension among middle schoolers, for which r values indicated average correlation. The correlation between the BMT-i pattern completion test scores and the WISC-V fluid reasoning subtests suggests the reliability of potential referrals for the indication of a psychometric assessment for which it is not a substitute. No comparisons were made in areas other than written language and reasoning.Comparison of BMT-Interpretation of these results must be tempered by recognition of the various limitations of the study. To begin with, the results of the reading comprehension assessment vary according to the nature of the tasks proposed, which points to a need for more precise tests. In addition, the reference tests selected were those available at the time of our study. Recent tests would have allowed a single, more elaborate battery to be used for all measures from second grade up , 44. Thei with a large sample of children representative of the diverse mainstream school population in France sets the stage for its use in first-line screening to identify LDs in children with difficulties flagged by parents or teachers. However, use in the diagnosis of LDs will require verification of its sensitivity, specificity, and predictive value, relative to other tests, in children with complaints. The BMT-i might be administered for preliminary cognitive assessment of children who are struggling in school, to properly refer them for specialized assessments.The present validation of the BMT-i is the only tool in French that meets this objective for all domains concerned, over a wide age range. For oral language, the reliability of current instruments is deemed insufficient to permit screening in young children without complaints  performed analyses. ET reviewed the analyses. AMi, J-CT, and AMu discussed the results. CB wrote the manuscript. MT and AMu revised the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Results: The injury risk of the male patients was 1.4 times higher than that of female patients . The rising trend of male injured hospitalized patients was also greater than that of female injured hospitalized patients. Conclusion: Males were more at risk of injury than females. Gender differences were related to the increased risk of epidemiological characteristics of injury.Objective: This study used a long-term trend analysis to investigate whether gender differences were related to the risk of injury and epidemiological characteristics in Taiwan from 1998 to 2015. Materials and methods: Data on 4,647,259 hospitalized patients that were injured from 1 January 1998, to 31 December 2015 were collected from the National Health Insurance Research Database (NHIRD). Among the injured patients, 2,721,612 males and 1,925,446 females were identified. Patients were age-, gender-, and index date-matched. Multiple logistic regression was used to analyze the risks of injury via gender differences. A  According to the Road Traffic Accident Injury Report issued by the World Health Organization (WHO) in 2020, approximately 1.35 million people die in road traffic accidents each year. Approximately 2000–5000 people suffer from non-fatal injuries, and many people become disabled [According to statistics from the Ministry of Health and Welfare in Taiwan in 2018, the total number of deaths due to “accident injuries” reached 6846. “Accident injuries” rank sixth among the top 10 mortality causes in Taiwan. Among other causes, traffic accidents accounted for 3209 persons (46.9%), whereas falls accounted for 1409 persons (20.6%) [Together, these top two causes of death accounted for 67.5% of deaths. Compared to 2008, the number of deaths caused by injury decreased by 231 persons (by 3.3%). Except for traffic accidents, which decreased by 17.1%, and accidental drowning, which decreased by 33.7%, all other categories showed an increasing trend [In 2002, the WHO published “Gender and Road Traffic Accident Injury”, which stated that, globally, gender differences account for the largest injury death rate. Male deaths due to traffic accidents are almost three times 2.7) that of females . In deve that of Although the issue of direct causality is still under debate, previous literature shows that gender differences are risk factors for occupational injuries. Do men suffer more occupational injuries than women, or vice versa ? VariousTo date, research on the relationship between gender and injury remains limited. Such research also has limitations, including small sample sizes, insufficient tracking time, physical and mental illnesses that are not controlled, and unexplored gender differences in injuries. Therefore, this study assumes that gender differences are related to injuries. Data on injured male and female patients from 1998 to 2015 were collected from the National Health Insurance Research Database (NHIRD) of Taiwan for a long-term follow-up analysis of the epidemiological characteristics of gender differences in relation to injury.Taiwan’s National Health Insurance System was implemented in 1995 and currently covers 99% of all citizens. The Data Science Center of the Ministry of Health and Welfare  collects all emergency room and hospitalization data. In addition, the law requires medical institutions to submit monthly declaration files for emergency room and hospitalization expenses. Therefore, the Data Science Center is the most authoritative data source for medical care-related research [This study used a cross-sectional design to analyze inpatient medical declaration files from 1998 to 2015. The data from 1998 to 2015 were derived from the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), while those from 2016 to 2020 were based on the 10th clinical revision of the International Classification of Diseases (ICD-10-CM). The ICD-9-CM codes do not match those of the ICD-10-CM. All procedures carried out involving human participants complied with the ethical standards of the institution, the National Research Council, and the 1964 Declaration of Helsinki and its subsequent amendments, or similar ethical standards.All methods were carried out following relevant guidelines and regulations. Informed consent was obtained from all participating subjects, including the parents and/or legal guardians of subjects under 18 years of age. This study used secondary data without any personally identifiable information and was approved by the National Defense Medical Center Tri-Service General Hospital Ethical Review Board (TSGHIRB 1-105-05-142), thereby waiving the requirement for individual written informed consent. Variables include: gender , age , Charlson’s Comorbidity Index (CCI), intentionality of injury  E-Codes: E800.0–E949.5 unintentional, E950.0–E979.9 deliberate, and E980.0–E989.9 undetermined whether accidental or intentional injury), cause of injury , low income , major disease , operation or not , history of mental illness , hospital level , degree of urbanization , seasonality , medical treatment types , length of stay (days), medical expenses (NT$), and prognosis . The CCI [p-value < 0.05 is considered statistically significant.The descriptive statistics of this study are presented in the form of percentages, averages, and standard deviations. A Chi-square test, Fisher exact test, Student’s t-test, and one-way ANOVA were used to assess the categorical and continuous variables between men and women. After adjusting for age, gender, and comorbidities, the CCI assesses comorbidity level by considering both the number and severity of 19 pre-defined comorbid conditions. A weighted score of a client’s comorbidities is then obtained and can be used to predict short- and long-term outcomes, such as function, length of hospital stay, and mortality rates. After controlling for the main reasons for admission and severity, survival analysis was used to explore the relationship between comorbidity and death within one year, and type 1 comorbidity was weighted according to the adjusted relative risk. The 10-year survival of the patient was verified. This study collected data on 4,647,259 hospitalized injured patients in Taiwan from 1998 to 2015. The proportion of male injured hospitalized patients was significantly higher than that of female injured hospitalized patients. Regarding the cause of injury, both men (37.35%) and women (38.23%) had the highest proportion of hospitalizations due to injuries from traffic accidents. In terms of the CCI, the scores of male patients were lower than those of females , which indicates a higher number and greater severity of injury complications for the latter.In this study, a logistic regression was used to analyze the prognostic factors of injury and death. The results show that from 1998 to 2015 in Taiwan, the proportion of hospitalizations due to injury among men was significantly higher than that of women (58.57% vs. 41.43%). The CCI scores of male injured patients were lower than those of females (0.46 ± 1.53 and 0.50 ± 1.64), indicating that the number or severity of injury complications of the latter was higher or greater than that for men. The risk of death among male patients was 1.4 times that for females . In Taiwan, from 1998 to 2015, the increase in the risk of death of hospitalized male injured patients was greater than that for women (133/105). Injury is shown as the main cause of mortality in developing countries, and more than 90% of injury-related deaths worldwide occur when prevention efforts are insufficient . The sexMen are born with a quantitative advantage, but this benefit diminishes over time. There are 105 boys for every 100 girls at birth . HoweverIn 229 countries in the world, there are more male than female births; the sex ratio of males to females is 107:100 . HoweverRelevant literature shows that after infancy and before old age, men engage in more risk-taking behaviors, becoming prone to and experiencing more injuries, and dying of such causes more frequently . For exaWhy do men have a greater risk of death from injury than women? At present, the general belief is that because of socialized relationships, men have engaged in more dangerous behaviors than women since a young age and are less supervised by people who might protect them (to keep little boys from being harmed). Based on this current theory, attributing all risk-taking behaviors between men and women to gender differences is the only plausible explanation . ObservaThis is not a strange statement for chimpanzees, as female toddlers maintain a close relationship with the chimpanzee mother, while male toddlers wander, fight, and carry out dangerous activities. The reason is that the chimpanzee mother teaches the female toddler that, “Your brother can do this, but the beautiful little chimpanzee girl will not do that.” Even if it is a lion, we can also imagine that male lion cubs use their fathers as an example, and female cubs are taught otherwise. . For exaThe biological differences between men and women affect the overall trend of behavior, the largest difference being levels of testosterone and estrogen. Each hormone has a different effect on the brain, e.g., in terms of driving, and each hormone provides its unique strengths and shortcomings .A high testosterone level contributes to visual processing and spatial perception. Visual processing refers to the brain’s ability to understand the images recorded by the eyes, and better visual processing enables a driver to interpret road conditions and the movement of other vehicles more quickly . When drEstrogen has a unique effect on women’s driving style. First, estrogen can improve concentration, thereby increasing women’s ability to focus on the road without distractions . Higher The difference between the benefits of estrogen and testosterone lies in their use: the concentration provided by estrogen and the improvement of memory often have no negative ramifications . HoweverIn other possible situations, the accident injury is at times caused by the person themself. Alcoholism is an example. Alcohol consumption is common in accidental injuries and violence-related mortality . Census The differences in the structure and function of the brains of men and women are also of great scientific significance . In geneThis study has several limitations. First, the data from the Data Science Center of the MOHW do not provide more important information about injuries. Second, information on other variables  is also restricted. This study used E-Codes to analyze “accident injury”, but such information was only recorded in the hospitalization documents, and not in the outpatient and emergency documents. Therefore, the number of cases and overall medical utilization may be underestimated. Finally, due to the use of auxiliary database analysis in this study, the possibility of data classification errors and information bias cannot be ruled out.This study confirms the correlation between gender difference and injury. The results show that the risk of injury and hospital death is greater for men than for women. Male patients have a greater risk of hospital death due to injuries than females.−Practice safe and alert driving: This practice includes getting enough sleep at night. While driving, avoid chatting, using mobile phones, or flipping through maps.−Maintain a safe driving distance: This includes the front and rear driving distance, lateral spacing, and overtaking distance.−Go out early, not in a hurry: On the way to or from work, avoid hurrying due to traffic jams and other factors.−Increase appropriate driving training: Training should include downhill driving, turning, avoiding improper braking, and other related aspects.−Be alert to changes in environmental conditions: These instances include late nights, cloudy and rainy days, dense fog, or road potholes.−Improve bad driving behavior: Avoid speeding, refusing to give each other courtesy, failing to let vehicles on the main lane go first on branch lanes, failing to maintain a safe distance, driving negligently, violating signal control, and failing to slow down.−Personal reasons for driving: These include drunk driving, taking psychedelic drugs and other similar controlled drugs, speeding, illegal parking, and failing to maintain a safe distance.A growing trend of fatal injuries is observed in both sexes, mainly due to the increase in traffic accidents. The possible solutions or interventions that can stop this negative trend are as follows:


This study shows that hyomental distance in the neutral position is the most reliable parameter for pre-operative airway ultrasound assessment. The main limitations of the study are the small sample size, heterogeneity of studies, and absence of a standardized ultrasonographic evaluation method [Registered at International prospective register of systematic reviews (PROSPERO): number 167931].Unexpected difficult airway management can cause significant morbidity and mortality in patients admitted for elective procedures. Ultrasonography is a promising tool for perioperative airway assessment, nevertheless it is still unclear which sonographic parameters are useful predictors of difficult laryngoscopy and tracheal intubation. To determine the ultrasonographic predictors of a difficult airway that could be applied for routine practice, a systematic review and meta-analysis was conducted. Literature search was performed on PubMED, Web of Science and Embase using the selected keywords. Human primary studies, published in English with the use of ultrasonography to prediction of difficult laryngoscopy or tracheal intubation were included. A total of 19 articles  were analyzed for the systematic review and 12 articles  for the meta-analysis. Standardized mean differences between easy and difficult laryngoscopy groups were calculated and the parameter effect size quantified. A PRISMA methodology was used and the critical appraisal tool from Joanna Briggs Institute was applied. Twenty-six sonographic parameters were studied. The overall effect of the distance from skin to hyoid bone ( Airway management is a core component of anesthesia care . In any Practice Guidelines for Management of the Difficult Airway by the American Society of Anesthesiologists (ASA), a difficult airway is present when “a conventionally trained anesthesiologist experiences difficulty with facemask ventilation of the upper airway (…) tracheal intubation or both,” a laryngoscopy is difficult when “it is not possible to visualize any portion of the vocal cords after multiple attempts at conventional laryngoscopy” and an intubation is difficult when it “requires multiple attempts”  are also low . Even thUltrasonography (US) is a promising tool for airway assessment, as it is safe, quick, repeatable, portable, widely available, and gives real-time dynamic images , 11. ManThis systematic review and meta-analysis was undertaken to identify and synthesize evidence from the existing literature (i) to determine the ultrasonographic predictors of difficult laryngoscopy and difficult tracheal intubation in anesthetized adult patients undergoing elective surgery, and to (ii) summarize the current knowledge and applicability of the sonographic measurements already trialed, in the hopes of contributing to establishing an ultrasonography standardized protocol for preoperative airway assessment.International prospective register of systematic reviews (PROSPERO): number 167931.The present review and meta-analysis was elaborated according to the transparent reporting of systematic reviews and meta-analyses, PRISMA , 14 and The articles were considered when they fulfilled the following inclusion criteria: (1) Use of ultrasonography; (2) Prediction of difficult laryngoscopy or tracheal intubation; (3) Humans; (4) Primary studies; (5) English language. No time period was established, so all articles were included until search dates (12/04/2019 and 12/06/2019).The exclusion criteria were: (1) Obstetric specialty; (2) Pediatric population; (3) Emergency context; (4) Laryngeal mask ventilation; (5) Gray literature. Reviews, editorials, conference abstracts and case reports were also excluded.The primary search was conducted using the following databases: PubMed, Web of Science and Embase. Keywords and Boolean operators used were:  AND (predict OR predictor OR predictors OR prediction) AND (intubation OR laryngoscopy OR “airway management”) AND difficult. The search results were organized using a Microsoft Excel datasheet with records of the exclusion rationale and duplicated citations.Three independent reviewers  screened studies on the basis of title and abstract to identify duplicates. The next step for screening was done by the same reviewers analyzing by title and abstract for eligibility and dissimilarities were solved by consensus after a review of full text publication by SHG. A full text analysis of the remain articles, for detailed information, was done by  and lead to article exclusion. The percent concordance value was calculated. In order to reduce the risk of publication bias, a reference list search of included studies and previous systematic review on the same topic was done .AMS, AMN, MVP extracted the data from each study and collected in a word file locally developed (similar to Cochrane Consumers and Communication review Group's data extraction template). SHG reviewed each data and supervised the process. Disagreements were resolved by discussion between authors. We contacted two authors for further information. One author responded and provided relevant information. No double counting was found. This study includes only two articles from the same author, but a different ultrasound parameter was studied in each article.From each study, information was extensively extracted and included: (1) study design and methods ; (2) sample selection ; (3) Exclusion criteria; (4) Variables and data type (dependent and independent); (5) Statistical analysis ; (6) US results; (7) Conclusions and (8) Limitations. The data was extracted and organized in The Joanna Briggs Institute (JBI), by four independent reviewers  (Appendix 1).The quality assessment of each study was done using the “Checklist for Analytical Cross Sectional Studies” tool, by VP, SHG)  . An value of I2 superior to 50% was considered significant which indicated a lower reliability of results.Considering the heterogeneity of the studies, random effect modeling was chosen, and the effect size measured by Standardized Mean Difference to allow comparison of the results. Authors tested heterogeneity using the method proposed by Higgins at al.  to measuα,df x2) being the mean and n values relative to the difficult group of each specific parameter x(Upper CI- Lower CI)/tarameter .To allow the comparison with other studies, the 4 categories of Cormack-Lehane classification, was dichotomized as easy and difficult by calculating the weighted average of the mean and standard deviation for each group (grades 1 and 2 vs. grades 3 and 4) –21.Ethical approval for this study was not required because no animals or patients were involved.The flowchart in One hundred and five articles were identified through database search. Thirty two duplicates were identified. Seventy three studies were analyzed by title and abstract by reviewers for eligibility and dissimilarities were solved by consensus after a review of full text publication by SHG. Due to the particular inclusion/exclusion criteria of this study, this step of screening was possible to do only with title and abstracts analysis, without significant bias, and 53 articles were excluded , except Wojtczak's  study whThe most common exclusion criteria reported were limited neck mobility secondary to cervical spine fractures or tumors , 24–30, Although upper teeth removal or absence , 24, 26 Previous history of difficult intubation , 33, 35 Patients with full stomach , 22, diaNinety percent of studies reported standard characteristics of age, sex, body mass index; with Reddy et al.  only conA population of obese patients were specifically studied in 21.1% of the articles , 25, 26.Difficult airway, clinically relevant history and objective signs from the physical examination were collected by the majority, except for Falcetta et al.  who did A history of Obstructive Sleep Apnea Syndrome (OSAS) was collected in 21.1% of the studies , 26, 30;The mobility of the temporomandibular joint was directly evaluated in only 10.5% of studies , 26, thoThe evaluation of the clinical predictors was done by the same practitioner in a minority of the studies , 25, 26,In 53% of the studies , 32–35, In all studies a direct laryngoscopy was used and the Cormack-Lehane (CL) grade was defined as the outcome variable (CL 1&2 = easy vs. CL 3&4 = difficult). In order to facilitate the laryngoscopy view, a backward, upward, and rightward pressure (BURP) was applied on the thyroid cartilage during all laryngoscopies in Ezri et al.  study. IUltrasound measurements were done by the same sonographer in 58% of the studies , 31, 34,Another essential aspect of the studies is the positioning of the patient in which US parameters were evaluated. All US measurements were conducted in supine position, except in Hui and Tsui  and Yao The majority of the measurements of the skin to structure distance were undertaken in the central axis of the neck, but Erzi et al. , KomatsuThe Joanna Briggs Institute (JBI), by four independent reviewers (Appendix 1).Quality assessment of the studies included in the systematic review and the meta-analysis was done using the “Checklist for Analytical Cross Sectional Studies” tool, by eviewers   , distancOutcomes from each study was profoundly analyzed, we present the most relevant.p < 0.0001) when hyoid bone visualization was not possible.Hui et al.  study cop = 0.02)  .p = 0.02)  .p = 0.02)  .2 , it predicted a difficult laryngoscopy.The pre-epiglottic area analyzed by Falcetta et al.  measuresOnly Mohammadi Soltani  evaluatep < 0.0001) even though (p = 0.01)  .Chan et al.  found thp = 0.06)  .p = 0.06)  .p < 0.0001)  .Petrisor et al.  concludep = 0.0002)  .Petrisor et al.  found thp = 0.001) (Patients with a difficult laryngoscopy presented with a significantly shorter HMDR2 [1.07 ± 0.08  and 1.02= 0.001) .p = 0.88) (The group of difficult laryngoscopy patients in Andruskiewicz's study  had sign = 0.88) .p = 0.55)  .Yao and Wang  conclude2) compared with the easy laryngoscopy group (21.6 ± 3.09 cm2).Only Andruszkiewicz et al.  evaluateOnly Yao et al.  evaluateAn overall view of the results of the difficult laryngoscopy group from the studies included in the meta-analyses is presented in significant predictor, whereas the distance from skin to anterior commissure of vocal cords  means it is less reliably applied in clinical practice.Concerning the distance from skin to the hyoid bone, the positioning of patients may explain why  was the Adhikari et al. , Pinto eThe methodology adopted by Adhikari et al.  and PintEighty and 76% of the difficult airway patients were males and a cut-off of >2.8 and ≥2.75 cm was established in Adhikari et al.  and Pint2), 75% of the difficult airway patients were female, and the patient position for collecting this measurement was omitted. Those facts can explain the differences from Adhikari et al.  was observed.Skin to epiglottis distance showed significant differences between the difficult and the easy laryngoscopy groups in all studies except in Petrisor's study . The stui et al. , Pinto ei et al. , Wu et ai et al. , and Alei et al. . AlthougThe distance from skin to the anterior commissure of the vocal cords studied by Ezri et al. , KomatsuI2 = 95%, p < 0.00001).The study design, methods and sample selection were very similar in Ezri et al.  and Koma2 and Reddy  was high.Rana et al.  and Guptnd Reddy  between Only Andruskiewicz et al.  found si2). This fact suggests that this predictor may be applied to the general population. However, HMD in extended position had a heterogeneity of 52%, meaning that their relevance for clinical practice is still unclear.Both HMD in extended position , 23, 33 Despite its widespread use, ultrasonography is not yet routinely used for airway assessment and management –39 and iIn the literature, several ultrasound measurements of cervical anatomic structures have been assessed and used as indicators of difficult airway, but there is still debate about the best parameter and the need for higher level of evidence .The present analysis revealed that 7 US measurements have a significant overall effect as predictors for a difficult laryngoscopy. We found that HMD in neutral position was the most consistent predictor. Other potentially useful measurements are HMD in extended position, HMDR2, Pre-E/E-mVC, as well as the distance from skin to hyoid bone, skin to epiglottis, and skin to the anterior commissure of vocal cords.One of the most important limitations of this systematic review and meta-analysis is the heterogeneity of the samples in the studies reviewed, namely BMI ranges, ethnic diverse populations, and female to male proportions. There is also significant discrepancy in study characteristics, mainly in the sample size and blinding. Another limitation of the study is related to the concepts of difficult laryngoscopy and difficult intubation. Both words are used interchangeably in same cases. Therefore, the use of the Cormack-Lehane classification as a surrogate outcome measure for a difficult tracheal intubation may imply a bias in this study. However, it has been thoroughly utilized in the literature, and a CL grade 3 was associated with an 87.5% likelihood of a difficult tracheal intubation .In the selected studies, there may be a selection bias as only articles related to elective surgeries were chosen, which can compromise external validity of the results. This resulted from the fact that only one article on the use of ultrasound in emergency surgery was identified and was not considered as representative sample. Additionally, our population study excluded pregnant , 43 and Finally, for the evaluation of each US parameter, a standardized US technique and positioning are missing, hence there may be a bias associated with the acquisition of the data, even though there was a significant effort to describe in detail the used technique and to train the sonographers to allow reproducibility of the results.Our findings suggest that ultrasonography is a useful tool for prediction of a difficult laryngoscopy and that the best candidate to implement in clinical practice is the measurement of the hyomental distance with the head and neck in neutral position.Future studies should include larger sample sizes with proportional standard characteristics and ensure a standardized US measurement technique and positioning. It would also be beneficial to assess inter and intra-rater reliability to ensure the validity of the results.Assessing HMD in neutral position may be the direction to go as it is the most promising US parameter. It may be relevant to define a specific cut-off for ethnicity, obesity, pregnancy, and pediatric patients and implement US airway evaluation in the context of emergency and intensive care.Finally, it would be advantageous to introduce ultrasonography for the preoperative airway assessment in anesthesiology curriculum training , to ensuThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.SG and JP: study conception and design. SG, AS, AN, MP, PT, PC, and JP: acquisition of data, analysis and interpretation of data, and drafting the article. SG, WT, MK, PT, PC, and JP: in depth revising the manuscript critically for important intellectual content. SG, AS, AN, MP, WT, PC, MK, PT, and JP: final approval of the version to be published and all agree to be countable for all aspects of the work thereby ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All authors contributed to the study substantially.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.


Background: Physiological function impairment is the main precursor of assisted living, movement disorder, and disability in the elderly. The relationship between a combination of healthy lifestyle factors and functional limitations is unclear. We investigated the association between healthy lifestyle scores and the risk of functional impairment in community residents.Methods: A total of 10,602 participants (aged 40–64 years) of the Atherosclerosis Risk in Communities (ARIC) study with no history of cardiovascular events and tumors and who came for their fourth visit (1997–1999) were included in the final analysis. Primary outcomes were recorded during the fourth visit; these included impaired lower extremity function, activities of daily living, and instrumental activities of daily living. A logistic regression model was used to test the associations between healthy lifestyle scores and functional impairment. The lifestyle score comprised six factors: healthy diet, moderate alcohol consumption, coffee consumption, physical activity, normal body weight, and no smoking.Results: Among the 10,602 participants with a median follow-up of 9 years, the prevalence rates of impaired lower extremity function, activities of daily living, and instrumental activities of daily living were 50.6%, 14.7%, and 21.6%, respectively. In the adjusted Cox regression model, participants with a healthy lifestyle score of 5 plus 6 had a significant lower risk of impaired lower extremity function , activities of daily living , and instrumental activities of daily living  than did participants with a score of 0. The association of healthy lifestyle scores with impaired activities of daily living and instrumental activities of daily living was stronger for individuals without diabetes than for those with it (P for interaction < 0.05). This can be partly explained by the fact that the lowest risk of functional impairment among the participants with diabetes was associated with being overweight.Conclusion: Adherence to an overall healthy lifestyle was associated with a lower risk of physiological function limitation. This study highlights the importance of behavioral interventions in the prevention of disabilities.Clinical Trial Registration: www.ClinicalTrials.gov; Unique identifier: NCT00005131. With the increasing average life expectancy and the number of elderly people in the United States, it is estimated that by 2030, approximately 20% of the population will be constituted of persons aged ≥65 years, resulting in an increase in the prevalence of chronic physical function impairment  study.This was a secondary analysis of data from the ARIC study. Data were obtained from the public database of the National Heart, Lung, and Blood Institute Biologic Specimen and Data Repository Information Coordinating Center. The ARIC study is a large prospective study covering four communities  in the United States. At baseline (1987–1989), 15,792 community residents aged 45–64 years participated in this study. The participants were followed up every three years. During the follow-up, information on their medical history, lifestyle, cardiovascular events, and other health-related events was collected. The study was approved by the institutional review board at each site. Informed consent was obtained from all the participants. All procedures in this study were done in accordance with the Declaration of Taipei. The study was approved by the institutional review boards at all field centers of the ARIC study and informed consent was obtained from all participants.n = 305); participants with myocardial infarction, stroke, or a malignant tumor at baseline ; participants with an unreasonable calorie intake ; participants who were neither white nor black (n = 31); and participants with incomplete data (n = 136). Finally, 10,602 participants were included in this study  were components of the healthy lifestyle scores. Their association with functional impairment was also assessed ] during follow-up sessions. A normal body weight was defined as a BMI of 18.5–24.9 kg/m2, according to the  divided by height  using a self-administered questionnaire. The questionnaire comprised 12 activities, and participants were asked to indicate whether they had no difficulties, had difficulties, or had great difficulties doing them or whether they were completely unable to carry out these activities when they were alone, and whether they used aids. As in the third National Health and Nutrition Examination Survey, the 12 activities were divided into lower extremity function, activities of daily living, and instrumental activities of daily living , health behaviors, and prevalence of cardiovascular events and cancer were collected through a standard self-reporting questionnaire. An enzymatic method was used to measure the serum lipid concentration. Hypertension was defined as a systolic blood pressure ≥140 mmHg, diastolic blood pressure ≥90 mmHg, or use of antihypertensive drugs in the last 2 weeks. The sitting arm blood pressure was measured three times after 5 min of quiet rest, with a standardized Hawksley random-zero sphygmomanometer. The final blood pressure value was the average of the second and third readings. Diabetes was defined as a fasting blood glucose concentration ≥126 mg/dl, self-reported history of diabetes, or use of diabetes drugs in the last 2 weeks. The concentration of blood glucose was determined using the improved hexokinase or glucose-6-phosphate dehydrogenase method. Coronary heart disease was diagnosed Parametric continuous variables are reported as mean ± standard deviation values; these were compared using ANOVA. Meanwhile, non-parametric continuous variables are reported as medians  and were compared using the Mann–Whitney U test. Categorical variables are expressed as frequencies and percentages, and these were compared using the chi-square test.A logistic regression model was used to assess the relationship of the healthy lifestyle score with impaired lower extremity function, activities of daily living, and instrumental activities of daily living. The group with a healthy lifestyle score of 0 was set as the reference group in the logistic regression model. To further determine whether these relationships were independent of risk factors, the model was adjusted according to age, sex, race, education level , annual household income , hypertension, diabetes, coronary heart disease, levels of total cholesterol, high-density lipoprotein, low-density lipoprotein, triglycerides, creatinine, and blood glucose, and total calorie intake. A logistic regression analysis was performed after the adjustment for confounding factors to evaluate the association between the healthy lifestyle score and functional limitation in different subgroups of age, sex, race, hypertension, and diabetes; their interactions were tested. Due to the small size of the coronary heart disease subgroups , the model was not used for the subgroups of coronary heart disease.To explain the different results in the subgroup of diabetes, the correlation of BMI with adjusted odds ratios for functional limitations was analyzed using linear splines with five evenly spaced knots in individuals with and without diabetes.P < 0.05 was considered significant for all tests. All statistical analyses were performed using SPSS version 26.0  and R software 3.5.0 .A two-tailed Data of the Atherosclerosis Risk in Communities study can be obtained from the National Heart, Lung, and Blood Institute Biologic Specimen and Data Repository Information Coordinating Center (BioLINCC)P < 0.001 for all).Among the 10,602 participants with a median age of 53 years, the participants with a healthy lifestyle score of 0, 1, 2, 3, 4, 5, and 6 were 698 (6.6), 2,645 (24.9), 3,351 (31.6), 2,472 (23.3), 1,114 (10.5), 290 (2.7), and 32 (0.3), respectively. The number of patients with a healthy lifestyle score of 6 was too small for the analysis; therefore, the participants were divided into six groups based on a healthy lifestyle score of 0, 1, 2, 3, 4, and 5 plus 6. Baseline (1987–1989) characteristics are described and compared in P < 0.001, During the median follow-up of 9 years, the prevalence of impaired lower extremity function, activities of daily living, and instrumental activities of daily living was 50.6%, 14.7%, and 21.6%, respectively. Participants with a high healthy lifestyle score had a significantly lower incidence of functional limitations than participants with a low healthy lifestyle score (P < 0.05). Among those participants, never smoking, physical activity, and normal body weight were the most significant healthy behaviors for preventing impairment of lower extremity function, activities of daily living, and instrumental activities of daily living (P < 0.001). Meanwhile, moderate alcohol intake, regular consumption of coffee, and healthy diet had a protective effect on physical function.In the adjusted logistic regression model , healthyP < 0.001], activities of daily living , and instrumental activities of daily living , than participants with a score of 0. Moreover, participants with a healthy lifestyle score ≥1 had a lower risk of impaired lower extremity function, and participants with a healthy lifestyle score ≥2 had a lower risk of impaired activities of daily living and instrumental activities of daily living than participants with a score of 0 (P < 0.001). This means that adherence to only one or two healthy lifestyle factors can decrease the risk of functional limitations. Notably, an increasing healthy lifestyle score was associated with a decreasing odds ratio for impaired function.Regarding comprehensive healthy lifestyle scores , particiAs shown in In the adjusted logistic regression model, all six binary variables of healthy lifestyle were significantly associated with impaired activities of daily living and instrumental activities of daily living for individuals without diabetes. Meanwhile, the associations of normal body weight with impaired activities of daily living and instrumental activities of daily living were not significant for participants with diabetes. Moreover, only physical activity and never smoked had a significant protective effect on both the risk of impaired activities of daily living and instrumental activities of daily living .P for interaction: 0.019 and 0.002, respectively), linear splines were used to assess the association between BMI and the adjusted odds ratio for impaired functional activities  were strongly associated with a lower risk of physiological function impairments. Adherence to only one or two healthy lifestyle factors could significantly reduce the risk of functional limitations. The reduction in the risk of functional limitations was more obvious in participants who maintained more healthy lifestyles. Therefore, assuming causal relations, the risk of functional limitations might be reduced by 20–70% in persons with a healthy lifestyle score >2.In this community-based cohort study, healthy lifestyle factors including healthy diet , no smoking, moderate alcohol intake , regular consumption of coffee (≥2 cups/day), physical activity , and normal body weight (BMI: 18.5–24.9 kg/m2). The lowest risk for participants without diabetes is associated with having a normal weight (18.5–25 kg/m2). Most previous studies have found that the extremes of the BMI distribution are associated with a higher risk for disability , sex, and hypertension; however, these associations were stronger in the participants without diabetes than in those with diabetes. Notably, normal body weight had no significant protective effect on physical function for patients with diabetes. Therefore, we analyzed the linear relationship between the BMI and functional activity limitation. The lowest risk of functional limitations in participants with diabetes is associated with being overweight  participants had a healthy lifestyle score of 6; thus, the findings for these participants were not conclusive. Third, although associations between the healthy lifestyle score and physical function remained strong and significant after adjustment for several variables, residual confounding  cannot be totally ruled out in an observational study. Fourth, we excluded people with cardiovascular events and cancer to obtain a relatively healthy cohort, but we cannot be certain that none of the participants in our analysis had a functional impairment at baseline. Fifth, we used the maximum lifetime BMI for analysis and did not consider BMI changes. Therefore, these findings should be further confirmed in other prospective cohorts and randomized-controlled studies.In general, adherence to an overall healthy lifestyle was associated with a lower risk of impaired lower extremity function, activities of daily living, and instrumental activities of daily living. Given the increasing prevalence of functional limitations and disability, our findings suggest that having at least two healthy lifestyle habits would substantially prevent functional impairments in the elderly and help to reduce the increasing healthcare burdens. Future research is needed to provide more accurate recommendations on healthy lifestyles for elderly individuals, especially for vulnerable populations, such as persons with diabetes.https://biolincc.nhlbi.nih.gov/studies/aric.The datasets presented in this study can be found in the BioLINCC repository. This data can be found here: The studies involving human participants were reviewed and approved by the institutional review boards at all field centers of the ARIC Study and informed consent was obtained from all participants. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.DL, ZZ, and ZW conceived the study design. DL, YJ, FL, YiL, JY, and QW collected the epidemiological and clinical data. DL, YJ, YaL, XL, and ZW summarized data and performed the statistical analysis. DL, YJ, and ZW interpreted the data and drafted the manuscript. ZZ and RZ participated in the design of the study, acquired the data, and helped to revise the manuscript. All the authors contributed to the article, accept responsibility for the entire content of the submitted manuscript and have approved submission.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The mortality-to-incidence ratio (MIR) is widely used to evaluate the efficacy of cancer management outcomes for individual countries. However, the association among health care expenditure, human development index (HDI), and changes in MIR over time (δMIR) remains unknown. We aimed to elucidate the significance between these indicators and gastric cancer outcomes in different countries. Among the regions, Asia had the highest number of new gastric cancer cases, gastric cancer-related deaths, age-standardized ratio of incidence, and mortality. Chile had the highest age-standardized ratio (ASR) for gastric cancer incidence and the highest ASR for mortality. Moreover, MIR was highest in Africa (0.91) and lowest in North America (0.43). Of note, MIR was negatively associated with HDI, current health expenditure (CHE) per capita, and CHE/GDP % and δMIR was positively associated with CHE/GDP % in countries with very high HDI. However, δMIR showed no significant associations with these indicators in the countries analyzed. In conclusion, increased HDI, CHE per capita, and CHE/GDP are associated with improved gastric cancer outcomes. In addition, the δMIR could be an indicator that can be used to evaluate the improvement in cancer management outcomes over time. Along with increasing life expectancy, cancer has become the leading cause of death in humans, and the incidence of cancer and cancer-related deaths is growing rapidly . GastricSeveral risk factors are involved in gastric cancer, such as obesity and gastro-esophageal reflux disease, which are risk factors for cardia gastric cancer, whereas Helicobacter pylori (HP) infection, alcohol consumption, and intake of salty and salt-preserved food are risk factors for non-cardia gastric cancer –6. EfforThe mortality-to-incidence ratio (MIR) is an indicator that is widely used to evaluate cancer management outcomes in different countries –12. MIR To elucidate the relationship, we conducted an analysis using the 2012 and 2018 GLOBOCAN gastric cancer incidence and mortality statistics from 59 countries to determine the association among the human development index (HDI), current health expenditure (CHE), MIR, and the change in MIR between 2012 and 2018.http://gco.iarc.fr/), which is maintained by the International Agency for Research on Cancer of the World Health Organization. GLOBOCAN, which received an update in 2018, is a public access database that provides contemporary estimates of cancer epidemiology worldwide. HDI data was obtained from the Human Development Report Office of the United Nations Development Programme (http://hdr.undp.org/en). HDI was categorized as very high (0.800–1.000), high (0.700–0.799), medium (0.550–0.699), and low (0.350–0.549). In this investigation, countries were excluded based on the data quality report in GLOBOCAN (N = 123), based on missing data (N = 7), and based on outlier MIRs (N = 2). A total of 59 countries were included in the final analysis. No personal information was used in this study, and all data were obtained from public databases. No approval of the Institutional Review Board was needed as well.Cancer epidemiological data were obtained from the GLOBOCAN project . MIR was defined as the ratio of the crude rate (CR) of mortality to the CR of incidence, as previously described , were obtained from the World Health Statistics database , and CHE as a percentage of GDP , with the crude rate of incidence and mortality in gastric cancer . HoweverP = 0.006; We further analyzed the association of MIR with HDI, CHE per capita, and CHE/GDP. These three indicators were negatively associated with the MIR for gastric cancer in 2018 (Spearman's rank correlation coefficient ρ, −0.618, −0.628, and −0.592, respectively; all P < 0.001; This study aimed to analyze the association among the levels of economic development, health expenditure, gastric cancer outcomes globally in 2018, and the improvement of gastric cancer management over time. We found that gastric cancer incidence, mortality, rank of all cancers, and cumulative risk of incidence were highest in Asia. Chile had the highest ASR for gastric cancer incidence and the highest ASR for mortality. Overall, our findings suggested that gastric cancer in countries with higher CHE per capita and CHE/GDP ratio had better clinical outcomes. Improvement of gastric cancer management was found in highly developed countries with high health expenditures.Previous studies have indicated that the MIRs are directly correlated to the health system ranking in lung, colorectal, prostate, stomach, and breast cancers . MIRs arAlthough the MIR indicates the quality of gastric cancer care, the disparity in gastric cancer incidence and mortality is influenced by many factors. The incidence of gastric cancer is highly dependent on diet, lifestyle, and HP infection in different regions. Japan is one of the regions where gastric cancer is endemic . The impMedical expenditure also increased with the progression of gastric cancer treatment. The treatment for gastric cancer nowadays includes endoscopic resection, surgical resection, adjuvant chemotherapy, and targeted therapy . A recenIn our study, several countries had negative δMIR values, which may indicate poor clinical outcomes and worsening cancer care. Increased risk of mortality and more postoperative complications were found in some low/middle-income countries. These findings may suggest the need to enhance surgical techniques and postoperative care. Meanwhile, δMIR could be a useful indicator to evaluate the improvement of gastric cancer care in countries with good healthcare systems.Our study has some limitations. First, not all countries were analyzed in our study, which may not be exactly the overall burden of gastric cancer in the world. Some countries with high gastric cancer incidence, such as Japan, South Korea, and China, were not included in the analysis due to limited data sources. However, we believe that 59 countries could be a representative study of the cost and outcome of the global burden of gastric cancer. Second, we determined the δMIR between 2012 and 2018, and this parameter could serve as an indicator of the improvement in cancer management for individual nations. However, it cannot be a good surrogate for cancer survival because long-term survival is unknown . Third, In conclusion, we found that δMIR of gastric cancer is positively associated with health care expenditure in very high HDI developed countries. This is the first study to use δMIR as an indicator to evaluate the improvement of gastric cancer management. Future studies are warranted to determine the impact of the health care system on the clinical outcomes of gastric cancer in different countries.The original contributions presented in the study are included in the article/T-WY and C-CW: conceptualization. C-CW: methodology and investigation. W-WS: software and formal analysis and project administration. W-WS, Y-HL, and M-CT: validation. T-WY: resources. W-CH: data curation. Y-HL: writing—original draft preparation. W-WS and T-WY: writing—review and editing. C-CW and W-CH: visualization. T-WY: supervision. All authors have read and agreed to the published 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. The reviewer XL declared a shared affiliation with the authors, to the handling editor at time of review.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.


Tuberculous meningitis (TBM) has a variety of clinical manifestations and complications, and ischemic stroke is a common complication of TBM. However, there is no established prevention or treatment for stroke associated with TBM, and the safety and efficiency of thrombolysis in acute stroke caused by TBM remain unknown. Herein, we present a case of successful intravenous thrombolysis in ischemic stroke caused by TBM. A 50-year-old male patient with cerebral infarction had substantially improved neurological function after intravenous thrombolysis, and he was subsequently found to have TBM. Our findings suggest that intravenous thrombolysis might be an effective acute treatment method for infectious stroke. Tuberculous meningitis (TBM), an important cause of infectious stroke, is the most devastating form of extrapulmonary tuberculosis , 2. IntrA 50-year-old man was admitted to our emergency department with sudden-onset right-sided weakness and aphasia that occurred 3 h ago. In the past month, the patient had headaches, manifested by paroxysmal pain in both temples and the base of the neck. He had a history of fever and chills and vomited 3 days ago. His initial National Institutes of Health Stroke Scale (NIHSS) score was 10 based on analyses of drowsiness, global aphasia, dysarthria, right-sided hypoesthesia, and facial nerve paralysis.Initial laboratory examinations showed a white blood cell (WBC) count of 12.56 × 109/L , blood sodium level of 124.2 mmol/L, and chlorine level of 88.2 mmol/L. Initial non-enhanced head computed tomography (CT) revealed no hemorrhage but showed hypodensity throughout the left frontal lobe and left insular lobe, indicating acute ischemia . TransthMycobacterium tuberculosis with high confidence. Re-examination of head MRI enhancement revealed that the left pontine cistern showed nodular enhancement  analysis revealed a WBC count of 66 × 106/L, lymphocyte count of 70%, protein level of 925.1 mg/L, glucose level of 3.0 mmol/L, and chloride level of 103.5 mmol/L. Findings of CSF cryptococcal antigen and bacterial and fungal cultures, as well as results of the purified protein derivation test and sputum cultures, were all negative. High-throughput sequencing of the CSF detected ancement , and mulancement . The patTBM is the most life-threatening extrapulmonary tuberculosis due to its high mortality rate, and stroke may occur in 15−57% of TBM cases , and theAspirin is the most commonly used treatment for ischemic stroke secondary to TBM because it can prevent stroke and modulate the host immune response in TBM patients , 8. HoweOne limitation should be mentioned in this study. This study only analyzed one clinical case; thus, it is difficult to draw a firm conclusion, and further studies with a larger sample size are needed to confirm our present findings. Our findings suggest that in patients with acute cerebral infarction accompanied by headache and fever, the possibility of an infectious stroke should be considered, and intravenous thrombolysis might be an effective acute treatment method for patients with infectious stroke.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.XW and YZ are the guarantor of integrity of the entire study. LL and QX performed data acquisition. XP was responsible for manuscript preparation and editing. CW and HZ performed manuscript review. All authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Multivariable logistic regression analysis was used to examine the association between eating speed and undernutrition. Among adult men, compared with eating quickly, eating slowly was associated with elevated prevalence of undernutrition (odds ratio (OR) 9.68, 95% confidence interval (CI) 2.32–40.51, p = 0.001). Among older adult women, the prevalence of undernutrition in the slow-eating group was higher than that in the fast-eating group . Eating slowly is independently associated with the prevalence of undernutrition among community-dwelling adult men and older adult women in Japan.The double burden of malnutrition refers to the co-occurrence of overweight and obesity and undernutrition. Eating quickly has been linked to overweight and obesity. However, no study has examined the association between eating speed and undernutrition. This retrospective, cross-sectional study analyzed data from 3529 community-dwelling residents. Eating speed was divided into three categories: fast, medium, and slow. Undernutrition was defined as body mass index (BMI) of <18.5 kg/m The double burden of malnutrition refers to co-occurrence of overweight and obesity and undernutrition in the same population . The comAsian populations, including the Japanese population, have a lower prevalence of obesity than Western populations ,15. In cUndernutrition is both a cause and a consequence of health problems ,19. TherIn this study, we aimed to examine whether eating slowly is associated with undernutrition in middle-aged and older adults, controlling for other related lifestyle habits and using data from a cohort study of community-dwelling adults.In this retrospective, cross-sectional study, we used baseline data from the Takashima Study, a prospective cohort study of community-dwelling residents . The TakThe participants were residents of Takashima County, a rural area in Shiga, Japan, with an initial sample of 3529 individuals (1341 men and 2188 women) aged 24–87 years. This study was approved by the Institutional Review Board of Tsuruga Nursing University (No. 19002), Shiga University of Medical Science (No. G2005-103), and the Institutional Review Board of Ryukoku University, Shiga, Japan . The study was conducted in accordance with the principles set forth in the Declaration of Helsinki. Written informed consent was obtained from all participants. However, participants aged <30 years were excluded because of their short time since aging beyond 20 years.The health examination included a medical history, physical examination, and anthropometric measurements. Self-administered questionnaires were distributed to the participants, physical and clinical examinations were performed, and fasting blood samples were collected.The questionnaire collected data on the following variables: eating speed and lifestyle habits such as exercise, smoking, and drinking. Eating speed was self-reported according to participant perception and categorized by selecting from five categories  in response to the question, “How fast is your eating speed?” As very few participants had a very slow eating speed, we assigned eating speed into three categories: slow (very slow and relatively slow), medium, and fast (relatively fast and very fast). The habit of exercise was assessed based on yes/no responses to the question, “In terms of a month, do you exercise regularly for a total of 60 min or more per day?” The habits of smoking and drinking were first classified as never, former, or current; then, “current” was recategorized to “yes,” and “never” or “former” to “no.” A food frequency questionnaire (FFQ) containing 80 food items and dishes and dietary habits was recorded for over 1 month. Energy intake  was calculated according to the method of a previous study, where the data obtained from the one-day dietary record method  was replThe current body height and weight were measured in the fasting state to measure other biomarkers. We used an analog height meter , which was set up to measure the height of the examinee in a sitting position with the eyes vertical. The scale was read as an approximation of 1 mm. We used an analog weight scale , and the nurse adjusted the zero point daily by subtracting 1 kg for clothing . The sca2 for Asians aged <70 years and as less than 20 kg/m2 for those aged ≥70 years. Undernutrition in older adults is reflected in unwanted weight loss and low BMI. In this study, we defined low BMI in accordance with this criterion as undernutrition. Obesity was defined as BMI of ≥25 kg/m2, according to the Japan Society for the Study of Obesity [According to the Global Leadership Initiative on Malnutrition criteria , a low B Obesity .The baseline fasting blood glucose and lipid profiles of the participants were measured. Their serum TG, HDL, LDL, total cholesterol, and fasting blood glucose levels were recorded. Blood pressure of the participants was measured twice in accordance with the manual , and thePositive histories of hypertension, diabetes, dyslipidemia, cerebrovascular disease, coronary heart disease, and cancer were obtained using the self-reported questionnaire. The history of hypertension included participants who had a systolic blood pressure (SBP) of 160 mmHg or higher and a diastolic blood pressure (DBP) of 95 mmHg or higher . In addiWeight at the age of 20 years was obtained using the question, “What was your usual weight at age 20 years?” Body-weight change was calculated by subtracting the weight at age 20 years from the current weight. The completed questionnaires were checked by trained nurses with the help of the participants and rechecked by nurses at the health screening center. Participants who did not complete the questionnaire were excluded.We used SPSS, version 27.0, for Windows  to perform all statistical analyses stratified by sex. We divided the participants into two groups for data analysis: adults (24–69 years) and older adults (≥70 years). The data are shown as means and standard deviations for continuous variables and as counts and percentages for categorical variables. To evaluate any significant differences in the three categories of eating speed, the Kruskal–Wallis test was used, and the Jonckheere–Terpstra test was used to test for trends. The chi-square test was used to evaluate the differences in the percentages of answers for categorical variables among the three categories of eating speed, and the Mantel–Haenszel test was used to test the trend. Residual analysis was performed to determine the significant differences among the three groups. The Spearman rank-correlation test was performed to examine the correlation between BMI and age.p-values of <0.05, were considered statistically significant.Multivariable logistic regression analysis was performed to examine the associations between eating speed (eating fast as reference) and prevalence of undernutrition adjusted for candidate confounders including age (continuous) in model 1; body weight at the age of 20 years (kg), energy intake , smoking habit , drinking habit , exercise habit , and positive history of diseases , such as hypertension, diabetes, dyslipidemia, cerebrovascular disease, coronary heart disease, and cancer, were additionally adjusted in model 2. The group assigned “0” for each confounder was treated as the reference group. To avoid overestimation, BMI at the age of 20 years was used instead of the current BMI. Two-sided With a 0.10 effect size, an alpha of 0.01, and a sample size of 1341 for males and 2188 for females, the analysis yielded the power values of 0.86 and 0.98, respectively (G*Power 3.1) .Among the 3529 participants, we excluded six participants aged <30 years, 150 with missing data, and 12 with daily energy consumption of <500 kcal or >4500 kcal. The final sample included 3361 participants . 2, respectively. There was no correlation between BMI and age in men  or women . The mean (standard deviation) times from age 20 years to current age were 39.3 (9.8) years for adult men, 53.0 (2.6) years for older men, 36.8 (10.7) years for adult women, and 52.9 (2.3) years for older women.The mean age of men and women was 62.8 (10.5) and 59.7 (11.6) years, respectively; the mean BMI was 23.5 (2.9) and 22.3 (3.1) kg/mp = 0.052).The age of adult men became lower with a significant trend as they ate faster. Current BMI was positively associated with eating speed in both sexes and the two age groups. Body weight at age 20 years was negatively and body weight-change was positively associated with eating speed in adult and older adult men and women. Energy intake was not associated with eating speed; however, it trended higher with slower eating speed in older adult men. The habit of exercise was not associated with eating speed in either sex or age groups. Older adult women with a smoking habit tended to eat slowly; meanwhile, adult men with a drinking habit tended to eat slowly. The history of dyslipidemia was negatively and history of diabetes or cancer positively associated with eating speed in adult men.p < 0.001). Similarly, the percentage of undernutrition among older adult women was 18.9%, which was approximately 1.5 times that of adult men (12.3%) (p = 0.038). The percentage of undernutrition among older adults was approximately four times that of adult men and approximately two times that of adult women. The distribution of BMI categories by eating speed was significantly different in both sexes and the two age groups  . Compared with eating fast, eating moderate and slowly was associated with the prevalence of undernutrition in older adult men . However, after adjusting for lifestyle and chronic diseases, the results were not significant. Compared with eating fast, eating moderately quickly and slowly were associated with the prevalence of undernutrition in older adult women . However, there was no association between eating speed and the prevalence of undernutrition among adult women. Body weight at the age of 20 years was positively associated with the prevalence of undernutrition but not with energy intake in both men and women. Smoking habit was positively associated with the prevalence of undernutrition for adult men . History of hypertension was negatively associated with the prevalence of undernutrition in adult men . History of dyslipidemia was negatively associated with the prevalence of undernutrition in adult and older adult women . History of myocardial infarction was positively associated with the prevalence of undernutrition in adult men .To the best of our knowledge, this is the first study to examine the association between eating speed and the presence of undernutrition among community-dwelling residents in Japan. The results of this study show that eating speed is associated with undernutrition in adult men and older adult women.In this study, a higher percentage of undernutrition was found among adults who ate slowly. In particular, the percentage of undernutrition among older adults who ate slowly compared to those who ate quickly was approximately 20% higher among older men and about 30% higher among older women. A review has shown that eating quickly is associated with obesity and metabolic syndrome, while it has shown that, compared to eating quickly, eating slowly results in a lower energy intake . Eating The traditional Japanese diet is characterized by a high consumption of vegetables, fish, and soy products and low consumption of animal fats, meat, and dairy products. The traditional Japanese Diet Score is inversely correlated with obesity . The oldHowever, in this study, eating speed was not associated with energy intake in adults and older adult women. In a cross-sectional study of middle-aged Japanese men and women, it was reported that fast eating increased energy intake . There aFurthermore, there are several possible metabolic mechanisms involved. The first is diet-induced thermogenesis, an increase in energy expenditure associated with the digestion, absorption, and storage of food, which has been reported to be expedited by eating slowly, accounting for about 10–15% of total daily energy expenditure . Second,In this study, adult men who ate slowly were 10 times more likely to have undernutrition than adult men who ate quickly; meanwhile, there was no significant association in adult women. This may be because almost none of the men who ate fast had undernutrition. Adult men have a larger bite size, chewing power, and eating speed than adult women . These dOlder adult women who ate slowly were three times more likely to have undernutrition than those who ate quickly. However, in older adult men, eating slowly was associated with undernutrition only when age-adjusted, but the difference became not significant when adjusted for lifestyle habits and for chronic diseases. Chronic conditions and social factors might contribute to undernutrition. A systematic review, meta-analysis, and meta-regression reported that the prevalence of malnutrition in rural communities was twice as high as in urban communities and was higher among women than men . A studyHistory of hypertension and dyslipidemia were negatively associated, and the history of myocardial infarction was positively associated with the prevalence of undernutrition. It has been reported that both acute and chronic disorders can cause or exacerbate undernutrition . One of Smoking habit was positively associated with the prevalence of undernutrition for all men. A study of the relationship between smoking and nutrients in community-dwelling Japanese adults found that smokers had a lower appetite, that female smokers had a significantly lower energy intake than non-smokers, and that both men and women smokers reported drinking more than non-smokers . SmokersSimilar to previous studies ,49,50,51Other factors that may affect eating speed and outcomes include dentition, taste perception, changes in appetite and satiety, and swallowing difficulties, all associated with old age . Eating This study has several limitations. First, the eating speed used in this analysis was self-reported, and we did not measure eating speed. Therefore, the eating speed was a subjective assessment and dependent on the participants’ personal views. However, the similar question in Japanese showed high agreement with friends’ evaluations  and highIn conclusion, eating slowly was associated with undernutrition independently of lifestyle and chronic disease among community-dwelling adult men and older adult women in Japan. As with residents who eat quickly and become obese, attention should also be paid to residents who eat too slowly and become undernourished. If they are unable to cover their energy deficits, opportunities for nutritional interventions sufficient to prevent nutritional deficiencies are required.