Escherichia coli and Enterococci). The physicochemical water quality parameters as well as basic anions  determined complied with the regulatory guideline of the World Health Organization (WHO) and the South Africa National Standards (SANS). Some of the trace metals  were found below the guideline values, while others (Pb and Cd) exceeded the threshold limit. The counts for E. coli (814.5–2169 cfu/100 mL) and Enterococci (333–9396 cfu/100 mL) in the study did not comply with the regulatory guidelines. The water quality status using the water quality index (WQI) indicated that on the average, the water quality from Mutangwi River is poor (WQI > 100). The hazard quotient through ingestion exposure did not exceed the threshold limit of 1, for adults and children. This implies that there is no potential non-carcinogenic health risk from trace elements via ingestion of drinking water for children and adults. However, cancer risk for adults and children was computed in relation to Cd and Pb levels and exceeded the threshold limit 10−4, indicating a possible carcinogenic risk. Water from the river should be adequately treated prior to domestic and agricultural use.Freshwater supply is essential to life on Earth; however, land use activities such as mining and agriculture pose a significant danger to freshwater resources and the wellbeing of aquatic environments. This study temporarily assesses the water quality characteristics of Mutangwi River. Physicochemical parameters , salinity, electrical conductivity (EC), and turbidity) were determined in situ using an Extech multimeter and turbidity meter. The concentration of the selected metals  were analysed using an Atomic Absorption Spectrophotometer. Membrane filtration method was used to analyse microbiological parameters ( Water quality often determines the fitness of water use for a variety of purposes. The assessment of water quality is thus important to evaluate the water use potential of any water resource . The conIn many cities and towns globally, sustainable access to clean and safe water has been reported; however, unfortunately, many people who live in peri-urban and rural regions of the world do not have continuous access to clean and safe water and they often resort to several alternative sources for their domestic water needs ,6,7,8,9.In South Africa, surface waters such as rivers, lakes, ponds, and streams are key components for water supply due to the numerous dams that are fed from them. In the absence of sustainable access to potable water in rural areas, people are left to seek for alternative sources to meet their basic needs, and surface water is the first point of call as it is easy to access and use ,3,11. CoAnthropogenic and natural factors can cause an increase in the level of contamination of freshwater sources ,15. ActiMutangwi River is widely used for domestic, recreational, and agricultural purposes . Moreover, small-scale businesses such as car washes abstract water from the river. Small-scale fishing also occurs within the river course. Edokpayi et al.  reportedWe, therefore, report our findings on the physicochemical and microbiological characteristics of Mutangwi River. In addition, we present the overall status of water in the river using the Water Quality Index (WQI), which is a versatile tool for summarizing the water quality status of a river system. Furthermore, since the water is used for several purposes, we computed the potential carcinogenic and noncarcinogenic health risk associated with its consumption based on the trace metals levels recorded.The study area is situated at Mudunungu Village, Thulamela Municipality. It is located at a height of 1318 m above the sea level. Its geographical location is 22°52′60′′ S and 30°13′0′′ E. Mutangwi River  is generThe mean yearly precipitation ranges from 480 to 560 mm, with a mean annual runoff of about 50 million cubic meters . The potential pollution sources include ablution facilities, sanitation, car wash, laundry, and dumping of refuse on open spaces and on the riverbank. Land use activities vary in the upper, middle and lower parts of Mutangwi River. The river is covered by large-scale agricultural activities, there is dominant forest in the upper stream and the lower part has cropping plantation. Mutangwi River was divided into three sections, which are the upstream, midstream, and downstream, for samples collection. Twenty-seven water samples were collected in triplicate using sterilized plastics bottles on a monthly basis between June and August 2018. Samples were collected for physicochemical, microbiological, and trace metals analyses. Water samples for metals were preserved with concentrated nitric acid. Collected samples were kept in an ice chest and transported to the Hydrology Laboratory of the University of Venda for further examination. Microbial analysis was performed within 6 h of sample collection.Temperature, pH, electrical conductivity (EC), salinity, and total dissolved solids (TDS) were measured in the field using an Extech multimeter . Turbidimeter was used to measure the turbidity  of the water samples.Trace metals were analysed using an atomic absorption spectrophotometer . Calibration standards were prepared from 100 mg/L stock solution of the test metals.Anion  concentrations were determined using Ion Chromatography (IC). The water samples were filtered with syringe filters (0.45 μm) and placed in a standard vial in an automated autosampler connected to the IC . Escherichiacoli and Enterococcus levels in the samples were evaluated using Membrane Filtration (MF) technique. M-Tec Chromo select Agar  was prepared for E. coli enumeration while m-Enterococcus Agar  was used for the determination of enterococci levels. The agars were prepared according to the manufacturer’s guidelines. The samples (100 mL) were filtered through 47 mm sterile membrane filters using a vacuum pump and a manifold by adhering to the protocols of the American Public Health Association [E. coli and enterococci, respectively. The results were reported as colony-forming units per 100 mL of sample.ociation . The filiw) according to their relative importance in the overall quality of water for drinking purposes  below ,19.(3)WWQI ranks water quality in the range of excellent to unsuitable for drinking with numerical values computed using Equation (3) .Human exposure risk pathways of an individual to trace metals contamination could be through three main pathways including inhalation via nose and mouth, direct ingestion, and dermal absorption through skin exposure. Common exposure pathways to water are dermal absorption and ingestion routes. Exposure dose for determining human health risk through these two pathways has been described in the literature  and can RfD). The constant of Potential noncarcinogenic risks due to exposure of trace metals were determined by comparing the calculated contaminant exposures from each exposure route  with the reference dose ( and 140 . The Haztion (6) .(6)HQinterature ,21,23. ATo assess the overall potential noncarcinogenic effects posed by more than one metal and pathway, the sum of the computed HQs across metals was expressed as hazard index (HI) . HI > 1 Carcinogenic risk . The values recorded complied with the standard guideline of <1700 mS/m , respectTemperature plays a crucial role in water bodies with regards to chemical responses and the metabolic rates of life forms and it is therefore a controlling factor of aquatic species distribution ,28. MeanSalinity level varied between 83.89 and 133.52 mg/L . Excessi−, NO3−, PO43−, and SO42−) were within the permissible limit for domestic and agricultural water use. The levels of nitrates and phosphates determined in this study can be linked with the practice of agriculture around the river course. Fluoride  is vital major cation for biochemical interactions in living organisms. The recorded levels varied between 1.96 and 23 mg/L  and compThe concentration of lead (Pb) ranged from 0.05 to 0.07 mg/L and exceeded the threshold limit of 0.01 mg/L for drinking water. The levels found are of health risk to humans and aquatic organisms. High levels of Pb above 0.01 mg/L have been linked to anaemia, memory loss, anorexia, brain damage, and death. Furthermore, this finding can be compared to studies reported by Ayandiran et al.  in RupshThe levels of cadmium (Cd) determined in this study ranged between 0.01 and 0.02 mg/L and did not comply with safe levels as stipulated by WHO  and SANSIron is a metal at the dynamic site of numerous significant redox proteins in plants and animals . The conE. coli count were in a range of 814.5–2169 cfu/100 mL, and higher values were recorded at the downstream sampling sites of the river  is significant rating that determines the general overall water quality status in a singular term that is useful for the determination of suitable treatment and use ,21,57. OThe WHO guideline for drinking water quality was used for the calculation of WQI. The rating of the river water was computed using the physicochemical parameters obtained. Results from r = 0.74 (r = 0.99), as expected, as they are both directly proportional to each other. The more solids that are dissolved in the water, the higher is the value of the electric conductivity. The sources of ions could be natural, i.e., geological condition, and from human activities such as domestic and industrial waste and also from agricultural activities. E. coli had a strong correlation with Enterococci with (r = 0.99) (E. coli can be used to infer the presence of Enterococci. Pb showed a strong correlation to Cd (r = 0.86). Other correlation results can be seen in There was a strong correlation between nitrate and phosphate with a value of r = 0.74 , inferri = 0.99) . Hence, E. coli and enterococci recorded. Similar findings have been reported in previous studies [Summary of Hazard Quotient (HQ) values for some trace elements  in drinking water through ingestion and dermal routes were computed for adults and children . The tra studies ,60,61,62CRingestion values for adults were in the range of  associated with the consumption of the river water. However, carcinogenic risk was computed for both children and adults. Therefore, adequate treatment of water from this river is highly recommended.


The working conditions exact new physical and mental tolls that can have an impact on their state of health and health behavior. Well-developed health literacy helps to encourage greater self-responsibility with respect to health and safety in the workplace. This study aimed to contribute to the evolution of health-related interventions in vocational training and instruction. (2) Methodology: This cross-sectional study examined health literacy, health behavior, and states of health among trainees engaged in work-and-study vocational training in 11 professions at the start of their education courses in northern Germany. The data were collected using a paper and pencil format. (3) Results: The survey was approved by 47 vocational schools (response rate 14%), with 1797 trainees returning their questionnaires (response rate 36%). The average age of the overall cohort was 21, and 70% of the trainees were female. A total of 47% of the participants began their careers with sufficient health literacy; health literacy was problematic in 40% of cases, and inadequate in 13% of cases. Around 50% of trainees exhibited poor dietary regime and risky alcohol intake, while 58% reported having a medical condition that had been previously formally diagnosed. (4) Conclusion: There is a need to provide support for developing a healthier approach to work at the start of vocational training. Health literacy (HL) provides resources and potential for enabling individuals to gain more control over their health and over factors that affect their health . The impHL in this context is understood to be an individual dynamic ability that can be learned. It also relates to the healthcare system and to the needs of that system. If external conditions or individual circumstances change, the acquired skills must be adapted and expanded accordingly .HL influences well-being and health . In the Current concepts encouraging HL to promote a healthy working environment are designed to be employed in the workplace and in the education system ,3. ThereMeasures for improving HL should be geared towards the life conditions and needs of the target group . In the The vocational training courses come from five different industries: healthcare: geriatric nursing specialist, medical nursing specialist, medical assistant; cosmetic: hairdresser; education: educators; technical: plant mechanic for sanitary, heating and air conditioning equipment, electronics technician for operational and building systems; business and administration: office manager/management assistant, retail manager/assistant, wholesale and export manager/assistant, industrial clerk.The aim of our study was to present (i) HL among trainees undertaking vocational training in a variety of professions, (ii) the distribution of HL relative to sociodemographic variables, and (iii) the distribution of HL relative to health behavior and the state of health at the start of vocational education.The study presented here is part of a longitudinal study. Further surveys will examine the development of HL, health behavior, and states of health as well as the associations between HL and indicators of health. Additionally, satisfaction with the training experience over the course of vocational education and when trainees transition into actual employment will be examined in future surveys.The cross-sectional study for the start of vocational education was performed in Northern Germany. The performance of the study was approved by the education authorities to whom inquiries were submitted in the Federal States of Bremen, Mecklenburg-Western Pomerania, Lower Saxony, and Schleswig-Holstein; Hamburg was an exception in this regard see . An ethiThe data were collected using a paper and pencil format in Spring 2018. Questions on sociodemographic data covered age, gender, country of birth, nationality, and highest level of educational attainment.HL was surveyed using the short version of the validated German Health Literacy Survey Questionnaire (HLS-EU-Q16) . This daQuestions on state of health included a subjective assessment , medicalRegarding health behavior, data were collected on the frequency of physical exercise , smokingOn the basis of the state of health and health behavior, we categorized subjects into health lifestyles according to the work of Betz et al. . The staA pretest was performed with trainees from four occupational groups.U test and the Kruskal–Wallis test. The significance level was set at 5%. The software IBM SPSS Statistics for Windows, Version 23.0.  was used for the statistical analyses.The sample was described in terms of absolute and relative frequencies (the latter specified as percentages), arithmetic mean values, and standard deviations. The individual items in HLS-EU-Q16 were presented as relative frequencies (percentages) and their 95% confidence intervals. To examine the relationships, we applied Spearman’s rank correlation coefficient and, for normal distributions, Pearson’s correlation coefficient, depending on the scale of measure. For unpaired group comparisons, the chi-squared test was applied for values with dichotomous outcomes. Data without normal distributions were analyzed using the Mann–Whitney Among the 1797 trainees, those striving to become medical assistants constituted the largest group at 17%. Those working towards becoming retail managers/assistants, educators, and office managers/management assistants each also represented more than 10% see . The tecHalf of the trainees completed their school education with a “Realschule” qualification. In the German school system, all children attend elementary school (Grundschule) up to fourth grade. Afterwards, they are separated according to academic abilities and wishes of their families. They attend either Hauptschule, Realschule, or Gymnasium. The Hauptschule (grades 5–9) teaches the same subjects as the Realschule and Gymnasium, but at a slower pace and with some vocationally oriented courses. It leads to enrollment in a part-time vocational school. The Realschule (grades 5–10) leads to part-time vocational schools and higher vocational schools. The Gymnasium leads to a diploma called the Abitur and prepares students for university study or for a dual academic and vocational credential. Study participants who left school without any qualifications (1%) were mostly found in the hairdresser and electronics technician groups.p = 0.036), educators (p = 0.015), hairdressers (p = 0.005), and electronics technicians (p = 0.003). In the sample, there were no significant differences between the genders in terms of HL, and only very weak negative correlation with age . Trainees who had left school without qualifications had significantly lower HL compared to trainees with Abitur qualifications (p = 0.020), Realschule qualifications (p = 0.009), Hauptschule qualifications (p = 0.001), and trainees with other school qualifications (p = 0.036). Trainees with Hauptschule qualifications have a much lower HL than those who possess qualifications from a vocational school (p = 0.024). The effects in each case were weak. Trainees without German citizenship did not differ from other participants in terms of HL.Around 53% of the study participants had limited HL, with 40% possessing problematic HL and 13% inadequate HL see . A totalResponses to individual items regarding HL were highly diverse in terms of the proportions of persons responding to questions with “fairly difficult”/“very difficult” see . While tp < 0.001) (see p < 0.001). As HL declined, so too did the proportion of trainees who engaged in physical exercise. A total of 52% of the trainees had an unhealthy diet, 29% had a normal diet, and 19% had a healthy diet, with the latter applying to women in particular. The proportion of participants with unhealthy diets was around 7% higher in the limited HL group than it was in the sufficient HL group.In all three HL groups, around one-third of the participants smoked daily see . The pro001) see . A totalp < 0.001) (see p < 0.001). The most common conditions were disorders of the respiratory tract (18%), skin (16%), and musculoskeletal system (15%). Poor mental well-being was quoted by 44% of the respondents, with female study participants quoting this significantly more frequently than male respondents (p < 0.001). Trainees with sufficient HL had a more positive estimate of their state of health and reported a formally diagnosed medical condition or poor well-being less frequently than participants with limited HL  see . Over had HL see .One-quarter of the trainees had a conscious attitude towards their health and reported having no medical conditions  see . AnotherWe believe that the study presented here is the first to examine health literacy among trainees in a broad range of occupations. According to our data, 53% of respondents possess limited HL. Schaeffer et al. found in a recent study among the German population a proportion of 59% . In a saAnother study examined HL among students at the University for Health Sciences in Bochum, Germany, wherein 69% of the students had limited HL . CompareThere were no demonstrable gender-related differences in HL in our study or in the previously quoted studies ,27,28,35For the individual items of the HLS-EU-16, proportions for the responses “fairly difficult”/“very difficult” were calculated on the basis of the Jordan and Hoebel methodology. Compared to the results of a study on HL among adults , traineeThe higher prevalence of risky behaviors among youth  was confTo ensure that trainees who are just starting their vocational education can receive information on disease prevention and health promotion, it is first necessary to improve awareness of the relevance of health in the first place. It may be possible to encourage such awareness and make trainees more receptive with concepts related to well-being, enjoyment of life, and happiness ,40. WhenReviewing the literature, one does not find examples of interventions designed to increase HL of trainees in vocational schools. Peralta and Rowling reviewed studies that observed implementations of HL programs in Australian schools . Only onTo our knowledge, this is the first study in Germany reporting about HL in trainees. The cross-sectional design of the study means that it is not possible to draw conclusions on causal relationships. A longitudinal study design, however, would enable such conclusions for later data samples. According to our study protocol, two more follow-up assessments will be performed during training time and another two in subsequent working life. Although education authorities from four Federal States provided their support for the study, the response rate of the vocational schools was low, limiting the sample size. Therefore, the degree of generalization on the basis of the study results is limited. Despite the moderate response rate of the participants, it is not possible to eliminate the possibility of selection bias. The data protection requirements that education authorities are bound by prevented them from providing information on the trainees’ parents, which is why it was only possible to derive data on social status and on parental migration histories to a limited degree. The sample consisted of 70% women and 30% men and was therefore not balanced. Interviews with teenagers have suggested that there were problems with understanding the language and content of the long version of the HLS-EU-Q . These aCommunicating and encouraging health literacy is important for the study group under review, as the majority of them showed limited HL. Raising awareness of the need to take a healthier approach to working life and provide trainees with the skills they need to be aware of their health in an occupational context may mitigate the development of existing medical conditions, reduce risky behaviors, and have a positive effect on well-being. Our findings show that there is no gender-specific difference in HL. In contrast, we observed gender-specific differences in health behavior and health outcomes. Thus, independent of HL measures for the total group “in order to make judgments and take decisions in everyday life concerning healthcare, disease prevention and health promotion…” , health


There is limited research on the biomechanical assessment of the lower limb joints in relation to dynamic movements that occur at the hip, knee, and ankle joints when performing dorsiflexion (DF) and plantarflexion (PF) among males and females. This study investigated the differences in joint angles (including range of motion (ROM)) and forces (including moments) between the left and right limbs at the ankle, knee, and hip joints during dynamic DF and PF movements in both males and females. Using a general linear model employing multivariate analysis in relation to the joint angle, ROM, force, and moment datasets, the results revealed significant main effects for gender, sidedness, phases, and foot position with respect to joint angles. Weak correlations were observed between measured biomechanical variables. These results provide insightful information for clinicians and biomechanists that relate to lower limb exercise interventions and modelling efficacy standpoints. The Augmented Video-based Portable System and the gold standard 3D Vicon Motion Analysis System  are validated motion analyses systems that are useful for evaluating the motion characteristics of the lower limbs . These sThe ankle and the lower limb joints assist with the transmission of forces and loads between the leg and foot during weight-bearing activities resulting in effective mobility and flexibility . The ankThe normal range of motion (ROM) of the ankle during DF is 10-20 degrees (°) and 25-30° during PF, contributing to inversion and eversion . Among hThe knee is able to passively affect the DF and PF angles at the ankle through the Achilles tendons becoming contracted or relaxed on potentially compromising surfaces . In doinThe hip works as a ball and socket joint with motion occurring in three dimensions. The hip joint has two ligaments which anteriorly stabilise the hip  and one ligament which is used for posterior stability . This allows the femur to flex between 120 and 135° (90° when fully extended) and extend between 10 and 30° . Arnold To date, no research has effectively measured the kinematics and kinetics of the lower limbs during ankle DF and ankle PF in a standing position. Nor has a longitudinal study been completed to incorporate changes over time under DF and PF conditions. Therefore, further in-depth investigation is required. There has been a definitive need, previously and presently for reliable research studies to focus on the differences in ankle, knee, and hip kinematics and kinetics with direct association to PF and DF. There are research topics on DF and PF during landing and other movements; however, there is little information regarding the dynamic movements of the ankle whilst standing in relation to the biomechanical correlates of movement at the knee and hip joints.The purpose of this study was to investigate any differences in joint angles, range of motion (ROM), forces, and moments between the left and right limbs at the ankle, knee, and hip joints during dynamic DF and PF movements in both male and female subjects. It is hypothesized that (a) females will have a greater ROM in both DF and PF in comparison to males and (b) the heel raise task will produce higher ground reaction forces, higher forces at the lower limb joints, and larger moments at the lower limb joints in comparison to the fore-foot raise task.Twenty-two healthy individuals, twelve males and ten females, with a mean ± SD age, height, and body mass of 23.04 ± 2.8 years, 169.82 ± 5.88 cm, and 69.83 ± 15.03 kg , respectively, volunteered to participate in the study. All participants were physically active and able-bodied whilst being free from any lower limb injuries at the time of testing. Additional information from the participants regarding activity levels and time of activities before embarking on the experimental protocol was controlled prior to data collection. All participants were required not to have engaged in any physical activity for 48 hours before commencement of the experiment. All participants were right leg dominant. This was confirmed by identifying what leg the subjects preferred to kick a football with. All subjects were tested at the same relative time (morning testing) to minimize data contamination from diurnal variation effects.Ethical approval was obtained from the University of the West of Scotland . Each participant reviewed the information sheet, completed a medical health questionnaire, and provided written informed consent. There was no obligation from the individuals to complete the study, and participants were given freedom to withdraw at any time. A risk assessment was also completed prior to experimental testing.Eight Vicon Bonita Motion Analysis cameras  mounted on scaffolding provided a field of view that allowed the lower limb movements to be captured for analysis. The Vicon Bonita Motion Analysis System was linked to an ultra giganet box which collected the lower limb kinematic data at a rate of 250 Hz. The two AMTI force plates (1.2 m)  were connected to the Vicon Bonita Motion System and interfaced via the ultra giganet box. Kinetic data were collected at a sampling rate of 1000 Hz. Prior to data capture, the reset button was activated as data were collected from both systems integrated through the Vicon Nexus software.http://ProHealthcareProducts.com, Lehi, UT, USA) and clinical measuring tape. All acquired measurements were imputed into the Vicon Nexus software to define each participant before running the Lower Limb static and dynamic Plug-In-Gait models. The Plug-In-Gait model is the Vicon Nexus' implementation of the conventional gait model. Using a direct  pose estimation, the Plug-In-Gait computes and defines the position and orientation of each segment based on a set of three tracking markers.The experimental protocol for this pilot study required one visit per participant to the Biomechanics Laboratory at the University of the West of Scotland. Prior to testing, reflective objects in the laboratory were removed or concealed to prevent interference during the data capture session. Cameras positioned within the field of view of the participants were inspected, and any reflections identified were masked using the Vicon Nexus Mask Cameras software function. The Vicon Bonita Motion Analysis system was both statically and dynamically calibrated before each session of testing. Prior to testing using the Vicon Nexus software, individual participant details, i.e., age (years), and anthropometric measurements, i.e., height (cm) and body mass (kg) alongside right and left leg length (mm), right and left knee width (mm), and right and left ankle width (mm), were obtained. Body mass and height were measured using a calibrated scale  and stadiometer . All other measurements were obtained using a small anthropometer measurement instrument-Lafayette  retroreflective markers accurately on each individuals' lower limbs according to the Plug-In-Gait marker placement guide. A double-sided tape was used to ensure adherence of retroreflective markers to the skin and fitted clothing of the limb joints and segments. The placements on both the left and right limbs were as follows: anterior superior iliac spine (ASIS), posterior superior iliac spine (PSIS), lateral midthigh, lateral knee, lateral midtibia, lateral malleolus, and calcaneus and 2Prior to commencement of the dynamic trials, a familiarisation period of ten minutes was permitted to ensure participants were able to complete the movements at a controlled speed. They were only allowed five repetitions for each movement to reduce the potential impact and learning effects of the protocol as outlined by behavioural learning theory. Although the order of the tasks was randomised, to standardize the test protocol, the number of trials, experimenter, and stance were kept consistent throughout each session. Following this, each participant stood on the AMTI force plates, ensuring that the feet were a shoulder width apart and that the hands were placed on the hips. The left and right feet were positioned on two independent force plates. Both feet were placed at the centre and fully within the boundaries of each force plate. Two static trials were taken in this position whilst the participant stood still, followed by two sets of three dynamic trials—DF and PF . The firStatistical analysis software Jamovi (Version 0.9.5.12) was used to determine descriptive and inferential statistics. Kinematic (joint angle and ROM) data were manually transferred from the Vicon Nexus 2.8.1 into Microsoft Excel 2019 version 16.23 . The normality of distribution was determined using the Shapiro-Wilk test. Anthropometric statistical differences between gender and sidedness were examined. Both PF ROM and DF ROM were calculated as follows:The ROM represented the lower limb range of motion . The loaded phase represented the joint angle/force/moment at the initial foot flat position, unloaded phase represented the joint angle/force/moment at the fore-foot raise (or heel raise) position, and reloaded phase represented the joint angle/force/moment at the final foot flat position.X), medial/lateral (Y), and vertical (Z) directions at the ankle, knee, and hip joints. External moments were reported and together with the force outputs were extracted from the Plug-in-Gait model. The between subject factors (independent variable) included gender, sidedness, phases, and foot position. The Pearson correlation (r) was performed to establish the level of interaction between the foot position independent variable and the joint angle position, joint force position, joint moment position, and joint angle ROM-dependent variables. When implementing the Pearson correlation, the r values obtained varied between −1 and +1 where 1 is a perfect correlation and 0 represents no correlation. Further interpretations of r include the following: 1 > r ≥ 0.8 (very strong), 0.8 > r ≥ 0.6 (moderate), 0.6 > r ≥ 0.3 (fair), and 0.3 > r ≥ 0.1 (poor) [ηp2) in relation to multivariate analyses was calculated. The values of 0.0099, 0.0588, and 0.1379 were considered small, medium, and large effect sizes, respectively [p < 0.05 was considered significant.General linear model multivariate analyses were applied to the joint angle, joint force, joint moment, and ROM datasets using IBM SPSS Statistics for Windows, Version 25.0. . The within subject variables (dependent variables) were joint angle position, joint force position, joint moment position, and joint angle ROM in the anterior/posterior (1 (poor) , 17. To ectively . A Bonfep > 0.05) or between genders (p > 0.05). The anthropometric measurements in terms of gender and sidedness are displayed in (X), mediolateral (Y), and longitudinal (Z) axes and resultant datasets are displayed in (The leg length (mm), anterior superior iliac spine trochanter distance (mm), knee width (mm), and ankle width (mm) anthropometric measurements showed no statistical differences between the left and right limbs . Females displayed a decreased ROM compared to males in the X- and Z-axes of the knee joints  and on the X-axis of the hip joint for both limbs .In terms of DF movement, the female ankle ROM on the X and Y components for both the left and right limbs during PF . Females displayed an increased ROM compared to males at the Y-axis for knee joints  and at the X-axis of the hip joint for both limbs . Bar chart displays for males and females in terms of differences in sidedness with respect to DF and PF are shown in Figures Similar to the DF trials, females produced a higher ROM at the ankle over the F = 18.273, p < 0.001, ηp2 = 0.415, large), sidedness , phases , and foot position . There were also significant main effects for gender and sidedness interactions , as well as phases and foot position interactions . No significant differences were observed for interaction effects between gender and phases ; gender and foot position ; sidedness and phases ; sidedness and foot position ; gender, sidedness, and phases ; gender, sidedness, and foot position ; gender, phases, and foot position ; sidedness, phases, and foot position ; and gender, sidedness, phases, and foot position .The multivariate analysis for the joint angle results showed that there was a significant main effect for gender ; hip joint angle in the Y direction ; knee joint angle in the X direction ; and knee joint angle in the Y direction . Sidedness also yielded a significant effect for the ankle joint angle in the Y direction  and hip joint angle in the Z direction . Significant effects were observed for phases regarding the ankle joint angle in the X direction  and hip joint angle in the X direction . The foot position also produced significant effects with respect to the ankle joint angle in the X direction ; and hip joint angle in the X direction . Apart from the gender and sidedness interaction  and hip joint angle in the Y direction ); and phases and foot position interaction  and hip joint angle in the X direction ); no significant effects were observed for all other interactions.The between-subjects effect yielded a significant effect for gender with respect to the ankle joint angle in the F = 82.448, p < 0.001, ηp2 = 0.912, large). All other main effects and interactions were not significant, i.e., sex ; sidedness ; gender and sidedness interaction ; sex and foot position interaction ; sidedness and foot position ; and gender, sidedness, and foot position .The multivariate analysis for the ROM results only produced a significant effect for foot position . The following between-subject effects with respect to ROM produced significant effects, namely: sidedness at the knee in the Z direction  and at the hip in the Y direction ; sidedness and foot position at the hip in the Z direction ; and gender, sidedness and foot position at the knee in the Z direction . With the exception of knee ROM in the X direction  and knee ROM in the Y direction , all other dependent variables showed significant between-subject effects.No significant between-subject effects were observed for gender; gender and sidedness interaction; and gender and foot position interaction, with respect to the dependent variables ; phases ; foot position ; and phases and foot position interaction . All other main effects and interactions were not significant.The multivariate analysis for the joint force results only produced a significant effect for sidedness . The following between-subject effects with respect to joint force produced significant effects, namely: sidedness at the knee in the Y direction  and at the hip in the Y direction ; foot position at ankle in the Z direction  and at the knee in the X direction ; sidedness and foot position at the ankle in the Y direction ; and phase and foot position interaction at the ankle in the Z direction .No significant differences between-subject effects were observed for gender; phases; gender and sidedness interaction; gender and phase interaction; gender and foot position interaction; sidedness and phase interaction; gender, sidedness, and phase interaction; gender, sidedness, and foot position interaction; gender, phase, and foot position interaction; sidedness, phase, and foot position interaction; and gender, sidedness, phase, and foot position; with respect to the dependent variables ; sidedness ; phases ; foot position ; gender and sidedness interaction ; and phase and foot position interaction . All other main effects and interactions were not significant.The multivariate analysis for the joint moment results only produced a significant effect for gender (r = −0.411 (fair) to r = 0.315 (fair). Similarly, the foot position and the ROM dependent variables ranged from r = −0.887 (very strong) to r = 0.065 (poor).Only the ankle resultant ROM and force range during PF produced greater ROM and force range in comparison to DF. A converse trend was observed for the ankle moment range datasets see . All othp < 0.001) higher PF ROM in comparison to the DF movement. The knee and hip joints showed inconsistencies in their ROM patterns with respect to sidedness and foot position. No observed significant (p > 0.05) main effects and interactions for ROM were observed for gender, sidedness, and their combined interactions with foot position. Significant main effects for both joint forces and joint moments were observed for sidedness, phases, foot position, and phases and foot position interaction.This study investigated the joint angle, joint force, joint moment, and ROM responses of the left and right ankle, knee, and hip lower limb joints between genders whilst performing dynamic DF and PF movements. Specifically, only the ankle joint during the DF and PF movement produced a significantly  and the lower limb joint angle and ROM outputs were weak, i.e., poor to fair.X-axis of the ankle for both the left and right limb in males and females are higher in PF than in DF; however, they do not significantly differ from each other statistically [Our joint motion and ROM analysis revealed findings, which differed to expected results. As shown in Tables 1stically . The avestically . The lefFemales exhibited higher DF than PF measurements for the left limb knee joint moments, left limb hip joint forces, and left limb hip joint moments. A similar trend was observed for the right limb knee and hip joint forces and joint moments. The males exhibited similar trends; however, differences were observed in the knee joint forces and in the left and right limb joint moments which produced lower DF outputs in comparison to the PF measurements. There are multiple possibilities as to why lower limb DF and PF ROM, forces, and moments may be decreased. These include, but are not limited to, age, gender, prior injury, degenerative diseases, and immobilisation. For example, a traumatic brain injury and fractures are both, in addition to others, known to decrease the compliance of the calf muscles and therefore inhibit full flexibility . GeograpMechanical stress exerted on the body and the physiological adaptations of tissue over time must also be considered prior to analysing results as this can be apparent with increasing age . AlthougGender-related disparity can arise due to muscle recruitment that is used repeatedly; for example, during a fall, a female is thought to be able to stabilise/recover quicker using ROM and flexibility than males . There aEarlier studies by Ugbolue et al. have designed, developed, and validated a new methodological approach to evaluate heel pad stiffness and soft tissue deformation in both limbs between males and females during ankle dynamic unloading and loading activity . To comp


The safety and efficacy of laparoscopic pancreaticoduodenectomy (LPD) in elderly patients who often suffer from pre-existing conditions  and poor functional reserve remain unclear. This meta-analysis aimed to evaluate the safety and efficacy of LPD in elderly patients.A systematic literature search was conducted using the PubMed, Embase, Web of Science, and Cochrane Library databases. All studies published from their inception to January 2022 reporting perioperative outcomes after LPD in elderly patients were included in the search . The evaluated outcomes included perioperative mortality, postoperative complications, conversion, operative time, estimated blood loss (EBL), postoperative hospital stay (POHS), and readmission.In total 8 studies were included in the meta-analysis. Pooled analysis of Group 1 showed that EBL, 90-day mortality, major morbidity, bile leak, POH, abdominal infection, reoperation, POP, POCE, and readmission were not significantly different between the LPD and the OPD group. LPD was associated with longer operative time, lower POPF rate, lower DEG rate, and shorter POHS. Pooled analysis of Group 2 showed that mortality, major morbidity, POPF, DEG, bile leak, POH, abdominal infection, reoperation, conversion, operative time, EBL, and readmission were not significantly different between the elderly and the non-elderly group. The POHS of elderly group was significantly longer than non-elderly group.LPD may be a safe and feasible procedure for elderly patients and is associated with short POHS. According to the Global Health Observatory data released by the World Health Organization (WHO), in 2015, the average life expectancy of the global population was 71 years –6. For pPD which involves multiplex anatomical structures and requires extensive reconstruction. Consequently, it is one of the most challenging surgeries . SeveralThis study was designed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines .We conducted a systematic literature search using the PubMed, Embase, Web of Science, and Cochrane Library databases. All studies published from their inception to January 2022 reporting perioperative outcomes after LPD in elderly patients were included in the search. The following headings: “laparoscopy,” “laparoscopic,” “minimally invasive,” “Whipple's procedure,” “pancreaticoduodenectomy,” “elderly,” “geriatric,” “old,” “aged” were used in the advanced search. The key review articles and references of the retrieved studies were manually searched to discover further potentially relevant literature. In PubMed, the detailed literature search strategy is  AND (“elderly” [Title/Abstract] OR “geriatric” [Title/Abstract] OR “old” [Title/Abstract] OR “aged” [Title/Abstract]) AND (“Whipple's procedure” [Title/Abstract] OR “pancreaticoduodenectomy” [Title/Abstract]).Comparative studies on the effects of LPD in elderly patients were analyzed. The inclusion criteria in the light of the PICOS were defined as follows : (1) parTwo researchers independently evaluated the studies obtained from the above databases. If discrepancies emerged during the process of selection and evaluation, they were resolved by discussion or consultation with the third author. Two reviewers independently extracted and summarized material from each study. The collected information included: (1) The name of the first author, publication year, age and sex of the patients, and the number of patients; (2) study outcomes. Death within 90 days post-surgery was defined as perioperative mortality. Grade III or higher complication based on the Clavien–Dindo classification of surgical complications was defined as major morbidity . A POPF I2 statistic  was utilized for statistical analysis. For dichotomous variables, the Mantel–Hansel method was used to estimate the odds ratio (OR) with a 95% confidence interval (CI). The inverse variance method was employed with a 95% CI when continuous parameters were reported as a mean and standard deviation. Heterogeneity was evaluated with the tatistic . I2 <30%ogeneity . A fixedectively . The poor et al. .We retrieved 621 articles matching the initial search criteria. 170 duplicate articles were excluded. Among the remaining 451 articles, 414 were excluded following title and/or abstract screening according to the inclusion and exclusion criteria. Overall, after full-text review, 8 studies , 23–25 wTable 3). The demographics of the study populations in group 1 are demonstrated in In total, 6 retrospective studies , 24, 25 In total, 4 retrospective studies , 23, 24 p = 0.72). Major morbidity, POPF, DEG, POH, operative time, and EBL were reported in five studies. The results of the meta-analysis indicated that the major morbidity rate  and POH rate  between the LPD and the OPD group were not significantly different. There was no statistical difference in EBL  between the LPD and the OPD group. However, the POPF rate  and DEG rate  in LPD group were significantly lower than OPD group. Additionally, the operative time of LPD group was significantly longer than OPD group . Abdominal infection was reported in four studies. No statistical difference was found in abdominal infection rate between the LPD and the OPD group . Reoperation, POP, POHS, and readmission were reported in three studies. No statistical difference was found in reoperation rate , POP rate , and readmission rate  between the LPD and the OPD group. However, the POHS of LPD group was significantly longer than OPD group . Bile leak and POCE were reported in two studies. There was no statistical difference in bile leak rate  and POCE rate  between the LPD and the OPD group. All outcomes between the LPD and the OPD group in the analyzed studies are shown in Post-operative mortality was reported in six studies , 24, 25.p = 0.09), major morbidity rate , POPF rate , DEG rate , POH rate , reoperation rate , and conversion rate  between the elderly and the non-elderly group. There were no statistical difference in operative time  and EBL  between the elderly group and the non-elderly group. However, the POHS of elderly group was significantly longer than non-elderly group . Abdominal infection was reported in three studies. No statistical difference was found in abdominal infection rate between the elderly group and the non-elderly group . POH and readmission were reported in two studies. There were no statistical difference in bile leak rate  and readmission rate  between the elderly group and the non-elderly group. All outcomes between the elderly and the non-elderly group in the analyzed studies are shown in Mortality, major morbidity, POPF, DEG, POH, reoperation, conversion, operative time, EBL, and POHS were reported in four studies , 23, 24.I2= 92%, p < 0.01) and EBL . In the sensitivity analysis, the recalculated MD of operative time ranged from 38.79  to 63.65 . The recalculated MD of EBL ranged from −208.10  to −48.69 . Sensitivity analysis revealed that the meta-analysis result for operative time was unstable. Subgroup analysis for the operative time indicated that the difference of pathological types may be the main reason for the high heterogeneity  and readmission rate . In the sensitivity analysis, the recalculated MD of EBL ranged from 35.37  to 69.64 . The outcome of sensitivity analysis revealed that the meta-analysis results for EBL was unstable. For the readmission, sensitivity analysis and subgroup analysis could not be performed because of the limited number (n = 2) of included studies. Subgroup analysis for the EBL indicated that the difference of pathological types may be the main reason for the high heterogeneity  were included in the meta-analysis. Similarly, just four studies were included in group 2. Hence, the publication bias was not assessed using a funnel plot.Since 2004, the annual pancreatic cancer and pancreatic cancer-related mortality has increased by 1.5 and 0.5% among the American population, respectively . The datIn the present study, we followed strict inclusion and exclusion criteria. The safety and efficacy of LPD in elderly patients were comprehensively investigated. At last, we pooled six studies to compare the perioperative clinical outcomes of LPD (519 patients) and OPD  in elderly patients. Concurrently, we pooled four studies to compare the perioperative outcomes of LPD in elderly (175) and non-elderly (393) patients. In the two studies reported by Liang et al.  and Tan The pooled result for EBL was inconsistent with the findings of several recent meta-analyses , 31, 32 Longer operative time was found in the LPD group than in the OPD group. The difference in pathology type may be one of the reasons for longer operative time in LPD group. The pathological types in two included studies , 14 wereThe conducted pooled analysis showed that the POPF rate and DGE rate in LPD group was lower than that in OPD group. This was inconsistent with the results of two recent meta-analyses , 32 whicAs demonstrated in a previous meta-analysis, the incidence of postoperative major morbidity of PD between elderly (≥75) and non-elderly group was not significantly different . In grouCertainly, our study had some limitations. Firstly, all studies included in our analysis were retrospective. Secondly, the difference between the pre-operative pathology type increased the risk of selection bias. Thirdly, the studies were from different medical centers, at which surgeons had varying operational skills, experience, and learning curve, resulting in bias. Moreover, a small number of studies with a small sample size were included in this work, which impeded heterogeneity testing and might cause inherent biases. We also did not assess the overall survival of elderly patients after LPD due to limited availability of data. Lastly, publication bias, which could influence the reliability of our results, cannot be fully excluded in this meta-analysis. Thus, the findings reported herein should be interpreted with caution. Well-designed randomized trials with a large sample size are necessary to further confirm our conclusions.The conducted meta-analysis revealed that LPD may be a safe and feasible procedure for elderly patients and is associated with short POHS. Age itself may not affect the postoperative mortality and complications and should not be considered as a limiting factor for LPD.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.QW is the principal investigator with overall responsibility for the original draft. QW and CC performed searching for relevant studies, data collection, and data analysis. HL provided help in designing, data analysis and editing of the manuscript. All authors read and approved the final manuscript.This work is supported by the Science and Technology Program of Guizhou Province (No. [2020]4Y232).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.


Staphylococcus aureus (MRSA) has been recently documented to be an important foodborne pathogen, in addition to its recognition to be a leading clinical pathogen for some decades. Standard identification for MRSA has been commonly performed in both clinical settings and food routine detection; however, most of such so-called “standards,” “guidelines,” or “gold standards” are incapable of detecting viable but non-culturable (VBNC) cells. In this study, two major types of staphylococcal food poisoning (SFP), staphylococcal enterotoxins A (sea) and staphylococcal enterotoxins B (seb), as well as the panton-valentine leucocidin (pvl) genes, were selected to develop a cross-priming amplification (CPA) method. Limit of detection (LOD) of CPA for sea, seb, and pvl was 75, 107.5, and 85 ng/μl, indicating that the analytical sensitivity of CPA is significantly higher than that of conventional PCR. In addition, a rapid VBNC cells detection method, designated as PMA-CPA, was developed and further applied. PMA-CPA showed significant advantages when compared with PCR assays, in terms of rapidity, sensitivity, specificity, and accuracy. Compared with conventional VBNC confirmation methods, the PMA-CPA showed 100% accordance, which had demonstrated that the PMA-CPA assays were capable of detecting different toxins in MRSA in VBNC state. In conclusion, three CPA assays were developed on three important toxins for MRSA, and in combination with PMA, the PMA-CPA assay was capable of detecting virulent gene expression in MRSA in the VBNC state. Also, the above assays were further applied to real samples. As concluded, the PMA-CPA assay developed in this study was capable of detecting MRSA toxins in the VBNC state, representing first time the detection of toxins in the VBNC state.Food safety and foodborne infections and diseases have been a leading hotspot in public health, and methicillin-resistant  In the past few decades, public health has been a major issue for society. From various points of view, food safety and foodborne infections and diseases have been a leading area of concern. Among food safety problems, foodborne infections or diseases caused by food pathogens have made up the majority of the cases .Staphylococcus aureus is an important foodborne pathogen that is responsible for a large variety of foodborne infections and diseases (S. aureus (MRSA) is one of most widely distributed human and animal pathogens that produce a variety of toxins and cause a range of serious illnesses of the skin, soft tissue, bone, and bloodstream  was first proposed. A large proportion of studies have been done on foodborne microorganisms, as once having failed to allow detection of the bacterial cells, the food sample is likely to be mistakenly determined to be safe or qualified. In addition to foodborne pathogens, laboratory researchers in clinical settings commonly fail to detect or identify the pathogens responsible in apparently infected patients. Culturability-based methodology has been significantly challenged as the “gold standard” when it comes to microbiological identification. Therefore, rapid detection of MRSA is imperative for both MRSA-related foodborne outbreaks and clinical diagnosis. Current methodologies available for detection of MRSA include standard clinical testing (such as disk susceptibility tests or broth dilution) and molecular methods  . The forcolitica ,b.pvl, based on the PMA-CPA methodologies.In this study, the VBNC state formation of MRSA has been studied in different real food samples. After confirmation of the VBNC formation, the expression of pathogenic, virulence factors was performed on three enterotoxins and mecA detection by PCR as described previously. The MRSA and MSSA strains used in this study were previously detected by the toxins by PCR and further Sanger sequencing, which were found to carry different toxins. Thus, such strains are included in different detection assays in this study. Three pathogenic targets have been selected for primer design (sea) and staphylococcal enterotoxins B (seb) are the two most commonly detected enterotoxins in Staphylococci strains and are responsible for various foodborne cases. Another key toxin for Staphylococci is panton-valentine leucocidin (pvl), which is a cytotoxin produced by Staphylococcus and causes leukocyte destruction and tissue necrosis. Pvl is an important toxin for MRSA, and it has been found in the recent decade that the community-associated MRSA (CA-MRSA), commonly carrying type IV or V SCCmec, is highly associated with these toxins. In addition, ST398 is well known to be a major type for liverstock-associated MRSA (LA-MRSA), which has been reported to be primarily within CA-MRSA instead of hospital-associated MRSA (HA-MRSA), commonly carrying types I, II, and III SCCmec. Based on the correlation between toxins and CA-MRSA, the carriage of pvl is high in food-contaminated MRSA strains, as they are commonly CA-MRSA. The above three targets have been selected to be included in the following studies.A total of 36 strains were included in this study, as shown in r design . Staphyl8 CFU/ml was used, and the cells are kept at 4 and −20°C, respectively. CFU counting was performed first to obtain the growth curve, and 10 representative time points were selected. Then strains were grown strictly as described above, and for the selected time points, VBNC was confirmed. In addition, VBNC formation was also performed in the real food samples, such as Cantonese cake, as described previously. In brief, the same concentration of bacterial culture was inoculated into the food sample and was kept at 4 and −20°C, respectively. Similar time points were selected as above, and VBNC cells were further confirmed. For VBNC confirmation, total cell numbers, culturable cell numbers, and viable cell numbers were determined as described previously. The LIVE/DEAD BacLightTM kit was used before performed subjecting to flow cytometry. CFU was counting for culturable cell numbers. After VBNC cells were obtained, introduction of PMA was performed as described previously. Further, DNA extraction was processed, and CPA was also performed for detection.Culturing, incubation, and inoculation of MRSA and non-MRSA strains were performed using routine procedures. All strains were stored in −80°C and were streaked on TSB plates overnight at 37°C. Colonies were picked and then inoculated into fresh TSB medium to obtain different strains in log phase, ranging from 2 to 6 h. For genomic DNA extraction, bacterial cells after overnight culturing were used, and after centrifugation, DNA extraction was performed using the Dongsheng BioTech DNA extraction kit, according to their manufacturers’ instructions. All extracted DNA samples were qualified and confirmed by both under 260/280 and electrophoresis. For VBNC formation, the procedure has been conducted as described previously. In brief, an initial concentration of bacterial cells at 102⋅4H2O) was added. For the reaction program, 63°C for 1 h then 80°C for 2 min was used.After primer design on three targets, primer was synthesized. CPA reaction was carried out as described previously. The reaction volume is first 25 μl, and further 1 μl mixed chromogenic agent  was determined on the CPA assays, and 10-fold serial dilutions of total genomic DNA were used. All experiments were performed in triplicate.The specificity study on the CPA assay consists of two parts. The first one is the specificity of primers. The CPA was performed with any one of the five primers  omitted to confirm that every single primer is strictly and specifically required for the reaction. Second, the specificity of the primers set was confirmed by including five MRSA strains with 31 non-MRSA strains.To evaluate the CPA reaction, PCR was also performed using all primers with the following program: 95°C for 3 min, 30 cycles of amplification at 95°C for 30 s, 55°C 30 s, 72°C for 1 min, and final amplification at 72°C for 7 min. Nuclease-free water was used as a negative control. All PCR products had been subjected to Sanger sequencing to confirm the highly conserved region used for CPA primers design.2 and calcein), and the color green was an indicator of positive yielding.For all nucleic acid isothermal amplification assays, the determination of results shows significant advantages when compared with traditional methods like PCR. In this study, two ways were used as a basis of comparison for the determination of results. First, amplicons were detected by agarose gel electrophoresis, and the bands were observed under UV light. Second, color change was observed and determined by using a mixture of chromogenic agents  omitted. According to the results, every single primer is strictly and specifically required for the reaction. In addition, the specificity of the set of primers was confirmed by including five MRSA strains with 31 non-MRSA strains. As shown by the results , all tar4 CFU/ml for all three targets (data not shown). Compared with PCR, the sensitivity of CPA, as was demonstrated, is significantly higher than that of PCR. Furthermore, this result was obtained using real food samples, such as Cantonese cake, indicating the applicability of the developed assays.Limit of detection of CPA was also determined in real food samples, and the LOD was found to be approximately 10sea, seb, and pvl. As PMA was concerned, the concentrate influenced the final results. The concentrate used in this study was 5 μg/ml, as described previously. After the combination of PMA, the samples were first kept in the dark for 15 min and then under the halogen lamp for another 15 min, as described previously. Centrifugation was then performed and DNA was extracted accordingly. PMA-CPA was further performed. In addition, the PMA-CPA was confirmed by using PCR and the VBNC confirmation. According to the results, PMA-CPA showed significant advantages when compared with PCR assays, in terms of rapidity, sensitivity, specificity, and accuracy. Compared with conventional VBNC confirmation methods, the PMA-CPA showed 100% accordance, which demonstrated that the PMA-CPA assays were capable of detecting different toxins in MRSA in VBNC state.Formation of VBNC was investigated using the previous procedure. After VBNC formation, the MRSA cells were detected using the PMA-CPA on the expression of S. aureus isolates in nosocomial infection and caused significant morbidity , which will significantly aid in the detection of MRSA in clinical samples, especially in the case of non-culturable cells.Three CPA assays were developed on three important toxins for MRSA, and in combination with PMA, the PMA-CPA assays were capable of detecting the toxins from the expression of MRSA in the VBNC state. The above assays were further applied in real samples. We have concluded that the PMA-CPA assays developed in this study are capable of detecting MRSA toxins in the VBNC state, representing success for the first time in the detection of toxins in the VBNC state.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.JL and KW conceived of the study and participated in its design and coordination. HJ, LC, MY, QY, XL, and YY performed the experimental work and collected the data. LZ and TH analyzed the data and wrote the manuscript. All authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Females had a significantly higher starting frailty, and males had a significantly greater change rate with age. FI against age for Cameron Park Colonia and Indian Hills Colonia was regressed. We calculated a significantly higher starting FI in Indian Hills and a significantly greater change rate in Cameron Park residents. Frailty's contributors are complex, especially in neighborhoods of poverty, immigration, low education level, and high prevalence of chronic disease. We report baseline Frailty Index data from two Colonias in South Texas and the clinical and research implications.Frailty is the age-related decline in well-being. The Frailty index (FI) measures the accumulation of health deficits and reflects biopsychosocial and cultural determinants of well-being. Frailty is measured as a static phenotype or as a Frailty Index comprising a ratio of suffered health deficits and total deficits. We report a Frailty Index calculated from routinely measured clinical variables gathered from residents of two Colonias (neighborhoods) in South Texas. A Colonia is a predominantly Hispanic, economically distressed, unincorporated neighborhood. We analyzed retrospective data from 894 patients that live in two Colonias located on the Texas-Mexico border. We calculated the FI with seven physiological variables, PHQ-9 score, and the 11 domain-specific Duke Profile scores, for a total of 19 possible health deficits. FI against age separately in males ( Socioeconomic status, poverty, social determinants of health, and health disparities contribute to Frailty and affect healthcare planning and delivery. Frailty is associated with chronic disease, aging, and quality of life. We can define Frailty as a biological phenotype with three or more components ,  or as a In studies involving over 1.5 million participants, various Frailty Indices are calculated based on as few as twenty and up to as many as one-hundred-thirty factors. Studies using multiple factors to calculate the Frailty Index are consistently associated with the risk regardless of the specific factors measured –27. AlthThere are a disproportionate number of patients with chronic illness and disease on the Texas- Mexico border region. Obesity (53.8%); hypertension (38.9%); diabetes (28.8%); and depression (21.8%) are epidemic in the area –31. One Demographic characteristics of this self-selected cross-sectional cohort and description of services provided are reported in earlier work completed by our research team . The purThe protocol was approved by the University of Texas Institutional Review Board. All patients signed a consent for care. was funded through a grant to develop a Colonia Care Program. VIDAS's clinical arm serves to unite the region by building a consortium of professionals collaborating as a team to create a healthcare model for the community's most vulnerable members. The UniMóvil mobile clinic was created to address access to healthcare across the Colonias throughout the region.VIDAS The UniMóvil provides care in two Colonias, each with significant differences. Cameron Park was selected as the representative “green” Colonia because of a long history of an established indigent care model and the proximity to the Mexico border that facilitates ready access to affordable healthcare in Mexico. Indian Hills, a “yellow” Colonia, was chosen because of the location , low social capital, low socio- economic reserve, and poor transportation resources.The team travels to the Colonias twice a month and provide routine primary care. As part of clinical care, we collect body mass index (BMI), systolic blood pressure, diastolic blood pressure, glycated hemoglobin (HbA1c), total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides, glucose concentration, health-related quality of life as measured by the Duke Health Profile, and Patient Health Questionnaire-9 (PHQ-9). The team used Duke Health Profile results to evaluate the relationship between HrQOL and chronic disease . Other sThis Community Case study is further analysis of our previous report. The report is a convenience sample of patients seen during 2016–2018, using anonymized linked healthcare data from 1400 patients treated on a mobile medical van. To preclude biased estimation of effects when the level of missing data is greater than 5 percent (up to 20% in our sample), we used a missing data imputation approach that uses a “random forest” algorithm implemented in R (Version 3.2.3) in the MissForest package to account for missing data. Consequent to imputation using MissForest, we arrived at a final data set of 894 observations for all variables of interest. We analyzed the 894 charts for baseline prevalence, associations, and contributing factors and measured seven health-related variables , high LDL (low-density lipoprotein), and high total cholesterol) routinely measured on patients in our clinics. We also collected information from two survey instruments routinely administered by clinicians staffing the Mobile Unit. The Duke Health Profile is a 17-item self-report questionnaire measures health-related quality-of-life (HrQoL) (reliability 0.30–0.78)  and inclLogistic regression analysis and factor component analysis were used to determine potential associations between clinical variables and candidate predictor variables and seven physiological health variables and two survey instruments: The PHQ-9 surveys, used to monitor depression, and the Duke Health-Related-Quality-of-Life survey consisting of 11 domains, were analyzed. The FI was computed over the seven physiological variables, PHQ-9 score, and the 11 domain-specific Duke scores for a total of 19 possible variables.We used the seven physiological health variables, 17 item scores of the Duke Health Profile, and the PHQ-9 score to calculate the FI. Regressions of the Frailty Index against age were performed in subsamples of males, females, Cameron Park patients, and Indian Hills patients. We assessed the difference between males and females and between Colonias, using the difference between slope and intercept tests .2 given as the squared difference of mean vectors scaled against the sample covariance matrix while taking sample size differences into account. Hotelling's T2 was computed and then transformed into an F-statistic for statistical inference in r (Version 3.2.3).Using a complementary multivariate test, we examined the difference between the vectors of means for all the variables considered by way of Hotelling's Tp values. Obesity, diabetes, hypertension, and depression are highly prevalent in both Colonias. Men score significantly higher than women in hypertension and hypertriglyceridemia. Men score better than women in all four domains of HrQoL function . Women score worse in anxiety, depression, anxiety-depression, and pain. The plot of the difference of means as calculated by Hoteling T2 is the squared difference of mean vectors scaled against the covariance matrix for age (in years), systolic blood pressure (SBP), HbA1c (A1c), high-density lipoprotein (HDL), total cholesterol (Chol), physical health (Phys), mental health, perceived health (Perc), anxiety (Anx), anxiety-depression (A_D), pain (pain), and disability (Disab) compared across both Colonias. If we look across Colonias (P < 0.001), with higher SBP, HbA1C, low HDL, and high cholesterol measurements. Residents of the two Colonias score similarly between 10 of the 11 domains of the Duke Profile other than perceived health  from the younger to older age groups (20–45 vs. 46–93). The initial Frailty Index for women is higher than men, but as men age, they decline faster than women (p < 0.01), which is consistent with their significantly different mean vectors as inferred from the Hotelling's T-squared result (p < 0.001).Frailty increases with age and peaks between the ages of 40 and 60 years . The proan women . The meap < 0.001), and the Frailty Index was significantly higher in Cameron Park (p < 0.02), consistent with their significantly different mean vector (p < 0.001).The Frailty Index in Indian Hills remained stable with increasing age  when comWe developed a Frailty Index calculated with 19 variables from two surveys  and seven clinical measurements. We chose the seven clinical measurements and the two surveys because they are evidence-based screening metrics routinely used in primary care to evaluate for health and quality of life.The prevalence of chronic disease in the region is high. The residents from Cameron Park Colonia are older, and hyperlipidemia and hypertension are more prevalent in this population than in Indian Hills Colonia. The prevalence of diabetes and obesity (high) are similar in both Colonias. A cross-sectional representation of residents of Indian Hills demonstrated little change of Frailty with age, whereas Frailty increased dramatically with age in the more established Cameron Park, with the peak frailty index scores occurring between 40 and 60 years of age.Cameron Park is located on the US-Mexico border and is within the boundaries of the city of Brownsville. The proximity of Cameron Park to the border means that many residents can find affordable healthcare a few minutes away in Mexico. Cameron Park appears more stable, and although poor, most residents live in constructed houses rather than manufactured homes, the roads are paved, and city services are available. Housing options, community services, and life in Indian Hills are more problematic. Indian Hills only recently paved roads, and most residents live in trailers and make-shift housing without central air conditioning.The Frailty Index was calculated against age, and Colonia was regressed against age. Indian Hills had a significantly higher starting frailty, while Cameron Park had a significantly greater change rate with age.Prior researchers note positive contributors to Frailty in Hispanic dense, cultural and language congruent neighborhoods, suggesting that social capital, positive cultural protection, reduced social vulnerability, and proximity to appropriate language- and culturally based assistance protect against Frailty. The immigrant paradox may also explain the improved health of families in Indian Hills; families residing in Indian Hills may be more willing to seek medical care, support the elderly, or are newer immigrants –16. We pWe also found that women score higher in Frailty than men when young, but the FI for men worsened rapidly with advancing age. Prior studies have attempted to explain gender-based differences found in Frailty , 36–38. The Frailty Index can be used to identify at-risk patients that live in vulnerable environments. Those residents who score high in depression or low in domains of quality of life and suffer from obesity, hypertension, and depression may be identified earlier and focused interventions provided at the healthcare and public health level. The Frailty Index is easy to calculate with evidence-based data routinely collected.The findings in this report are subject to several limitations. The sample is a convenience sample, the data are cross-sectional, and the community case study represents a picture of what is going on in the Colonias. The acute decline of Frailty in men could be related to early death, migration away from the community, and decreased healthcare access and there may be other contributors  that influence decline to frailty. Finally, although evidence-based metrics, the variables used to calculate may be insufficient to measure Frailty in our population. Evidence-based research is required to determine the significant contributors to Frailty and determine a causal link.Patients seeking care through a mobile clinic serving Colonias in South Texas suffer from a high prevalence of diabetes, hypertension, obesity, depression, hypertriglyceridemia, and depression. The Frailty Index is suggested by the US Preventive Services Task Force Recommendations for Primary Care Practice as a measure and is a good predictor of Frailty.Although social determinants of health and health equity are strong predictors of chronic disease, it is essential to study how these stressors affect immigrants living in underserved areas.Life stressors for vulnerable populations contribute to increased Frailty with age, and the variables are biopsychosocial based. The prevalence of chronic disease and depression in our region is epidemic. Hispanic patients that seek healthcare from a mobile clinic serving Colonias in South Texas suffer from high rates of diabetes, hypertension, obesity, depression, hypertriglyceridemia, and they score poorly on health-related quality of life measures. Research in highly vulnerable populations, such as residents of the Colonias of the US-Mexico border, is inadequate. These preliminary data can serve as background evidence to design future research to incorporate stressors and social support in examining those who become frail, especially in minority populations. Although social determinants of health and health equity are strong predictors of risk for chronic disease, it is crucial to study how these stressors affect minority residents and immigrants living in medically underserved areas. The Frailty Index, however, provides information for the accumulation of deficits and may help clinicians to focus on interventions to prevent eventual Frailty.10.17632/zz2b3wdf5r.2.The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found below: manusov, eron (2021), “Mobile Medical Van in the South Texas Colonias”, Mendeley Data, V2, The studies involving human participants were reviewed and approved by University of Texas Rio Grande Valley Institutional Review Board. The patients/participants provided their written informed consent to participate in this study.EM was the Principal Investigator on the United Health Foundation grant, collected data, analyzed data, wrote, and was substantially involved in editing the manuscript. CG analyzed data, wrote, and was substantially involved in editing the manuscript. VD analyzed data and completed the statistical analysis, was substantially involved in editing. GM-M analyzed data, contributed to the manuscript, and was substantially involved in editing. SW-B analyzed data and was substantially involved in editing. All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.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.


Objective: The purpose of this study was to compare the prevalence of MetS and the associated sociodemographic, clinical, and pharmacotherapeutic characteristics of patients with schizophrenia in three psychiatric hospitals in the West Siberian region.Methods: Patients with a clinical diagnosis of schizophrenia (ICD-10: F20) and an age between 18 and 60 years were included in the study after giving informed consent. Metabolic syndrome was diagnosed according to the International Diabetes Federation criteria. This research was carried out at three Western Siberian psychiatric hospitals in Kemerovo, Tomsk, and Omsk. The study population included respectively 94, 131, and 91 inpatients with schizophrenia. We carried out schizophrenia symptoms assessment by PANSS, antipsychotic therapy evaluation, anthropometry, and biochemical analysis. Statistical Analysis included the Shapiro–Wilk test, non-parametric Kruskal–Wallis H-test for independent samples, Mann–Whitney U-test for independent samples, the chi-square test, stepwise multiple regression analyses. The level of significance was p < 0.05.Results: The metabolic syndrome prevalence was higher among patients in Tomsk (36.6%), compared with Kemerovo  or Omsk , mainly due to the high prevalence of abdominal obesity, while men from Tomsk were more susceptible to this condition than men from other regions (p < 0.05). Patients from Omsk had the highest severity schizophrenia symptoms according to PANSS, and patients from Tomsk had the lowest severity of positive symptoms according to PANSS. Patients from Tomsk had the minimum duration of antipsychotic therapy compared with the patient from Kemerovo (p = 0.017) and from Omsk (p = 0.000019), but most patients from Tomsk received second-generation atypical antipsychotics, while patients from Omsk received mainly conventional antipsychotics (p = 0.0001). Multiple regression analysis showed that metabolic syndrome associated with schizophrenia duration and body mass index, although the association was not so strong .Discussion: The study illustrates that in different psychiatric hospitals within the same region, the prevalence of metabolic syndrome in patients with schizophrenia can vary significantly, which dictates the need to look for opportunities to minimize the risk of its occurrence, taking into account the experience of each hospital. Schizophrenia is a chronic and severe mental disorder. There is generally accepted that its prevalence in the population is relatively stable at 1%  in persons with schizophrenia . AnotherResearchers from Japan found a greater prevalence of MetS in the outpatient group compared with the inpatient group with schizophrenia. This difference can be explained by the peculiarities of the Japanese mental health care system, which provides for constant lifestyle management in hospitals , 20. SimSeparate studies conducted in Korea and Taiwan compare a cohort of patients with schizophrenia with the general population, revealing a high prevalence of MetS in the first group, which is consistent with data from European studies , 23. HowThe question of the effect of antipsychotic treatment on MetS in patients with schizophrenia is remaining open. A major recent review noted differences between antipsychotics in terms of metabolic side-effects, with olanzapine and clozapine exhibiting the worst profiles and aripiprazole, brexpiprazole, cariprazine, lurasidone, and ziprasidone the most benign profiles. The risk factors of antipsychotic-induced metabolic change were increased baseline weight, male sex, and non-white ethnicity . At the Thus, despite the existence of differences between subpopulations of patients with schizophrenia, the amount of data on this topic remains insufficient, which determines the relevance of this study. The purpose of this study was to compare the prevalence of MetS and the associated sociodemographic, clinical, and pharmacotherapeutic characteristics of patients with schizophrenia in three psychiatric hospitals in the West Siberian region. We hypothesized that there may be differences in MetS prevalence in patients with schizophrenia taking antipsychotic therapy across multiple psychiatric hospitals within the same region, associated with differing sociodemographic, clinical, and pharmacotherapeutic characteristics. Western Siberia is an industrial and scientific region with a continental climate, long cold winters, short summers, located in the geographic center of Russia, known for its hydrocarbon deposits and an extensive network of gas and oil production. The administrative centers are large cities, but the region has a relatively low population density, due to which psychiatric hospitals are concentrated in large cities. Mental health care in this region, as well as throughout Russia, is funded by the state and is free of charge for patients. Hospitals, as a rule, do not have significant differences among themselves in the organization of mental health care.This research was carried out from September to December 2019 at three Western Siberian psychiatric hospitals in Kemerovo, Tomsk, and Omsk. The study population included respectively 94, 131, and 91 inpatients with schizophrenia who written informed consent and met the following inclusion criteria:presence of schizophrenia diagnosed according to the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10: F20);antipsychotics therapy for at least 6 months before entering the study;age range 18–60 years.Exclusion criteria:a history of eating disorders;a history of alcohol or drug abuse;diabetes;treatment for organic comorbidities.The groups of patients recruited in each of the hospitals did not differ in sex, age, educational level, and marital status . All patThe study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Ethics Committee of Mental Health Research Institute of the Tomsk National Research Medical Center of the Russian Academy of Sciences . All participants provided written informed consent to participate in this study.We used the World Health Organization World Mental Health Composite International Diagnostic Interview (WHO WMH-CIDI) for schizophrenia diagnostics. Symptom severity assessment was carried out with the Positive and Negative Syndrome Scale (PANSS) . InformaWe used the criteria of the IDF for MetS diagnostics . These cthe concentration of triglycerides in serum is higher than 1.7 mmol/L (150 mg/dl) or lipid-lowering therapy is carried out;the concentration of high-density lipoprotein in serum is below 1.03 mmol/L (40 mg/dl) in men and 1.29 mmol/L (50 mg/dl) in women;the arterial blood pressure level is systolic above 130 mmHg or diastolic above 85 mmHg (or with treatment of previously diagnosed hypertension);serum glucose concentration is >5.6 mmol/L .After 12 h of overnight fasting, blood samples were taken into BD Vacutainer® with a clot activator  for biochemical tests of glucose, HDL-C, and triglycerides using commercial kits .H-test for independent samples. The pairwise analysis was performed using Mann–Whitney U-test for independent samples. The chi-square (χ2) test was used to analyze the categorical variables. Bonferroni correction was applied for multiple comparisons to erroneous inferences prevent. Descriptive statistics are presented as the median with 25 and 75% quartiles, Me . We conducted stepwise multiple regression analyses to examine the relevance of variables for the presence of the MetS. We entered into the model variables that in univariate analyses were different between patients in three groups . The level of significance was p < 0.05.We used the Shapiro–Wilk test to assess the data correspondence to the normal distribution at the first stage. The significance of intergroup differences was evaluated using the non-parametric Kruskal–Wallis p = 0.0405 and 0.0019, respectively). There were fewer unemployed patients from Omsk compared to patients from Kemerovo and Tomsk . However, the majority of patients from Omsk had psychiatric disability compared to patients from Kemerovo and Tomsk . A psychiatric disability was also more common in Kemerovo than in Tomsk patients  and Kemerovo (p = 0.075). Patients from Tomsk had a minimum score of PANSS positive symptoms compared with the patient from Kemerovo (p = 0.00001) and from Omsk (p = 0.00000). The maximum total PANSS score was in patients from Omsk , mainly due to negative symptoms  and from Omsk (p = 0.00007). The PANSS total score was higher in males from Omsk than in males from Tomsk  and from Omsk (p = 0.00057). Females from Omsk had a higher PANSS negative symptoms score than females from Kemerovo (p = 0.0176), as well as a higher total PANSS score than females from Tomsk  and from Omsk (p = 0.000019). The minimum duration of antipsychotic therapy was recorded in males from Tomsk as compared to males from Kemerovo (p = 0.00206) and from Omsk . Patients from Omsk most often received a combination of two antipsychotics compared to patients from Kemerovo and Tomsk . The patients from Kemerovo were more likely to take three antipsychotics at the same time as compared with the patients from Tomsk .Patients from Tomsk, both in the general group  and whenp < 0.05 in each case). Moreover, the maximum and minimum fasting glucose values were achieved mainly due to the level of this indicator in females (p < 0.05 in each case). The triglyceride level was higher in patients from Tomsk (p = 0.040) than from Omsk (p = 0.020). Females from Kemerovo had a lower HDL-C (p < 0.05 in each case).The maximum level of fasting glucose in the blood serum was registered in patients from Kemerovo , the min females  and male females , respectom Tomsk , mainly er HDL-C  level thp = 0.008; Odds Ratio (OR): 2.283, 95% Confidence Interval (CI): 1.233–4.228] or Omsk , mainly due to the high prevalence of abdominal obesity (p < 0.05 in each case). The incidence of elevated HDL-C levels was higher in individuals from Kemerovo than in individuals from Omsk  and BMI (p < 0.0001)  as a result of the multiple regression model  in this study.We consider the strengths of our study to be the assessment with standardized instruments, the collection of a large number of laboratory and anthropometric parameters, and the rigorous way of MetS diagnostic, are making the study reproducible.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethics Committee of Mental Health Research Institute of the Tomsk National Research Medical Center of the Russian Academy of Sciences. The patients/participants provided their written informed consent to participate in this study.EK, AK, and SI: conceptualization. EK and SI: methodology and data curation. AK, IM, and IP: software. EK, IM, and AK: validation and writing—original draft preparation. IM, AG, and IP: formal analysis. IM, AG, AB, and VG: investigation. EK and AK: resources. EK, IM, AL, and VG: writing—review and editing. AS and SI: supervision. NB: project administration. AB: funding acquisition. 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.