P < 0.01. Home cardiac rehabilitation guided by mobile Internet technology can improve the function of cardiac, exercise tolerance, life's quality, and compliance of patients with heart failure.In this paper, we are going to explore the effect of mobile Internet technology in health management for the heart failure patients with cardiac rehabilitation. To implement and evaluate its effects in real environment, a total of 60 heart failure patients were divided, preferably in random fashion, into two groups of 30 cases, i.e., control and observation groups. The former group has received the routine home cardiac rehabilitation after discharge, and the latter group, i.e., observation, has received home cardiac rehabilitation based on mobile medical technical guidance after discharge. The 6 min walking test, Minnesota Cardiac Dysfunction Quality of Life Scale score, cardiac function index, and cardiac rehabilitation training compliance were matched between these groups specifically before and after the intervention. After 12 weeks of intervention, the 6 min walking test, Minnesota Cardiac Dysfunction Quality of Life Scale score, B-type natriuretic peptide of N-terminal, end-diastolic diameter preferably left ventricular, left ventricular ejection fraction, and compliance of training, specifically in the observation group, were better than the control group whereas statistically significant differences were observed, i.e.,  Heart failure (HF) is a group of complex clinical syndromes in which ventricular filling or ejection ability is impaired due to any abnormality of cardiac structure or function . SymptomHome, as one of the alternative places for exercise rehabilitation for patients with heart failure after discharge, not only saves resources but also is simple and easy to participate in, which is conducive to the long-term persistence of patients . Home exIn this paper, we are going to explore the effect of mobile Internet technology in health management for heart failure patients with cardiac rehabilitation. To implement and evaluate its effects in real environment, a total of 60 heart failure patients were divided, preferably in a random fashion, into two groups of 44 cases, i.e., control & observation groups. The former group has received the routine home cardiac rehabilitation after discharge, and the latter group, i.e., observation, has received home cardiac rehabilitation based on mobile medical technical guidance after discharge. The 6 min walking test, Minnesota Cardiac Dysfunction Quality of Life Scale score, cardiac function index, and cardiac rehabilitation training compliance were matched between these groups specifically before and after intervention.The rest of the article is organized according to the following agenda items where a comprehensive but brief description of every activity is provided.In Sixty HF patients admitted to our hospital from June 2020 to May 2021 were selected as the research subjects.Inclusion criteria are as follows: conforming to the diagnostic criteria of 2014 Guidelines for the Diagnosis and Treatment of Heart failure in China [Exclusion criteria are as follows: patients with uncontrolled hypertension, severe ventricular arrhythmia, hypertrophic obstructive cardiomyopathy, aortic stenosis, intracardiac or deep vein thrombosis, severe pulmonary disease, and other reasons for exercise contraindications. This study has been approved by the hospital ethics committee.  Control group: After discharge, patients were given routine treatment of HF and family cardiac rehabilitation, including regular administration of G receptor blockers, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, aldosterone receptor antagonists, and guidance on reducing body weight, changing dietary habits, and quitting smoking. Before discharge, according to the ECG treadmill test, individualized exercise prescription was formulated according to Bruce scheme or symptom restrictive scheme , the for  Observation group: ofter discharge, on the basis of HF routine treatment, family cardiac exercise rehabilitation training guided by mobile medical technology (sports rehabilitation app) was conducted.A smartphone exercise rehabilitation app based on an Android system is designed, which has the following functional modules: data reading module, which can read various exercise data of smart bracelet in real time, such as heart rate, exercise speed, exercise time, and other parameters. Exercise prescription module sets exercise intensity, exercise frequency, exercise time, maximum heart rate, weekly exercise course arrangement, and alarm clock reminder; Exercise guidance module voice prompts current exercise speed, heart rate, acceleration or deceleration reminder, exercise rhythm adjustment, etc. In remote guidance module, the patient's mobile phone app can automatically upload various exercise parameters to the cardiac rehabilitation center of the hospital, and the cardiac rehabilitation center can timely adjust the exercise prescription according to the actual exercise situation of the patient. Health education module regularly receives the rehabilitation education knowledge pushed by the hospital rehabilitation center. The exercise rehabilitation app software is designed by the family cardiac exercise rehabilitation training research team  and the engineers of the information department, who are responsible for software debugging, operation, and system maintenance.Before the patients were discharged, the nurses in the research team assisted the patients to install the exercise rehabilitation app and taught the patients to use it. In the movement process, the app guides the patients all the way, who were with headphones and a bracelet with functions of monitoring the heart rate with intelligence; according to app voice prompt, there are pace of warm-up exercise, formal sports, and exercise. In the process of formal movement, the software automatically obtain real-time motion in patients with heart rate, and according to the preset target heart rate, combined with patient toil, voice prompts the patient to speed up or slow down. Patients choose exercise time and intensity according to their own situation. The cardiac rehabilitation center provides remote guidance and health education through the online data of various actual exercises fed back by mobile terminals. The rehabilitation team adjusts exercise prescriptions in time by analyzing the feedback data. If the patient does not complete the exercise plan, a remote reminder will be carried out to urge the patient to complete the training.6 MWT was used to evaluate the therapeutic effect of heart failure. Patients were asked to walk in a straight corridor at the fastest speed they could tolerate, and their walking distance for 6 min was measured. Walking distance <150 m was severe heart failure, 150–450 m was moderate heart failure, and >450 m was mild heart failure . The twoLHFQ included 21 questions in physical field (8 questions), emotional field (5 questions), and other fields (8 questions). The Likert 6-point scoring method was adopted. 0 points indicated that heart failure had no impact on patients, and 5 points indicated that heart failure had a serious impact on patients. It indicates that the quality of life of patients with heart failure is worse . PatientCardiac function indexes of patients in both groups were examined before discharge and at the follow-up of 12 weeks after intervention: N-terminal B-type natriuretic peptide (NT-proBNP), left ventricular end-diastolic diameter (LVEDD), and LVEF were recorded by color ultrasound examination. The effect of exercise rehabilitation was evaluated according to the data mentioned above.The control group received regular telephone follow-up, and on completion of an outpatient appointment, the patients' exercise prescriptions were asked, and the movement of the group was monitored according to uploaded software to ensure that the background prescribed exercises were completed. The compliance of exercise rehabilitation of patients was evaluated, with more than 80% for good adherence, 50%∼79% for compliance, and below 50% for poor compliance.x ± s) whereas two samples (preferably independent) were utilized to carry out the comparison of intergroup. The χ2 test was used for counting the data. Grade data were analyzed by Ridit with the significance level = 0.05.We have utilized the SPSS 19.0 software to perform the statistical analysis of data. Measurement data are depicted as (P > 0.05) specifically in the general data.The proposed study was approved through the ethics committee of the concerned hospital. Finally, 60 patients were enrolled which have signed the consent and were divided into control and observation groups where each group was assigned 30 patients through a random mechanism (preferably random number table). The control group consists of 18 males and 12 female patients with age (55.27 ± 6.01) years, and 20 patients with grade-II cardiac function and 10 with grade-III cardiac function. The observation group has 17 males and 13 females patients with average age (53.27 ± 7.1) years, and 22 patients with grade-II cardiac function and 8 patients with grade-III cardiac function. We have observed no or zero significant difference in these groups (P > 0.05). After 12 weeks of intervention, 6 MWT and MLHFQ scores in the observation group were better than those in the control group, with statistically significant differences (P < 0.01)  see .P > 0.05); After 12 weeks of intervention, the index values of NT-proBNP, LVEDD, and LVEF in the observation group were better than those in the control group, and the difference was statistically significant (P < 0.01)  see .P=0.001) (see The compliance of exercise rehabilitation in the observation group was significantly higher than that in the control group (001) see .P < 0.01).HF patients are prone to shortness of breath, palpitation, fatigue, and other symptoms during activities and often dare not exercise, resulting in decreased exercise endurance. In addition, HF patients have poor self-care ability, recurrent illness, high readmission rate, and great psychological pressure, resulting in decreased quality of life. A meta-analysis of 729 HF patients in 11 randomized clinical studies showed that exercise rehabilitation reduced the risk of death by 39% . With thP < 0.01), indicating that family cardiac rehabilitation exercise based on mobile medical technology guidance can effectively improve the cardiac function of patients.NT-proBNP, LVEDD, and LVEF are all used for cardiac function monitoring and prognostic judgment. NT-proBNP as a peptide hormone, by ventricular cardiomyocytes subdivided and reflect ventricular tension and the body ventricular pressure, hormone regulation system, dyspnea degree is directly related, the change of NT-proBNP level can effectively reflect the degree of heart failure. LVEF reflects cardiac contractility and reserve function and increases as cardiac function improves. The results of this study showed that after 12 weeks of family cardiac rehabilitation testing, the observation group NT-proBNP and LVEDD were significantly lower than the control group. LVEF was significantly higher than the control group, and the difference between the two groups was statistically significant (P < 0.01), indicating that home cardiac rehabilitation guided by mobile medical technology can improve the compliance of cardiac rehabilitation exercise in patients.Routine home cardiac rehabilitation for HF patients lacks real-time guidance from medical staff and poor compliance, and patients cannot correctly master the amount of exercise, which affects the effect of exercise rehabilitation. The home remote cardiac rehabilitation guided by mobile medical technology can solve most of the obstacles for patients to participate in home cardiac rehabilitation . The bacAs a chronic disease, heart failure has a long time span of health management and a wide range of fields. The traditional medical care model is limited by time and space and cannot provide continuous high-quality health management services for patients. Health analysis is to manage personal health information and evaluate personal health and disease risks. At present, we use mobile Internet technology to carry out personalized nursing and health management for individuals, which has the advantages of convenience, openness, interaction, and real-time. Doctor-patient communication can better supervise and remind patients and provide professional health guidance for patients. The results of the nursing application based on mobile Internet technology in the health management of patients with heart failure show that patients' compliance behavior is better and patients' health literacy is higher. Nursing based on mobile Internet technology has to be implemented to build a new nursing concept, across time and geographical boundaries and to inform the disease knowledge continuously to patients. On the one hand, health education is relatively insufficient to solve the medical information and the increasing contradiction of supply and demand of patients with chronic disease, which leads to heart failure. On the other hand, to ensure that patients undergo health education repeatedly and in stages, the health management effeciency has to be better. In conclusion, the implementation of nursing based on mobile Internet technology can help improve the effectiveness of health management of patients with heart failure and improve the health literacy of patients.In future, we are eager to extend the proposed mobile Internet technology-based system for the early prediction of heart failure specifically in elder patients with an age factor of 60 plus.


Internal migration is essential to understand the population dynamics and the multifaceted relationship between population and development of a nation. In Bangladesh, the study of international migration is more frequent due to its socioeconomic importance and data availability. However, the study of internal migration is less frequent as there lie complexities in measuring internal migration, and data are less available. Thus, this paper aimed to explore the dynamics of internal in Bangladesh.Methods of Measuring Internal Migration- Manual VI. District-wise lifetime and net internal migration rate were the dependent variables where several socioeconomic variables were used as independent variables. The correlation and the stepwise multiple linear regression analysis were employed.We utilized data from the Bangladesh Population and Housing Census 1991–2011. The number of internal migrants was estimated using the United Nations Manual on Dhaka, Gazipur, Narayanganj, and all the Divisional cities have the highest in-migration rate, whereas the northern and southern districts of Bangladesh have the highest out-migration rate. The regression model showed that activity rate appeared to be the strongest predictor  of net migration for 2011, followed by city corporation  and poverty rate . However, the lifetime internal migration rate was 9.8% in 2011. The pooled model (1991–2011) for lifetime internal migration showed that activity rate , population density , literacy rate , and city corporation  were the significant factors of internal migration. Marriage, looking for a job, employment/business, education, and natural calamities were the reasons for internal migration.The destinations of migrants are few developed and urbanized cities which needs particular attention in policy planning. If the current migration trends continue, few cities will have an excessive population, which will increase density and pollution, thereby decreasing living standards. Thus, along with comprehensive urban planning, decentralization of government and private institutions must be ensured. Since the rural to urban migration rate is high, the findings recommend more development and concentration in the rural area. Finally, education, training, and work opportunities for migrants should be safeguarded in the area of origin. As the fundamental component of population change, migration is generally the movement of people from one geographic location to another to live permanently or temporarily -. Various countries worldwide are experiencing migration as a significant component in shaping population distribution between and within countries after completing the first demographic transition . As a coInternal migration has generally been considered the significant urbanization process , becominIn contrast, the influence of international migration on the economy has mainly been positive , where 3The first influential work of internal migration in Bangladesh was in 1992, where the author tried to show the trends and determinants of internal migration using census data between 1974 and 1981 –24. HoweMigration affects and is affected by numerous socioeconomic, demographic, political, and environmental factors. Therefore, the development of universal migration theory is hindered due to the dynamic and complex nature of migration , 28. SevHistorical-structural theories of migration such as neo-Marxist conflict theory, world-systems theory, dual labor market theory, on the other hand, interpreted migration as a result of structural economic, and power inequalities; thus, they see migration from a macro perspective , 33–36. Based on the above discussions, the causes of migration can broadly be categorized as economic, social, and environmental factors . EmployaWe used the Population and Housing Census data to analyze the dynamics of internal migration in Bangladesh from 1991 to 2011 –43. SincThe dependent variables of this study were ‘lifetime internal migration’ (direct method) and ’net internal migration’ (indirect method) for each district. The questionnaire of the Census of Bangladesh had questions regarding birthplace and current living place, which was used to calculate lifetime internal migration –43 as a For this reason, we estimated the number of net migrants for each district (an indirect method) using the United Nations’ Manual on Methods of Measuring Internal Migration- Manual VI , 26 to oi (x) is the number of internal migrants in the ’i’ districts and ’x’ age category and Pi, x+n, t+n, meaning population in ’i’ districts in ’x+n’ age category in ’t+n’ year. The causes of internal migration were also taken from the Census. Under this manual, the definition of internal migration is "the change of usual place of residence from one civil division (for this paper District) to another within the country" [Here, Mcountry" . This prData of independent variables were collected from the Analytical Report of Population and Housing Census of 1991, 2001, and 2011 –43. All We produced two maps  for net internal migration rate  using ArcGIS: one for 2011 (migration rate between 2001 and 2011) and another for 2001 (migration rate between 1991 and 2001). Age-specific migration rates were presented using indirect estimation . CorrelaBangladesh consists of 64 Districts and eight major regions (Division). Each district had distinct socioeconomic characteristics. As for 2011, from The economically active population was the highest in Gazipur (61.2%), followed by Bandarban (60.2%), Dhaka (59.7%), and Narayanganj (56.1%). The literacy rate was also higher in divisional cities compared to others. Dhaka had the highest literacy rate of 70.5%, whereas Sunamganj had the lowest (34.9%) in 2011. Population Density was higher in divisional cities, which were also the industrial areas of Bangladesh. Dhaka, Gazipur, and Narayanganj are three districts having most of the readymade garments (RMGs), and other industries were most densely populated. Around 8299, 1884, and 4308 people lived per square kilometers in Dhaka, Gazipur, and Narayanganj. Never married male and female populations did not show much variation except for Sylhet, where both never-married males and females were the highest in Bangladesh (50.7% and 35.6%). Poverty was more elevated in coastal and northern districts than in others. Kurigram had the highest poverty headcount ratio (63.7%), followed by Barishal (54.8%), Shariatpur (52.6%), and Jamalpur (51.1%). Cities with more urban populations had lower poverty rate, such as Dhaka (15.7%), Gazipur (19.4%), and Chattogram (11.5%). The average household size was larger in districts with a less urban population, for example, Sunamganj (5.6), Maulvibazar (5.3), Brahmanbaria (5.3), and Feni (5.2), except for Sylhet (5.8).For 2001, we also observed similar results as in 2011. Dhaka was the city having the most urban population percentage (91.6%), followed by Chattogram (51.1%), Narayanganj (56.2%), and Khulna (54%). The activity rate was also higher in the metropolitan cities, including Dhaka (48.2%), Gazipur (43.9%), Narayanganj (42.3%), and Netrokona (47.7%). The literacy rate was the highest in Jhalokathi (65.4%) and the lowest in Cox’s Bazar (30.8%). The population density was higher in the urban cities, like Dhaka (5814), Narayanganj (3106), Cumilla (1490), and Gazipur (1129). Never married male and female population percentage was higher in Sylhet (52.6% and 37.3%) and Chattogram (52.5% & 37.3%) and the lowest in eastern-northern part of Bangladesh, including Joypurhat (36.1% and 22%), Meherpur (37.1% and 22.3%). The average household size was the highest in Cox’s Bazar and Sylhet and the lowest in Bogura.Trends in lifetime internal migration in Bangladesh is present in Rural to rural and rural to urban migration was higher than urban to urban and urban to rural migration . BetweenThe age-specific net migration rate between the 2001 and 2011 census year is revealed in The distribution of internal migration is depicted in Between 2001 and 2011, net internal in-migration was higher in Dhaka, Naraynganj, and Gazipur. In contrast, Sylhet and Cumilla had a moderate in-migration rate between 6% and 15%. Net out-migration was high like 1991–2001 in the Coastal and Northern part of the country. Bhola, Netrokona, Kishoreganj, Jamalpur, and Sherpur had the highest net out-migration rate, higher than -19%. Districts of Khulna and Barishal division had internal out-migration rate between -18% to -10%.The Divisional variation of net migration rate and relative changes between 2001 and 2011 is presented in The socioeconomic factors were then entered into a stepwise multiple linear regression model to determine the predictors of internal migration. Due to multicollinearity, the urbanization rate and the proportion of never-married (VIF >10) were excluded from the regression model. We excluded population and average household as insignificant at the bivariate analysis. We observed a similar result for the lifetime internal migration rate in 2001 and 1991. However, the strongest predictor of migration in 2001 and 1991 was population density  and City Corporation . An overall model for lifetime internal migration showed that activity rate , population density , literacy rate , and city corporation  were the significant factors of internal migration rate.This study aimed to understand the trends, patterns, and determinants of internal migration in Bangladesh based on the census data from 1991 to 2011. By analyzing the internal migration rate for 2001 and 2011, the study found that the number of net migrants was higher in the more urbanized city like Dhaka, Narayanganj, Gazipur, and Chattogram. The net migration rate was also higher in the divisional town than in other districts. Cities with more industries and more economic opportunities had a higher net in-migration rate; on the other hand, cities with higher poverty headcount ratio, coastal areas had a higher negative rate of internal migration. These findings are similar to a study conducted in Indonesia . AnalysiIn terms of age, the 20–39 age group had the highest internal migration rate (both in and out-migration). The IMAGE project also found that among Asian countries, migration intensity tends to peak at the 20s with a variation for Japan, which has a developed socioeconomic structure and comparatively aging population . The chaIn Bangladesh, the rural to rural and rural to urban migration rate was higher due to the inequality in development in the rural and urban sectors. In this regard, urban bias plays an essential role in developing countries. Urban bias interprets that most administrations in developing countries, for example, Bangladesh, favor the urban sectors in their development policies, making a large gap between the rural and urban economies . For insWe observed that economic reasons are the major causes of migration. People migrated for jobs or employment. In line with this, Todaro and Smith also found the movement of people from rural villages and peripheries to urban centers in search of jobs . The IMAMoreover, many of the population come to city corporation areas in Bangladesh. The notion of first-city, a form of urban bias, is responsible for this. The country’s first or largest city usually gets a substantial share of public and private investment and incentives than the second-largest city or other smaller cities. As a result, the first city receives a disproportionately and unproductively large population. Dhaka, the capital and first city, is central to any investment in Bangladesh, contributing 40% to the country’s total GDP, followed by Chattogram (the Second highest contributor in the GDP). In this way, we found that Dhaka and Chattogram are the two central areas of receiving migrants.We found that the activity rate was the significant predictor of both the net and lifetime internal migration. This finding is also supported by the studies from Indonesia and India- where employment and business were the striking force behind internal migration , 50. BasThere is a negative association between the poverty rate and migration. Theoretically, poverty creates the necessity for migration , 48. PeoOn the other hand, the Harris-Todaro model predicts that expected incomes are generally equated across rural and urban sectors when considering informal-sector activities and outright unemployment. The rural sector can implement all its labor in agriculture  or send the surplus to the urban specialized job sector where the migration decision depends on the expected real income in urban sector times unemployment ratio , 31. In We also found that 3% of migration took place due to natural calamities , which was around 11% in the Rangpur division, followed by Chattogram (4.3%) and Rajshahi (3.0%). Rajshahi and Rangpur is the northern region of Bangladesh. The population of the northern region is severely affected by flood and drought in the rainy and winter season, respectively. As a result, migration is a tradeoff for them to live . In ChatThe study of internal migration is of particular need to understand a country’s current and future population distribution. Due to the dearth of rigorous studies regarding internal migration in Bangladesh, we attempted to understand internal migration trends, patterns, and determinants using Population and Housing Census data from 1991 to 2011. We observed that rural to urban migration is still ahead of urban to rural migration, and migration occurs mainly for economic reasons. The destination of migration is a few developed metropolitan cities . In contrast, the areas of origin of migration are poor, less developed, and coastal districts. This finding has important policy implications. If the current migration trends continue, few developed cities will have an excessive population, which will increase population density and pollution, thereby decreasing living standards. There are disproportionate differences between metropolitan and other cities in terms of opportunities, which is one reason for having many migrants in those cities. Therefore, along with comprehensive urban planning, decentralization of government and private institutions must be ensured. To reduce urban migration, as stated in various policies and programs of Bangladesh, we also suggest that new employment opportunities should be created at the area of origin as economic activity is one of the key reasons for migration. This study also demonstrates that the working-age population has a higher migration rate; so, education, training, and work opportunities for the migrants should be guaranteed in the area of origin.This study showed dynamics of internal migration using both indirect  and direct methods to estimate internal migration data from population and housing census. As a result, this study becomes more credible in understanding the depths and patterns of internal migration. Since we appraised the migration using the balancing equation of population data, there would be both estimation error and content error. Moreover, the lifetime internal migration is calculated based on the ‘place of birth’ data, and indirect estimation is also based on place of birth and current place of residence; thus, they do not take account of timing and number of migrations that occurred during the inter-censual period. In this circumstance, the data from the vital registration system would be more credible and accurate as it collects data every year. However, with the unavailability of raw data, the vital registration system is not robust in Bangladesh, which leaves us no choice but to use these statistics. Some crucial determinants of migration, for example, specific natural calamity, the distance between the destination and current place of residence, could not be analyzed due to the unavailability of data. This study utilized the data from the macro-level (district as the respondents); however, the micro-level analysis would be more precise and accurate. Despite all those limitations, the study’s findings would help understand Bangladesh’s population dynamics and the relationship between development and migration.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.


Based on the leadership literature, this study investigates how paternalistic leadership (PL) and polychronicity (PC) affect the life satisfaction (LS) of nurses, specifically in public hospitals. Moreover, the mediating role of work-family conflict (WFC) and family-work conflict (FWC) is also assessed the relationships among PL, PC, and LS. The cross-sectional study design is used in this study due to its cost benefits and the convenience of data collection at a single point in time. A survey questionnaire is used to collect data from 226 nurses, and the Partial least squares structural equation modeling (PLS-SEM) technique is used to investigate the proposed model. The findings of this study confirmed that PL and PC have a positive relationship with LS. Furthermore, WFC partially mediated the relationships among PL, PC, and LS. In addition, FWC partially mediated the relationship between PL and LS; the role of FWC in mediating the relationship between PC and LS has been found to be insignificant. Employees with high PC and those whose supervisors show PL behavior become more satisfied with their lives and have relatively low WFC and FWC. In addition, the theoretical and practical implications have also been discussed. Paternalistic leadership (PL) has progressively attracted organizational researchers worldwide during the last two decades Aycan, . Most stTherefore, this study investigates the direct relationship of PL and PC with LS based on the conversation of resource (COR) theory; in addition to this, we also explored the mediating roles of WFC and FWC, especially in the healthcare sector. PL is defined as a fatherly leadership style: “the combination of authority and discipline based on benevolence and morality”  as suggested by Grzywacz and Bass  and GrzyThe LS scale was established by Diener et al.  using a The descriptive statistics of sample means, standard deviations, and Pearson's correlation (two-tailed) among this study constructs are shown in The complex relationships among constructs required more comprehensive data analysis methods  values are very close to Cronbach's α value, with the same threshold values applying to them. At the same time, reliability and consistency of all the indicators were assessed through outer loadings. Data were measured using outer loadings instead of convergent validity, and CR score, AVE value, and discriminant validity were assessed using cross-loadings, criteria, and the Heterotrait-Monotrait ratio  are greater than a threshold limit as suggested by Ringle et al. (Q2) values are intended by the blindfolding method. This approach is used for path modeling; the cross-validated redundancy (Q2) value is >0, but this study recommends predictive relevance. The predictive relevance (Q2) values of all endogenous variables are shown in This study followed the suggestion of Hair et al.  to confie et al.  and Lowre et al. , which re et al. . This ste et al. . The pret-values with the level of significance, as well as P-values 95% CI in percentile, and bias-corrected was shown to assess hypothesis relationship among the variables in the study model  has a significant relationship with LS, PL , and WFC. Moreover, PL  has a significant relationship with FWC. The results of this study show that WFC and FWC partially mediate the relationship between PL and LS. WFC shows the partially mediating role between PL and LS (43%), and FWC partially mediates the association between PL and LS (58%). However, PC  has a significant association with LS. P7: PC has a negative relationship with WFC  and PC is not associated with FWC. In addition, the WFC shows the partially mediating role (50%) and the association between PC and the LS of nurses. The FWC has no mediation effect between PC and LS. The effect size f2 is represented to the small effects (0.02), medium effects (0.15), and the large effects (0.35), respectively  to create y Cohen, . This sty Cohen, . The VAFy Cohen, .This study examined the effect of PL and PC on LS. Moreover, this study explored the mediating role of WFC and FWC among PL, PC, and LS. The results revealed that PL behavior positively affects LS of employees, whereas PL has a negative relationship with WFC and FWC. Moreover, WFC and FWC play a mediating role between PL and LS. The findings of this study show that there is a positive relationship between PC and LS. Also, PC has a negative relationship with WFC and FWC.WFC and FWC partially mediate the association between PL and LS. According to previous studies, some leaders served as a role model for their followers, and kind-hearted leaders showed good-quality interpersonal relationships and support their followers . 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.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.


Acute kidney injury (AKI) and obesity are independent risk factors for chronic kidney disease (CKD). This study aimed to determine if obesity modifies risk for CKD outcomes after AKI.This prospective multisite cohort study followed adult survivors after hospitalization, with or without AKI. The primary outcome was a combined CKD event of incident CKD, progression of CKD and kidney failure, examined using time-to-event Cox proportional hazards models, adjusted for diabetes status, age, pre-existing CKD, cardiovascular disease status and intensive care unit admission, and stratified by study center. Body mass index (BMI) was added as an interaction term to examine effect modification by body size.2, 56.4 per 1000-person-years with BMI 25–29.9 kg/m2, and 72.6 per 1000-person-years with BMI 20–24.9 kg/m2. AKI was associated with a higher risk of combined CKD outcomes; adjusted-HR 2.43 (95%CI 1.87–3.16), with no evidence that this was modified by BMI (p for interaction = 0.3). After adjustment for competing risk of death, AKI remained associated with a higher risk of the combined CKD outcome  and similarly, there was no detectable effect of BMI modifying this risk.The cohort included 769 participants with AKI and 769 matched controls. After median follow-up of 4.3 years, among AKI survivors, the rate of the combined CKD outcome was 84.7 per1000-person-years with BMI ≥30 kg/mIn this post-hospitalization cohort, we found no evidence for obesity modifying the association between AKI and development or progression of CKD.The online version contains supplementary material available at 10.1186/s12882-021-02400-3. An increasing prevalence of diabetes, proteinuria, chronic kidney disease (CKD) and obesity, together with an aging population at higher risk for hospitalizations, are likely contributors to the increasing incidence of acute kidney injury (AKI) . Both exMechanisms including renal hypoxia and inflammation may drive the transition from AKI to CKD , 21. ObeThe ASessement, Serial Evaluation and Subsequent Sequelae in Acute Kidney Injury (ASSESS-AKI) study is a multi-center prospective study that examined the risk of CKD development and progression and other clinical outcomes after an episode of hospitalized AKI. It is the only such prospective study including protocolized measurements of height and weight in a prospective cohort of hospitalized patients matched for baseline CKD status, with and without AKI. The purpose of this investigation is to evaluate whether obesity modifies the relationship between AKI and CKD outcomes in a matched cohort of participants hospitalized with and without AKI. We hypothesize that those with high BMI are a higher risk sub-set for subsequent CKD development or progression after an episode of AKI. Furthermore, we hypothesize that obesity is a risk factor for the development or progression of CKD in this hospital-based cohort, with, or without AKI.2 calculated from serum creatinine using the CKD-EPI equation [Study population: The ASSESS-AKI parallel matched cohort study includes hospitalized adult participants with or without an AKI who survived and completed a baseline study visit 3 m after hospital discharge. The full study methods, including detailed inclusion and exclusion criteria, and definitions of covariates, and the primary outcomes have been published previously . The stuequation , age, prTime of entry into the study was the date of AKI diagnosis in the AKI group and the date of index hospital discharge in the non-AKI group. Full eligibility was confirmed, and height and weight were measured, at the baseline study visit, 3 months post discharge from the index hospitalization. Study visits were conducted annually from the index hospitalization until the end of follow up, death, or censoring due to loss to follow up or participant withdrawal. Data collected at annual visits included measurement of kidney function using the CKD-EPI equation with serum creatinine  to deterHeight was measured, in centimeters, using a wall mounted stadiometer, or portable stadiometer with the baseplate placed against a wall. Participants stood against the stadiometer with the back, buttocks and heels touching the stand or backplate, arms and shoulders relaxed and the head in the Frankfurt plane so that the orbitale and the tragus were aligned horizontally, and the headplate was lowered to rest on the top of the head. Participants were weighed in their own clothes, with an empty bladder, and after removing items such as belts and jewellery. Weight was determined using a calibrated electronic scale . Weight was measured twice, with the first measure recorded if the second measure was within 0.1 kg of the first. If the difference between the two measures was more than 0.1 kg, weighing was repeated until 2 measures were within 0.1 kg and the first of these was recorded.2, and categorically, with obesity defined as BMI ≥ 30 kg/m2, and overweight defined as 25–29.9 kg/m2 according to the World Health Organisation (WHO) classification. Normal weight was defined as BMI 20–24.9 kg/m2 which is within the WHO normal weight range [2 was classified as underweight.BMI was calculated as weight in kilograms divided by height in meters squared. BMI was examined continuously, per kg/m2. Development of end stage renal disease (ESRD) was defined as any of the following: (1) peritoneal dialysis or hemodialysis treatment at least once a week for at least 12 consecutive weeks, (2) receipt of a kidney transplant and/or (3) death while receiving dialysis.Study coordinators screened for major events  from medical records and participant self-report at study visits. Kidney disease outcomes were calculated from serum creatinine-based estimated GFR obtained at annual study visits. The primary outcome was a combined CKD event comprised of incident CKD, CKD progression or the development of end stage renal disease (ESRD). In those without CKD at enrollment, incident CKD was defined as experiencing both a minimum 25% reduction in level of eGFR compared with pre-enrollment baseline eGFR and achieving CKD Stage 3 or worse during follow-up . CKD proDeath was ascertained by review of medical records or death certificates if available, or through cross checking with the National Death Index by social security number for participants lost to follow up. Major atherosclerotic cardiovascular events (MACE) of myocardial infarction, ischemic stroke and peripheral artery disease were self-reported or recorded from electronic medical records at follow up and adjudicated per protocol .p values were two-tailed and accepted type 1 error was 5% (α = 0.05).Statistical Analysis: Baseline co-variate distributions were tabulated with respect to baseline BMI categories and baseline AKI status. In the matched cohort, 61 participants did not have measurements of height and weight recorded at the baseline study visit  of incident CKD, CKD progression, MACE and ESRD, and death, per 1000 person years, were calculated for each combination of BMI and AKI groups. Kaplan-Meier curves were used to check for proportional hazards assumptions for each variable. Plots of Kaplan-Meier curves were additionally stratified by quantiles of log relative hazard to demonstrate that proportional hazards is a reasonable assumption. Time to event analyses using Cox proportional hazards models were conducted to estimate the relative hazard of events for the AKI group compared to the non-AKI group. Nested models were established to estimate adjusted associations based on a priori selection using matching criteria and other variables previously reported to be associated with kidney disease incidence, progression or cardiovascular events. Participants in the matched cohort remained unlinked and the matching factors age, pre-admission CKD status and CKD stage, diabetes, CVD, ICU admission, and urine albumin-to-creatinine ratio (uACR) were added in the first nested model (Model 1). The covariate uACR was logarithmically transformed for inclusion in the models. Further adjustments for race, gender, baseline eGFR as a continuous variable, sepsis, chronic heart failure (CHF) and smoking were included in the fully adjusted model (Model 2). For both models, baseline hazards were stratified by study center. Statistical interaction between AKI and BMI was modeled by including a product term for AKI and baseline BMI categories in the proportional hazards models. Models with, and without, the product term were compared using the Wald test. BMI subgroup-specific hazard ratios were obtained via linear combination of regression coefficients for main effect and BMI*AKI cross-product terms. Sensitivity analyses accounting for the competing risk of death were conducted using the Fine-Gray subdistribution hazard models , adjusteBMI was also modeled as a restricted cubic spline, generated from baseline BMI as a continuous variable, with knots at the 10th, 50th, and 90th percentiles. We constructed partial effect plots of the difference in hazard ratios between AKI and no AKI, which display the predicted outcome as a function of a single covariate while holding all other covariates constant for different levels of BMI. The plots are based on a multivariable Cox model that includes terms for AKI status, BMI as a restricted cubic spline, study center, baseline CKD status, ICU status, diabetes, age, cardiovascular disease, race, gender, smoking, sepsis, chronic heart failure, and the interaction between AKI status and BMI as a restricted cubic spline.2). Regression models included terms AKI status, BMI, baseline CKD, age, diabetes, CVD, race, gender, CHF, smoking, sepsis, ICU, uACR, the interaction term between AKI status and BMI, and were stratified by study center. Lastly, in order to examine the association between baseline BMI and CKD outcomes, multivariable time to event Cox models were constructed separately for the AKI and no-AKI groups with normal BMI as the reference group.Secondary outcomes included death, MACE, ESRD, incident CKD, and CKD progression. Supplementary analyses included examining the effect of baseline BMI on the change in kidney function by calculating the log transformed slope of eGFR from baseline at each study visit, in participants with ≥2 eGFR values. Linear regression was used to evaluate the relationship between slope of eGFR and AKI status, modified by BMI. The reference group was normal BMI  BMI was 31.6 (8.3) kg/m2 in the AKI group and 30.6 (7.0) kg/m2 in the non-AKI group  and there were 300 events, including 93 in the non-AKI group and 207 in the AKI group. In multivariable time to event analyses, AKI was associated with a higher risk for the combined CKD outcome, after adjustment for age, kidney disease, diabetes, CVD and ICU admission, and also in the fully adjusted model . Compared to the non-AKI group, AKI was associated with an increased risk of the combined CKD outcome, however, we found no detectable modifying effect of obesity on the risk for the combined CKD outcome  . In the sensitivity analysis including the competing risk of death, the subdistribution hazard risk of the combined CKD outcome in the fully adjusted model (Model 2) was SHR 2.27 (95% CI 1.76 to 2.92). The comparative cumulative incidence plots of the combined CKD outcomes using both Fine-Gray and Aalen-Johansen methods, are displayed in Fig. There was no detectable modifying effect of obesity on the association between AKI and the combined CKD outcome, after the adjustment for the competing risk of death, as the stratum specific risks with overweight and obesity sit within the 95% CI for the normal weight group Table .n = 924). There was an increased likelihood for developing incident CKD after AKI in the fully adjusted model , and the modifying effect of BMI was not detected . For CKD progression, the analysis was limited to those with CKD at baseline. In adjusted models, the risk for CKD progression after AKI was marginally increased (Model 2 aHR 1.62 (95% CI 0.90 to 2.92), and again, we were unable to detect a modifying effect by BMI .The secondary analysis for the development of incident CKD was limited to the participants without CKD at baseline in the matched cohort (p for interaction = 0.5) or ESRD (p for interaction = 0.08) in the fully adjusted models. BMI stratum specific HRs for CKD incidence, CKD progression, ESRD and death are listed in Table In fully adjusted models, AKI was associated with an increased risk for death , and ESRD , but not MACE . There was no detectable modifying effect of obesity on the relationship between AKI and risk of death (p for interaction = 0.91)  Table .The association between BMI and subsequent risk of the combined CKD outcome was also examined in this cohort of hospitalized patients, with or without an AKI event. In models adjusted for age, race and gender, there was no evidence for an increased risk for the combined CKD outcome, with higher BMI, in the non-AKI or AKI groups Table . HoweverIn this prospective matched cohort study, the fully adjusted risk of developing the combined CKD outcome was almost 2.5 times higher in those who experienced AKI, compared to those who did not. This was largely driven by increased CKD incidence after AKI. The risk for CKD outcomes was higher in the present study than in generally healthy, post AKI, community-based cohorts, indicating that the higher overall risk potentially blunted the hypothesized modifying effect of BMI. The majority of participants in our study were admitted to the ICU during hospitalization, indicating a high severity of illness and likely acute inflammation, which may have a greater impact on longer term outcomes than the more modest effect of high BMI. Risk for MACE was not different with or without AKI in this cohort, indicating that an acute insult to the kidneys did not impact upon the risk for cardiovascular events after hospitalization in this population.We were unable to detect a modifying effect of BMI on the association of AKI and the combined outcome of incident CKD, CKD progression or ESRD in this cohort, even after adjustment for the competing risk of death. In separate models examining incident CKD, CKD progression and mortality, there was also no detectable modifying effect of BMI on the primary study finding that AKI is independently associated with a higher risk of the development of CKD, CKD progression, and mortality with up to 8 y of follow-up. Several studies have examined the effect of BMI on mortality after AKI over the short term, although these were retrospective , 19, 37 This study explicitly examined how body mass index may modify the risk of further kidney damage after an episode of AKI. In a small feasibility study, obesity was not associated with the relative risk of CKD development or progression 12 months after AKI . The preRecent evidence which added genetic information to risk models, demonstrates that the independent risk of obesity on CKD outcomes is likely causal, however the associated risk is lower than observational studies using conventional methods suggested . FurtherThe strengths of this study include the inclusion criteria of pre-admission kidney function, the prospective matched cohort design, which matches on potential confounders, and the systematic follow up which included standardised measurement of height and weight at the baseline study visit, and measurement of kidney function at regular intervals. The statistical model was designed a-priori with established clinical factors included as potential confounders. However, there remain factors that may have limited the analyses, such as the very small underweight group with a larger number of events, the wide range of BMI which may have increased the variance in the sample and reduced the power, and the use of BMI as a proxy for obesity. No other measure of body composition or obesity, such as waist circumference, waist to hip ratio or fat mass derived from body composition analysis was available.2), and although participants with AKI were attempted to be matched with non-AKI participants for age, cardiovascular disease, diabetes, category of baseline eGFR, and ICU admission, matching on these factors was not always possible, and our AKI group had a higher prevalence of diabetes, ICU admission, CKD and also more men and more participants with Black race, than the no AKI group. Further adjustment was included in the models to account for the independent effects of these factors on CKD outcomes.BMI was a calculated from a single measure of weight and height at the baseline study visit 3 months post AKI. Weight loss during acute illness is common, and BMI at the first study visit may not have reflected usual BMI. The difference between usual BMI and the BMI at baseline is unknown and is a limitation in the study, as acute illness associated weight loss may have resulted in categorization to a lower BMI category than usual BMI would have. Whilst the matched cohort design is a strength in a longitudinal cohort study, the matching process may not always proceed as planned. Our cohort was primarily matched for study center and baseline CKD status  for the combined CKD event of CKD incidence, progression or End Stage Renal Disease in AKI group compared to non-AKI group, including the competing risk of death. Table S2: Body Mass Index stratum specific time to event adjusted hazard ratios (HR) for outcomes with AKI compared to no AKI in a matched cohort of hospitalized participants. Table S3: Body Mass Index stratum specific association between change in eGFR during follow up and the combined CKD event in a matched cohort of hospitalized participants. Table S4: Time to event Hazard Ratios (HR) for the combined CKD event of CKD incidence, progression or end stage renal disease by body mass index. Figure S1. Cumulative incidences for CKD comparing the Aalen-Johansen method and Fine-Gray models, stratified by AKI status at baseline. Figure S2. Aalen-Johansen cumulative incidence for CKD and death in all subjects. Figure S3. Aalen-Johansen cumulative incidence for CKD and death, stratified by AKI status at baseline.


As teachers provide one-way teaching demonstration or reference materials in class, students lack of the opportunities for direct operation. The provision of interactive e-materials could reduce the need for instructors to prepare complicated teaching aids and could deal with issues of climate and location. Learners could learn any time, anywhere, and learning could be reinforced by repeating the instruction with no need to disrupt timetables. The participants in the experimental teaching study were 275 product design students who engaged in e-learning for 15 weeks . The research results are summarized as follows: (1) Interactive teaching materials can enhance students' active learning styles so that, in the product design area, this method could reduce learning differences in students. (2) E-materials deliver knowledge using simple and specific images, animation, audio, and video, making learning interesting and relaxed for the product design students. E-learning is easy and practical and reduces learners' cognitive load. (3) Students' cognitive development and prior knowledge should be considered in the development of e-materials. Simple images, animations, text, and language could improve the attention and learning motivation of product design students and allow students to learn based on prior knowledge. A suggestion, based on the findings, is the application of various communication teaching models using e-materials to course work for the product design students, enabling discussion, analysis, concept formation, and problem-solving. E-learning presents the functions of global communication, message switching, cooperative learning, and instant messaging. When applied properly, it deals with traditional media deficiencies and enhances the high application value of learning effectiveness. Furthermore, using the convenience of the Internet for “Internet-assisted teaching,” and placing the e-learning content prepared by teachers on websites, teachers could organize the content and Internet resources for learning Internet learners and for teachers, classmates. Learning management platforms and digital content are required for Internet-assisted teaching. The learning management platform is the online instruction tool for teacher–student interaction. Students can engage in discussion, observation, and cooperative group learning on the learning management platform. Teachers can provide teaching and guidance activities on the platform.Digital content has various forms and characteristics. Simulation software can compress time, slow down the process, allow student participation, present safe experiments, and save money and other resources, making the impossible possible. E-learning material can be repeated in various forms and situations. Therefore, the form of digital content is a factor in online learning. Proper training is important to enable instructors to cope with different styles of learners. For maximum benefit, the content should match the learning styles, expectations, and approaches to instruction of the learners. Belonovskaya et al.  mentioneTeng  mentioneH1: The model of product design e-learning content would affect learning motivation.Frolova et al.  indicateH2: The model of product design e-learning content would affect learning effectiveness.Yaman  identifiH3: Learning motivation presents significant and positive effects on learning effect in learning effectiveness.H4: Learning motivation shows remarkable and positive effects on learning gains in learning effectiveness.Referring to Hwang et al. , learninReferring to Chung et al. , (1) leaIn the experimental research, 275 college students from the Department of Product Design in Taiwan participated in a 15-week  using experimental teaching. On completion of the e-learning course, the students completed a questionnaire. The answers to this questionnaire were analyzed using SPSS, factor analysis, reliability analysis, regression analysis, and analysis of variance to test the various hypotheses.Analysis of variance was used to identify the difference made by the model of product design e-learning content on learning motivation and learning effectiveness. The relations between learning motivation and learning effectiveness were further identified using regression analysis.Learning motivation, with factor analysis, was extracted using the two factors of “intrinsic orientation”  and “extrinsic orientation” . The cumulative covariance was 74.925%.Learning effectiveness, with factor analysis, was extracted using the two factors of “learning effect”  and “learning gains” . The cumulative covariance was 84.066%.Analysis of variance was applied to identify the difference made by the model of product design e-learning content in learning motivation. The results show a significant difference in the product design e-learning content in intrinsic orientation. Interactive simulation (4.17) shows higher intrinsic orientation than streaming (3.69). Different models of product design e-learning content reveal remarkable differences in extrinsic orientation. Interactive simulation (4.34) appears higher for extrinsic orientation than for streaming (3.42). Therefore, H1 is supported.Analysis of variance was applied to identify the difference made by the model of product design e-learning content on learning effectiveness. The result shows a noticeable difference made by the model of product design e-learning content on learning effectiveness. Interactive simulation (4.26) indicates a higher learning effect than streaming (3.75), and interactive simulation (4.51) appears to bring about higher learning gains than streaming (3.91). Therefore, H2 is supported.The analysis results in The analysis results in Digital content delivers knowledge through images, animations, audio, and video and stresses simplicity and specificity. The aim is to make students feel that their learning is relaxed, interesting, and easy. Over-elaborate material could result in an excessive cognitive load. Effective learning should take the relationship among stimulus, response, and reinforcement into considerations. Under such an idea, learning content is divided into small units for learning in order and designed with the following principles. (1) Make definite learning goal and learner characteristics. (2) Use job analysis for dividing the teaching unit into several small units, and merely a small unit is preceded at a time. (3) Learning content is presented from simply to difficulty. (4) Feedback or reinforcement must be suitable for learners' cognition to give proper feedback or reinforcement. (5) Teaching materials should match learners' characteristics to offer massed practice or distributed practice. When approached correctly, interactive simulation content seems to have better learning effectiveness than teaching material involving complicated concepts and operations. When content design follows content concepts, and the level of difficulty in digital content takes the cognitive load into consideration, students' learning effectiveness is enhanced. Students' cognitive development and prior knowledge should be taken into account when digital content is being developed. When content is designed and using simple images, animations, text, and language to the greatest possible degree, based on their earlier experiences, students' attention and learning motivation will be enhanced.The research findings show that interactive simulation content could enhance students' learning effectiveness. In the experiment, the experimental group and the control group show notable differences in teaching content. In other words, interactive simulation content could enhance the learning effectiveness of teaching content. This could be the reference for future content design. Interactive simulation content provides simulated situations, allowing students to operate computer software. The human–computer interaction allows students not only to accept the information delivery through the sounds and images in the content but also to operate freely, to explore, and to observe. Students can access individualized instruction and be taught in accordance with their aptitudes. In this case, digital content with interactive simulation could reduce differences in learning styles. Such a method could be considered in the content design to reduce the differences among students with different learning aptitudes. Instruction with interactive simulation-based digital teaching materials could provide large amount of information for learners in a unit of time but might result in leaders' cognitive overload. To reduce leaners' cognitive load, unloading technique, decomposition technique, drill technique, cleanup technique, tagging technique, adjustment technique, redundancy elimination technique, synchronous technology, and personalized design could be applied in the interactive simulation-based digital teaching material design.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The present study was conducted in accordance with the recommendations of the ethics committee of the National Cheng Kung University, Taiwan, with written informed consent being obtained from all the participants. All the participants were asked to read and approve the ethical consent form before participating in the present study. The participants were also asked to follow the guidelines in the form in the research. The research protocol was approved by the ethical committee of the National Cheng Kung University, Taiwan.M-DS performed the initial analyses and wrote the manuscript. H-YH assisted in the data collection and data analysis. Both authors revised and approved the submitted 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.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.


Patients with liver cirrhosis have an increased risk of in-hospital mortality or postoperative complication after surgery. However, large-scale studies on the prognosis of these patients after surgery are lacking. The aim of the study was to investigate the adverse outcomes of patients with liver cirrhosis after surgery over five years.We used the Health Insurance Review and Assessment Service-National Inpatient Samples (HIRA-NIS) between 2012 and 2016. In-hospital mortality and hospital stay were analyzed using the data. Mortality rates according to the surgical department were also analyzed. Of the 1,662,887 patients who underwent surgery, 16,174 (1.0%) patients had cirrhosis. The in-hospital mortality (8.0% vs. 1.0%) and postoperative complications such as respiratory (6.0% vs. 5.3%) or infections (2.8% vs. 2.4%) was significantly higher in patients with cirrhosis than in those without cirrhosis. In addition, the total hospitalization period and use of the intensive care unit were significantly higher in patients with liver cirrhosis. In propensity score matching analysis, liver cirrhosis increased the risk of adverse outcome significantly , especially in-hospital mortality. In liver cirrhosis group, presence of decompensation or varices showed significantly increased postoperative complication or mortality. Adverse outcomes in patients with cirrhosis was the highest in patients who underwent otorhinolaryngology surgery (aOR 1.86), followed by neurosurgery (aOR 1.72), thoracic and cardiovascular surgery (aOR 1.56), and plastic surgery (aOR 1.36).The adverse outcomes of patients with cirrhosis is significantly high after surgery, despite advances in cirrhosis treatment. The true prevalence of liver cirrhosis in the United States is difficult to determine since well-compensated, asymptomatic patients are easily undiagnosed. However, in 2015, Mellinger et al. suggested that at least 0.27% of the American adults with private health insurance had liver cirrhosis ,4. ThereAn accurate evaluation of liver function is necessary prior to surgical procedures with general anesthesia since the risk of surgery is affected by liver function . It is wTherefore, the aim of this was i) to evaluate the in-hospital mortality of patients with liver cirrhosis after surgery, and ii) identify the risk factors using a nationwide population-based study over five years.The Republic of Korea has a universal health coverage system with mandatory social health insurance. National health insurance in Korea covers 98% of the total population, and the number of patients claiming health insurance per year is about 46 million, reaching 90% of the resident registered population. Claims data of the Health Insurance Review and Assessment Service (HIRA) are an important source of information for healthcare service research. Claims data are generated when healthcare service providers submit a claim to HIRA for review for reimbursement. To improve the accessibility to HIRA data for healthcare service researchers, HIRA extracted 13% of the data into a national inpatient sample data (HIRA-NIS) set using a stratified randomized sampling method. The HIRA-NIS data consists of five tables, a table of general information containing demographic information such as gender and age, indicators for inpatient and outpatient services, a table of specific information on services provided, a table of diagnostic information, and a table of outpatient prescriptions.A flow chart of the study sample selection is shown in Liver cirrhosis was defined by at least one occurrence of the ICD-10 diagnosis codes K746 or K703 before surgery, regardless of the period. Decompensated cirrhosis was defined as the presence of any of the following procedures, medications, and diagnostic codes; procedure , medications , diagnostic code  .Adverse outcomes were defined in-hospital mortality or postoperative complications. Multivariate analysis of the factors affecting adverse outcome was performed for the entire patient group and matched set . After mP < 0.001) (P = 0.052)  . On the = 0.052) .P < 0.001)  .Next, we investigated the impact of severity of liver disease on the mortality or postoperative complications in patients with liver cirrhosis. For the evaluation of liver disease severity, presence of decompensation, ascites, varices, chronic hepatitis B, chronic hepatitis C were used. In multivariate analysis, presence of decompensation  or presence of varices  were related with mortality or post-operative complication in cirrhotic patients .In addition to these factors, older age (adjusted OR 1.01), male gender (adjusted OR 1.16), and multiple comorbidities such as diabetes, chronic obstructive pulmonary disease, heart disease were risk factors for adverse outcomes after surgery. In addition, among the types of surgery, otorhinolaryngology (adjusted OR 1.86), neurosurgery (adjusted OR 1.72), cardiothoracic surgery (adjusted OR 1.56), and plastic surgery (adjusted OR 1.36) showed higher postoperative mortality than other types of surgery .When the adverse outcomes were divided into postoperative complication  and in-hIn this nationwide population-based study, we found that the in-hospital mortality after surgery in patients with cirrhosis increased by about five times compared to the patients without cirrhosis, and additionally found that the risk varied according to age, sex, and the type of surgery.Previous studies showed that the burden of liver cirrhosis is growing regardless of the region . In partet al. in 2007, the Mayo score is now widely used in clinical practice [The results of published studies indicated that the postoperative mortality rate for general patients without cirrhosis is 1.1%, whereas the mortality rate for patients with cirrhosis is 8.3–25% ,15. The practice . Howeverpractice . This ispractice . Recent In our study, the in-hospital mortality of the patients with cirrhosis was 8%. Compared to the general population, it was more than seven times higher, and even after age-sex correction, it was more than five times higher. In addition, the rate of admission to the intensive care unit, the duration of hospitalization, and hospitalization costs were all significantly higher. Considering that previous studies reported that the in-hospital mortality rate of liver cirrhosis patients was 8.3–25%, the postoperative outcomes seem to have improved compared to the previous reports. This can be explained by two factors. The first is that the recent intraoperative and postoperative treatment for patients with cirrhosis of the liver has advanced, and the second is that most of the patients who have already undergone surgery are likely to have compensated cirrhosis and thus, relatively good liver function.In our study, the risk factors for postoperative in-hospital mortality in patients with cirrhosis were older age, male gender, low SES, and certain types of surgery. Old age is a risk factor already identified by other studies, and the other risk factors were newly identified in this study . Low SESRegarding the type of surgery, the risk of otorhinolaryngology, neurosurgery, and cardiothoracic surgery was high in our study. First, in relation to otolaryngology surgery, several small-scale head and neck cancer cohort results have been reported. In the previous study, the mortality rate of the group with liver disease was reported to be about 6 times higher than that of the control group, which is considerably higher than that of our study 3.8 times . In our On the other hand, in the case of general surgery or orthopedics, there was no significant difference in in-hospital mortality. The general surgery classified in this study include various types of surgery, and the risk is reported differently depending on the type of surgery. It has been reported that there is no difference in mortality in cholecystectomy or hernia operation compared to the control group, and it is performed commonly in clinical practice ,28. MeanMeanwhile, the high risk of plastic surgery was newly found in our study. Among plastic surgery, debridement, and escharectomy due to pressure ulcers were most frequently performed, and the risk of mortality after surgery was probably increased by patient factors rather than the type of surgery.The items used in the Mayo score are age, American Society of Anesthesiologists score, and scoring system related to liver function evaluation. The results of our study indicate that sex, socioeconomic status, and the type of surgery should be reflected in the surgical risk assessment. If these items are added to the existing Mayo score, it will be possible to more accurately predict the surgical risk of patients with cirrhosis.Our study had several limitations. First of all, there is an inevitable selection bias arising from the retrospective design. Since this study defined liver cirrhosis based on the diagnosis code, it is possible that cirrhosis that was not diagnosed before surgery was not included. In addition, patients with advanced liver cirrhosis are often unable to perform surgery, and sicker patients might excluded from the beginning. Therefore, only patients with relatively well-preserved liver function are selectively included, and there is a possibility of risk underestimation. And out-patient surgery was not included in this study.Second, there is no information on the Child-Pugh or MELD scores. It was difficult to calculate accurate liver function because we could not get the information of blood test, ascites or hepatic encephalopathy. Instead, we tried to overcome this problem by using the definition of decompensated cirrhosis, which has been commonly verified in previous studies . In thisThird, since we classified patients into departments that performed surgery rather than the type of surgery, it was difficult to find out the risk for each type of surgery. In addition, in this study, it was difficult to distinguish from emergency surgery and elective surgery, so the effect of emergency surgery, which is known as a common risk factor in previous studies, on the mortality rate was not calculated –33. FinaIn conclusion, the in-hospital mortality of patients with cirrhosis is significantly high, despite the advances in cirrhosis treatment. For precise surgical risk assessment of these patients, not only liver function, but also age, sex, and the type of surgery should be considered. In the future, an accurate formula for predicting postoperative mortality in patients with cirrhosis should be developed.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S4 Table(DOCX)Click here for additional data file.S5 Table(DOCX)Click here for additional data file.S6 Table(DOCX)Click here for additional data file.S7 Table(DOCX)Click here for additional data file.


Chenopodium quinoa Willd.) is receiving increasing attention globally due to the high nutritional value of its seeds, and the ability of this crop to cope with stress. In the current climate change scenario, valorization of crop byproducts is required to support a climate-smart agriculture. Furthermore, research works characterizing and evaluating quinoa stems and their putative uses are scarce. In this work, straw yield and composition, and the relative feed value of five quinoa varieties, were analyzed in two consecutive years (2017–2018) under field conditions in Southwestern Europe. High temperatures were recorded during the 2017 growing season resulting in significantly decreased straw yield and improved feed value, associated with compositional changes under elevated temperatures. Crude protein, ash, phosphorus, and calcium contents were higher under high temperatures, whereas fiber contents decreased. The relative feed value was also higher in 2017 and differed among varieties. Differences among varieties were also found in straw yield, and contents of phosphorus, potassium, and calcium. Overall, the results presented here support a sustainable quinoa productive system by encouraging straw valorization and shedding light on the mechanisms underlying heat-stress responses in this crop.Quinoa ( In the twenty-first century, climate change has become one of the most critical global challenges, and is particularly crucial for the agricultural and livestock sectors ,2,3,4. TIn addition, the current rapid growth in the global population is expected to lead to a sharp increase in demand for food in coming decades . FurtherChenopodium quinoa Willd.) is an ancient crop from South America that has expanded globally because of the increasing interest in the nutritional composition of its seeds. This has contributed to its selection as one of the crops destined to contribute to food security in the next century, according to the FAO  [Quinoa (ization) . Quinoa ization) . Howeverization) . Quinoa ization) , with reization) . It is aization) ,22,23, aization) .Quinoa has been cultivated for thousands of years in the Andean region comprising Peru, Bolivia, Colombia, and Ecuador although currently its cultivation has expanded globally ,24. IndeThus, in this study, aiming to further explore possible uses of quinoa crop byproducts, and therefore contribute to the implementation of sustainable quinoa cultivation under Mediterranean conditions, the straw production and composition of five quinoa varieties were evaluated in a field located in Southwestern Spain, where episodes of elevated temperatures are frequent. Differences in straw biomass and composition were expected to occur based on the developmental differences of the genotypes tested. Furthermore, the impact of high temperatures under field conditions was analyzed. These results will contribute to a better understanding of how temperature stress might influence straw production.−1) than that in 2017 (1.7 t ha−1), except for Roja and Duquesa, which achieved lower yields in 2018. Marisma reached the highest mean stem yield among varieties (2.8 t ha−1), and was remarkably high in 2018 (3.9 t ha−1). Biomass partitioning was evaluated by determining the HI index, which was significantly influenced by the variety and the year , acid detergent fiber (ADF), and acid detergent lignin (ADL) contents were determined in 2018  compared to 2017 , as shown in As can be observed in Interactions between year and variety were significant for the P and Ca contents. In addition, the P content was relatively similar in both years in the short cycle variety (Jessie), whereas in the other varieties, the P content was considerably higher in 2018, especially in Roja (medium-long cycle), for which differences were found to be higher than 60%. Regarding the Ca content, differences between years were small in Jessie and Pasto, whereas in 2018 the Ca content decreased by more than 18% in the other varieties.The year showed a significant influence on the digestible dry matter (DDM), the dry matter intake (DMI) and on the relative feed value (RFV), which were higher in 2017 . The var−1) compared to 2018 (2.1 t ha−1) , especially in 2018 (3.9 t ha−1), was well correlated with a higher seed yield, as previously reported [−1) achieved in this work was lower than those previously reported for Mediterranean field conditions  [−1). The results reported earlier can be partially explained by the lower HI obtained in these works, which resulted in higher straw yield per seed yield. This was probably a consequence of the different environmental conditions, and differences in the planting density and/or in the genotypes used, that resulted in detrimental effects on seed yield but positive effects on vegetative growth [The use of quinoa straw has the potential to contribute to the development of a cleaner agriculture. This byproduct has been used and studied for agricultural purposes as feed and bedding material, in addition to bioenergy or biomaterial production ,28. Quin t ha−1) , especiareported , which iegalona) , and sime growth ,39. In te growth , and hige growth . Nonethee growth ,43.The straw composition differed between years as observed in As can be observed in When analyzing the increased mineral and protein contents in 2017, the changes could point to a detrimental effect of higher temperatures in nutrient translocation into the seed as observed in wheat . HoweverThe relative feed value (RFV) developed by the Universities of Minnesota and Wisconsin and the American Forage and Grassland Council (AFGC), is an index widely used to determine the forage quality, which combines significant nutritional factors (including voluntary intake and digestibility) ,63. WhenOverall, the results here presented show that Marisma is the variety with the best cultivation potential in terms of straw yield for this particular area (Southwestern Spain), despite suffering important yield penalties linked to the elevated temperatures suffered in 2017 . FurtherA two-year field experiment was conducted during 2017–2018 at the experimental farm of the Center for Scientific and Technological Research of Extremadura (CICYTEX), located in Southwest Spain . Data of monthly mean minimum and maximum temperature (Tmin and Tmax), and the rainfall during the crop cycle  were obt−1. Weeding was carried out by hand when required. Irrigation was carried out by sprinkling to maintain the soil under non-limiting water conditions. The crop was fertilized at the rate of 150, 100, and 100 kg/ha of N, P2O5, K2O, respectively. Plants were harvested by hand at physiological maturity . The sampling area was 3 m2. A stationary thresher was used to collect the seed. The straw samples were ground through a 1 mm screen for further analysis.Five European varieties of quinoa  were evaluated in a randomized complete block design with four replications: Jessie ; Pasto and Marisma ; Roja and Duquesa . The plot size was formed by four rows 0.75 m apart and 10 m long. Sowing was conducted mechanically in early February, at a dose of 4 kg haData were expressed on a dried weight (dW) basis. Analysis of moisture, crude protein (CP), and ash contents were conducted following the AOAC Official Methods . The minRelative feed value (RFV) was calculated as calculated from the digestible dry matter (DDM) and the dry matter intake (DMI)  according to the following equations:Harvest index (HI) was calculated as the ratio between the grain yield (G) and the yields of straw plus grain (G + S), in order to determine the biomass partitioning index, as previously reported .p < 0.05), Tukey’s test was performed and used to compare means. Student’s t-test was used to determine statistically significant differences between years for each variety. Analyses were performed using the Statistix 8 analytical software.All measured and derived data were processed using a two-way analysis of variance (ANOVA), including the year, the variety, and their interactions in the model. The year was treated as a fixed factor. Normality and equal variances could be assumed, according to the results of the Shapiro Wilk test and Levene’s test, respectively. For better interpretation of the data, additional one-way ANOVA was carried out for each year separately. When the F ratio was significant (


Dysphagia is a common sequelae after stroke. Noninvasive brain stimulation (NIBS) is a tool that has been used in the rehabilitation process to modify cortical excitability and improve dysphagia.  To systematically evaluate the effect of NIBS on dysphagia after stroke and compare the effects of two different NIBS. Cochrane Handbook for Systematic Reviews of Interventions. A statistical analysis was carried out using RevMan 5.3 and ADDIS 1.16.8. The effect size was evaluated by using the standardized mean difference (SMD) and a 95% confidence interval (CI).  Randomized controlled trials about the effect of NIBS on dysphagia after stroke were retrieved from databases of PubMed, Embase, Cochrane Library, Web of Science, CNKI, Wanfang Data, VIP, and CBM, from inception to June 2021. The quality of the trials was assessed, and the data were extracted according to the P < 0.05) and the water swallow test score . NIBS could reduce the standardized swallowing assessment (SSA) score , the penetration-aspiration scale (PAS) score , and the functional dysphagia scale score . Network meta-analysis showed that the best probabilistic ranking of the effects of two different NIBS on the DOSS score is rTMS (P = 0.52) > tDCS (P = 0.48), the best probabilistic ranking of the SSA score is rTMS (P = 0.72) > tDCS (P = 0.28), and the best probabilistic ranking of the PAS score is rTMS (P = 0.68) > tDCS (P = 0.32).  Ultimately, 18 studies involving 738 patients were included. Meta-analysis showed that NIBS could improve the dysphagia outcome and severity scale (DOSS) score (standard mean difference (SMD) = 1.44, 95% CI 0.80 to 2.08,  Existing evidence showed that NIBS could improve swallowing dysfunction and reduce the occurrence of aspiration after stroke, and that rTMS is better than tDCS. Limited by the number of included studies, more large-sample, multicenter, double-blind, high-quality clinical randomized controlled trials are still needed in the future to further confirm the results of this research. Swallowing seems to be a simple action, but it actually involves the coordination of multiple muscle groups, the regulation of the cranial nerves, and the central nervous system . DysphagAt present, traditional treatment methods for poststroke dysphagia include neuromuscular electrical stimulation, feeding training, cold stimulation, acupuncture, biofeedback therapy, balloon dilation, and adjustment of food shape and eating posture. However, patients have different degrees of rehabilitation, and the effect is limited. Noninvasive brain stimulation (NIBS) techniques adjust the excitability of the cerebral cortex through electric or magnetic fields and accelerate the induction of neuroplasticity. Due to its advantages of noninvasiveness, easy operation, painlessness, and few side effects, NIBS has been widely used in the rehabilitation treatment of various brain dysfunctions, and the clinical application prospects are very broad , 7. RepeThe theoretical basis of NIBS is a model that involves interaction inhibition between the two hemispheres combined with the plasticity of the central nervous system. Changes of cortical plasticity are mainly achieved through neural network reconstruction, including functional compensation of the remaining brain regions around the affected lesion and the unaffected hemisphere , 10. UndAt present, some studies have explored the rehabilitation effect of NIBS on poststroke dysphagia. However, the sample size of a single study is small, and the inclusion criteria and research methods are different. Evidence-based research on the rehabilitation of poststroke dysphagia by NIBS is sparse, and there is no evidence to show the difference of effects between the two different NIBS. This is not conducive to the development of evidence-based clinical practice of NIBS in treating poststroke dysphagia. Therefore, this study will systematically evaluate the rehabilitation effects of NIBS on poststroke dysphagia through evidence-based medicine and compare the effects of two different NIBS, in order to provide some reference for the application of NIBS in clinical rehabilitation in the future.Randomized controlled trials about the effect of NIBS on dysphagia after stroke were retrieved by two researchers (Zhiyao Liu and Xin Shi) from databases of PubMed, Embase, Cochrane Library, Web of Science, CNKI, Wanfang Data, VIP, and CBM, from inception to June 2021. The databases can be searched flexibly according to the combination of medical MeSH terms and general terms. Taking the PubMed database as an example, the specific retrieval strategy is as follows: #1 “stroke”[MeSH] OR cerebrovascular accident OR apoplexy OR brain vascular accident OR cerebral vascular accident OR hemiplegia OR CVA, #2 “transcranial direct current stimulation”[Mesh] OR “transcranial magnetic stimulation”[Mesh] OR non-invasive brain stimulation OR noninvasive brain stimulation OR transcranial electrical stimulation OR rTMS OR tDCS; #3 “randomized controlled trial”[MeSH] OR random OR random allocation OR RCT, and #4 #1 and #2 and #3.Population: patients with poststroke dysphagiaIntervention: NIBS such as tDCS and rTMSComparison: sham-NIBSOutcome: primary outcomes: dysphagia outcome and severity scale (DOSS), standardized swallowing assessment (SSA), and penetration-aspiration scale (PAS). Secondary outcomes: functional dysphagia scale (FDS) and water swallow test (WST)Study design: randomized controlled trial (RCT)If the study meets the following criteria, it should be excluded: non-RCTs such as self-control, cohort studies, case-control studies, and cross-sectional studies; those combined with other therapeutic interventions; those that involve patients with severe aphasia or cognitive impairment; those that have baselines that are not comparable or do not report baseline conditions; those with poor design or improper statistical methods; those with incomplete data, original data, or full-text documents that cannot be obtained after contacting the author; those without corresponding outcomes; those where the diagnostic criteria and the intervention time are not clear; and case reports, protocols, conference abstracts, animal experiments and reviews, and so on.Two researchers (Zhiyao Liu and Xin Shi) independently read the studies, extracted the data, and cross-checked. If there were any disagreement, it was discussed with the third researcher (Fangqi Wang). The extracted data include the descriptive information of the literature  and general information of the included cases .Cochrane Handbook for Systematic Reviews of Interventions [Two researchers (Zhiyao Liu and Xin Shi) used the physiotherapy evidence database (PEDro) scale  to evaluventions . If the P ≥ 0.1 and I2 ≤ 50%, there was no significant heterogeneity among the studies, and the fixed effect model was used; if P < 0.1 and I2 > 50%, there was significant heterogeneity among the studies, and the random effect model was used. When heterogeneity is high, subgroup analysis and sensitivity analysis were used to explore its source. (2) Calculation of effects: the outcome indicators included in the study are all continuous variables; the standard mean difference (SMD) was used to represent the magnitude of the effect and calculated 95% confidence interval (CI).Traditional meta-analysis was carried out by RevMan 5.3 software: (1) Heterogeneity test: if R 4.0.5 software was used to draw a network diagram, and ADDIS 1.16.8 software was used for statistical analysis to compare the differences in efficacy of the two NIBS. Based on the Markov chain Monte Carlo algorithm, network meta-analysis and probability rankings were carried out by four chains and consistency models. The initial value was set to 0.5, the step size to 10, and the number of iterations to 50,000. The first 20,000 iterations were used for annealing to eliminate the influence of the initial value, and the last 30,000 iterations were used for sampling. The potential scale reduced factor (PSRF) was calculated by comparing the variance within and between chains to evaluate convergence. PSRF values close to 1 indicated good convergence, and the results of the consistency model analysis are more reliable.A total of 405 studies were retrieved from the database; 248 studies were obtained after eliminating duplication with EndNote X9. After layer-by-layer screening, 18 studies –34 were The basic information of the included studies is shown in P < 0.05) and . Meta-analysis showed that the DOSS score in the NIBS group was higher than that in the control group .Eight RCTs , 30, 31 P < 0.05) and . Meta-analysis showed that the SSA score in the NIBS group was lower than that in the control group .Seven RCTs , 32, 34 P < 0.05). The PAS score in the tDCS group was not statistically significant compared with the control group , but most of the black rhombic blocks fell in the experimental group, with a tendency to lower PAS scores. Meta-analysis showed that the PAS score in the NIBS group was lower than that in the control group .Eight RCTs , 33, 34 P < 0.05) and . Meta-analysis showed that the FDS score in the NIBS group was lower than that in the control group .Three RCTs , 25, 33 P < 0.05).Two RCTs , 32 repoEighteen RCTs –34 were In this study, there was no closed loop between the interventions, so there was no need for a consistency test.The primary outcomes of the eighteen RCTs –34, suchN is worst. For the SSA and PAS scores, ranking N is best and ranking 1 is worst.The probability ranking of the network meta-analysis is shown in P = 0.52) > tDCS (P = 0.48), the best probabilistic ranking of the SSA score is rTMS (P = 0.72) > tDCS (P = 0.28), and the best probabilistic ranking of the PAS score is rTMS (P = 0.68) > tDCS (P = 0.32).Network meta-analysis showed that the best probabilistic ranking of the effects of two different NIBS on the DOSS score is rTMS . Subgroup analysis showed that rTMS and tDCS were consistent with the results of the total combined effect in improving the DOSS score and reducing the SSA score, and both of them could improve the swallowing function of patients. The PAS scale [P < 0.05). Subgroup analysis showed that rTMS and tDCS were not consistent with the total combined effect in reducing the PAS score. rTMS was effective while tDCS was ineffective. There was no strong evidence that tDCS could reduce the incidence of aspiration in dysphagia patients after stroke. The efficacy of tDCS in reducing the incidence of aspiration needs further research. As for the secondary outcomes of FDS and WST, this study showed that the NIBS group is superior to the control group.Eighteen RCTs were included to evaluate swallowing dysphagia by primary outcomes of DOSS, SSA, and PAS. The DOSS scale  is dividAS scale  divides In contrast to previous systematic reviews and meta-analyses , 40, theAt present, the position of the swallowing center in the cerebral cortex is still unclear. Functional magnetic resonance imaging studies show that it may be related to the primary motor sensory cortex, insula, cingulate gyrus, prefrontal cortex, temporal lobe, and occipital region , 47. HamAlthough this study follows the criteria of systematic review and network meta-analysis report (PRISMA statement), there are certain potential biases. At present, there are relatively few RCTs about NIBS to improve dysphagia after stroke. The included studies are published in both Chinese and English, and the lack of relevant gray studies may lead to the bias of study selection. Some studies did not describe specific random methods, allocation concealment, or blind methods. Only seven studies reported follow-up, the follow-up time was short, and there was no long-term effect of NIBS on the swallowing function in stroke patients. The intervention time was 1~8 weeks, and the stimulation sites were unaffected, affected, or bilateral. The frequency and current of stimulation are also different. Our study could not determine the relationship between the length of the intervention period, the stimulation site and the intensity of stimulation, and the improvement of swallowing function.To sum up, the existing evidence shows that NIBS can improve poststroke dysphagia and reduce the incidence of aspiration to a certain extent. rTMS is superior to tDCS, but it is necessary to carry out more large-sample, multicenter, double-blind, high-quality RCTs. In addition, NIBS has no obvious adverse reactions in the treatment of dysphagia after stroke, which is worthy of clinical application.