A prior study showed an association between diversity in daily activities  and frailty in older adults. However, the causality of this relationship is unclear. Therefore, this study aimed to clarify the relationship between activity diversity and frailty through a 2-year longitudinal study conducted among community-dwelling older adults.We evaluated data from the 2018 and 2020 waves of the Otassha Study. Frailty was assessed using the Cardiovascular Health Study criteria, with pre-frail and frail participants defined as frail and the other participants categorized into the robust group. We enrolled a total of 207 participants who were not frail at baseline. Activity type, frequency, and evenness scores were calculated using an Activity Diversity Questionnaire. The association between each activity diversity score and the incidence of frailty was evaluated using logistic regression modeling (each diversity score was entered the model after Z-transformation).P < 0.05). These factors were significantly associated with the incidence of frailty.Of the 207 enrolled participants , 64 (30.9%) had incident frailty during the follow-up period. A logistic regression analysis adjusting for sociodemographic and psychosomatic factors revealed odds ratios for activity type and evenness scores of 0.64 and 0.61, respectively (Activity type and evenness (except frequency) within daily activities were predictors of frailty during 2 years of follow-up. Engagement in diverse activities appears to be more effective in preventing frailty than does engagement in a few activities. In developed countries, the burden of nursing care due to aging has become a major social problem, and extending healthy life expectancy is of urgent concern , 2. A deFrailty is defined as an age-associated syndrome presenting as decreased reserve and resistance to stressors that cause vulnerability to adverse health outcomes . It is aFactors have been reported to be associated with frailty, including sociodemographic, medical, physiological, and lifestyle factors , 7. In pSeveral studies have examined associations between activity diversity and health outcomes. Menec  and Lee In our previous study, we developed the Activity Diversity Questionnaire (ADQ), which is a questionnaire that assesses the implementation of 20 activities of daily living, including physical, intellectual, and social activities , 16. TheThe current study investigated the association between activity diversity scores and the incidence of frailty in community-dwelling older adults in a 2-year longitudinal cohort study aiming to clarify the causal factors in the association between activity diversity and frailty.We conducted a 2-year longitudinal study using data from the Otassha Study cohorts. The Otassha Study cohorts is conducted among older adults aged 65 years or older living in nine areas of Itabashi Ward, Tokyo, except for those residing in nursing homes. Comprehensive health checkup surveys, consisting of a mail survey part and a venue survey part, are conducted in September and October every year , 19.We enrolled individuals who participated in the 2018 survey. Individuals with frail or pre-frail at the time of the 2018 survey and those with missing data on outcomes or important covariates were excluded from the current study. In addition, individuals with cardiac disease or stroke in the past 6 months and with blood pressure above the reference value  were also excluded as grip strength  was not measured. All participants had been fully informed about the study  and had provided their written informed consent prior to participation. This study was approved by the Ethics Committee of the Tokyo Metropolitan Institute of Gerontology  and was conducted in accordance with the principles of the Declaration of Helsinki.Frailty was assessed in the 2018 and 2020 surveys using the five items in the Japanese version of the Cardiovascular Health Study (J-CHS) criteria (Activity diversity was assessed using the Activity Diversity Questionnaire (ADQ) administered during the 2018 survey . The ADQm represents the total number of activities (m = 20), i represents each activity, and Pi represents the proportion of each implemented activity. Evenness scores could range from 0 to 1, with higher scores indicating wide-ranging and even engagement in daily activities across the 20 evaluated items.Where 2), Mini-Mental State Examination (MMSE) , subjective financial status , and family structure  were examined as sociodemographic factors. In addition, physical and mental functioning were assessed using body mass index  , and then (MMSE) , 24. Subt-tests and χ2 tests. Logistic regression analysis was performed to examine associations between activity diversity and the incidence of frailty, with the presence or absence of frailty as the dependent variable. To evaluate these associations, we implemented the following models: (i) a crude model, in which each of the three indicators of activity diversity  were entered as independent variables; (ii) Model 1, in which sociodemographic factors were added as covariates to the crude model; and (iii) Model 2, in which physical and mental functioning factors were added to Model 1. The three indicators of activity diversity  were strongly correlated , respectively. Due to multicollinearity issues, each indicator was not put into the model simultaneously. In the logistic regression analyses, the three indicators of activity diversity were standardized via Z-transformation to compare the odds ratios (ORs). Moreover, a power analysis was conducted using the G*Power software  and those lost to follow-up (n = 119) using t-tests and χ-square tests. In addition, to ensure the robustness of the data in this study, missing value imputation was conducted supplementally using the multiple imputation method. The results with missing value imputation and the results from the complete case analysis were compared. Missing value imputation was performed on data from those who participated in both the 2018 and 2020 surveys (n = 456). Missing values were found in J-CHS criteria item , subjective financial status (n = 34), family structure (n = 4) and MMSE (n = 1). Multiple imputation was performed using an iterative Markov chain Monte Carlo method .The statistical significance level was set to a threshold of n = 62, frail: n = 2) participants in the frail group . One hundred nineteen participants were lost to follow-up as of the 2020 study wave. The final analysis included 207 participants . Of the enrolled participants, there were 143 (69.1%) participants in the robust group as of the end of the study follow-up period and 64 . The mean MMSE score was 29.0 [standard deviation (SD) = 1.4]. The mean WHO-5 score was 18.5 (SD = 3.8). The evaluated activity type, frequency, and evenness scores were 11.2 (SD = 2.3), 24.4 (SD = 5.1), and 0.77 (SD = 0.07), respectively (P = 0.015] and evenness scores  were lower in the frail group than in the robust group. There were no significant differences between the two groups with respect to the other evaluated items.Of the participants enrolled in the final analysis, 150 (72.5%) had an appropriate  BMI (18.5–24.9 kg/mectively . Type scn = 207) and those lost to follow-up (n = 119) are shown in P = 0.013). No significant differences were observed with respect to the other evaluated items.A comparison of medical and demographic characteristics between the participants enrolled in the final analysis  was 75.8%, and the average scores for the MMSE and WHO-5 evaluations were 29.0 and 18.5, respectively. These findings indicate that the physical and mental functioning of these older participants was superior to that of participants evaluated in other cohort studies . This may be because the evenness score weights each activity according to the proportion of each implemented activity, but is also greatly influenced by the number of types of activities, which may have approximated the type score. The current operationalizations failed to empirically distinguish the two concepts, i.e., type and evenness. The two scores are theoretically distinct but methodologically not distinct. Therefore, it may be necessary to consider a new methodology for evenness indicator that is separated from the effects of number of types.Logistic regression analysis demonstrated that both type and evenness scores were significantly associated with the incidence of frailty even after adjusting for all covariates, suggesting the importance of implementing more activities evenly. Seino et al.  investign = 119) or had missing data (n = 111). If the causes of dropout were related to the development of flailty, the bias due to lost to follow-up may have influenced the results of this study. The item with the highest amount of missing data was weight loss , followed by subjective financial status (n = 58). The missing data was considerable, as information was obtained through a mailed survey. However, comparing the baseline characteristics of the participants included in the final analysis and those lost to follow-up showed only a significant difference in age. No significant differences in physical and mental functioning were observed. Furthermore, the analysis was also performed for the dataset with missing data imputation, and the results were similar to those of the main analysis. These results suggest a slight bias due to loss of follow-up and missing data. Moreover, we did not evaluate the amount of physical activity. A decreased amount of activity may affect the association between activity diversity and the incidence of frailty. Thus, it is necessary to simultaneously evaluate activity diversity and the amount of physical activity. Future studies enrolling more participants and intervention studies aimed at maintaining and improving activity diversity in older adults are warranted to confirm the findings of this investigation.This study had some limitations. First, many participants were lost to follow-up  to prevent frailty. Furthermore, our findings demonstrate the need for future efforts to maintain and improve the diversity of daily activities in older adults.obuchipc@tmig.or.jp.The datasets presented in this article are not readily available because of ethical and privacy restrictions. Requests to access the datasets should be directed to The studies involving human participants were reviewed and approved by Ethics Committee of the Tokyo Metropolitan Institute of Gerontology. The patients/participants provided their written informed consent to participate in this study.JT: formal analysis, investigation, and writing—original draft. HK: methodology, validation, investigation, resources, data curation, writing—review and editing, project administration, and funding acquisition. ME: project administration and investigation. YF, HH, HS, and KIh: investigation, resources, and funding acquisition. KIs: methodology. KO: supervision and methodology. SO: conceptualization, resources, supervision, and funding acquisition. All authors contributed to the article and approved the submitted version.


Malaria remains a major public health burden to children under five, especially in Eastern Africa (E.A), —a region that is also witnessing the increasing occurrence of floods and extreme climate change. The present study, therefore, explored the trends in floods, as well as the association of their occurrence and duration with the malaria incidence in children < 5 years in five E.A partner countries of Forum for China-Africa Cooperation (FOCAC), including Ethiopia, Kenya, Somalia, Sudan, and Tanzania between 1990 and 2019.ρ= -1 to + 1, as well as the statistical significance of P = < 0.05. Time plots of trends in flooding and malaria incidence were generated in 3 different decades using R version 4.0.A retrospective analysis of data retrieved from two global sources was performed: the Emergency Events Database (EM-DAT) and the Global Burden of Diseases Study (GBD) between 1990 and 2019. Using SPSS 20.0, a correlation was determined based on ρ = -0.586**, P-value = 0.001) and duration .Between 1990 and 2019, the occurrence and duration of floods among the five E.A partner countries of FOCAC increased and showed an upward trend. On the contrary, however, this had an inverse and negative, as well as a weak correlation on the malaria incidence in children under five years. Only Kenya, among the five countries, showed a perfect negative correction of malaria incidence in children under five with flood occurrence (This study highlights the need for further research to comprehensively explore how different climate extreme events, which oftentimes complement floods, might be influencing the risk of malaria in children under five in five E.A malaria-endemic partner countries of FOCAC. Similarly, it ought to consider investigating the influence of other attributes apart from flood occurrence and duration, which also compound floods like displacement, malnutrition, and water, sanitation and hygiene on the risk and distribution of malaria and other climate-sensitive diseases. Malaria remains a major public health burden significantly contributing to morbidity and mortality, especially in children under five years of age in the highlands, tropical, and sub-tropical parts of the world –3. It isThe impact of climate change and its associated extreme events like flooding on the incidence of vector-borne diseases (VBDs), including malaria, has been of great concern for decades , 10–12. In recent years, China has made substantial commitments to assist Africa to overcome a wide range of challenges through the Forum for China-Africa Cooperation (FOCAC), also referred to as the Sino-Africa Cooperation , 26. To A 30-year retrospective analysis of data from two global sources was performed: the Emergency Events Database (EM-DAT) and the Global Burden of Diseases Study (GBD) between 1990 and 2019. Retrospective data analysis was considered because it is appropriate and routinely used to retrieve data from either the entire source of data or its subset to help to answer the key research questions of interest .The E.A region, which is located in SSA, comprises among other countries Ethiopia, Kenya, Somalia, Sudan, and Tanzania, which have been focused on in this study. The E.A was considered because it is one of the most fragile regions across the globe having countries encountering various political and socioeconomic challenges such as conflicts and wars, displacement and refugees, infectious diseases, poverty, famine, and population growth , 28–31. a) EM-DAT The Emergency Disasters Database (EM-DAT) is maintained by the Centre for Research on the Epidemiology of Disasters (CRED) of the Université Catholique de Louvain in Brussels, Belgium [https://www.emdat.be/guidelines. Belgium . EM-DAT  Belgium . For an  Belgium . A detaiEM-DAT data are collated from reliable sources such as the UN and NGOs, and they are assembled based on over 50 variables among others including, country, region, disaster number, year, occurrence dates (the start and end day(s), month(s), and year(s)), disaster group, disaster sub-group, disaster type, disaster sub-type, disaster sub-sub-type, number of injured, event name, total deaths, number of affected, number of homeless, total affected population, and total economic damages (adjusted in ‘000’ USD) .Data about the incidence of malaria in children under five were extracted from the GBD study, which is coordinated by the Institute for Health Metrics and Evaluation at the University of Washington, USA . GBD conThis database was accessed on numerous occasions between 1st and 30th September 2022 by one author (JBK) using his registered username and password to retrieve data about recorded floods in countries considered in this study from 1990 to 2019. This period was assumed to be appropriate in analyzing the occurrence of floods and their impacts among the five E.A countries so that in the future it can help to inform the relevant strategies for flood mitigation. Firstly, the following search parameters were applied to query the database: disaster group: ‘natural’; disaster subgroup: ‘hydrological’ disaster type: ‘flood’; location: continent ‘Africa’; region: ‘Eastern Africa’; period or from: ‘1990–2019’. Second, flood data meeting these parameters were downloaded from the EM-DAT in comma-separated values (CSV) format —which facilitates the processing of data in tabular format. Third, the data were manually checked for plausibility and then sorted in ascending order by the variable “country”. Thereafter, the data for five E.A countries under the review period (1990–2019) were considered for detailed analysis. It should be noted that any missing data were not imputed.https://www.healthdata.org/gbd/2019 [Data about the incidence of malaria in GBD for five E.A countries was retrieved in line with the current International Classification of Diseases and Injuries ICD-11) . This aigbd/2019  by filte1 . This Statistical Package for the Social Sciences (SPSS) version 20.0  was used for statistical analysis. At first, the duration for each flood event was calculated in terms of the days it took to occur between the start and end dates. Thereafter, the occurrence duration and three other variables, including the year, country, and number of occurrences among the five E.A countries, were used to calculate and generate the percentages and graphs in the Microsoft Office Excel version 2019  following the standard methods of descriptive statistics.ρ), and statistical significance  were conducted. Numerical bivariate analysis based on the Spearman rank-order correlation test (Spearman-rho) was used to establish the potential influence of flood occurrence and duration on malaria incidence in children < 5 years in five partner countries of FOCAC in E.A between 1990 and 2019. The ρ was evaluated based on -1 to + 1, whereby, 0 indicates that the two variables are uncorrelated; +1 is a positive correlation; and − 1 is a negative correlation. In this case, the larger value represents a stronger correlation. The statistical significance of P = < 0.05 was identified to be statistically significant.Using SPSS, the mean differences at 95% confidence intervals (CIs), standard deviations (Std Dev), correlation coefficient  was used to generate polylines for plotting and visualizing the trends in malaria incidence in children under five, and on the other hand, flood occurrences in three separate decades  among five partner countries of FOCAC in E.A. R is a free software environment for statistical computing and graphics .This study required no ethics approval since it did not directly involve humans.Trends in flood occurrences: A total of 205 floods were retrieved in EM-DAT to have occurred in five partner countries of FOCAC in E.A within thirty years. They were distributed as follows: Kenya 51(24.9%), Ethiopia 46(22.4%), Tanzania 38(18.5%), Somalia 36(17.6%), and Sudan 34(16.6%). According to Table The occurrence of 205 floods happened within a total of 2,869 days in five partner countries of FOCAC in E.A between 1990 and 2019. The highest number of days 833(29%) was recorded in Kenya and followed by Sudan, Ethiopia, Tanzania, and Somalia with 566(19.7%), 501(17.5%), 497(17.3%), and 472(16.5%), respectively  and Somalia . In the remaining three E.A countries, including Ethiopia , Sudan , and Tanzania ; there was an insignificant correlation of flooding with the incidence of malaria in children under five years between 1990 and 2019. On the other hand, apart from Somalia , the duration of flood occurrences was revealed to be statistically significant and associated with malaria incidence in under-five children all over the study period. Based on Table ρ = 0.294*, p-value = 0.0317), Kenya , Sudan , and Tanzania . In this case, only Kenya, among the five countries, showed a perfect negative association with malaria incidence in children under five years of age and flood occurrence and duration. All these results indicate inverse and negative, as well as weak correlations of flood occurrence and duration with the incidence of malaria in children < 5 years in five partner countries of FOCAC in E.A.According to Table Firstly, the upward trends in the occurrence and duration of floods revealed by this study could generally be deemed to have exacerbated the burden of malaria in five partner countries of FOCAC in E.A between 1990 and 2019. On the contrary, however, the result of inverse, negative, and weak correlations showed that malaria incidence in children < 5 years was not directly associated with flood occurrence and duration in five countries in the past three decades. Similar to this finding, some studies previously found climatic scenarios, in particular, floods, to have had either an inverse, negative, or neutral effect on malaria transmission in Ethiopia, Kenya, and Sudan , 12, 40.Additionally, an inverse, negative, or weak correlation the flood occurrence and duration had with malaria incidence between 1990 and 2019 can be explained based on the fact that floods are preceded and triggered by excessive rainfall and water. This situation is inevitable in five countries and E.A region at large, given their tropical and coastal locations, and above all, vulnerability to climate change and its adverse effects , 41–43. More so, the inverse relationship of floods with the burden of malaria in children < 5 years among five partner countries of FOCAC in E.A can be related to the impact of other natural hazards. They include drought, desertification, tropical storms, landslides, and mudslides, all of which are inextricably linked to or influenced by climate change , 41–43. Amid the continued burden of malaria in children < 5 years of age, the five E.A countries and many other less-developed alike are still having their healthcare systems grappling with various challenges —ranging from insufficient financing and shortage of health personnel to medical supplies , 46. MorBy and large, cognizant of the devastating impacts of climate change and its associated effects, not just limited to floods only but also other natural hazards , 26, 51;The current study showed that the malaria incidence in children < 5 years in the past three decades was negative and weakly correlated with the increasing trends in floods among five partner countries of FOCAC in E.A. Possibly, this was due to the influence of different economic and sociocultural dynamics, as well as natural hazards that oftentimes compound floods, and, on the other hand, the concerted interventions taken to ameliorate the burden of malaria in five E.A countries. This, therefore, highlights the need for further studies to comprehensively explore how those factors or conditions, which oftentimes also complement floods, may influence the risk of malaria in children below five years in five E.A countries and elsewhere, where the disease is still endemic. This is highly warranted at this particular moment when the five partner countries of FOCAC and the E.A region at large are witnessing an increase in the occurrence of climate-induced floods and other extreme hazards. This ought to leverage the existing bilateral and multilateral partnerships, in particular, FOCAC —an initiative in which China is committed to addressing the different challenges faced by African countries, including the burden of malaria and climatic hazards like floods.


Bifidobacterium counts, bacteria beneficial to the health of birds, from day 11 onwards.Although antibiotic resistance emerges naturally, this process has been accelerated by the worldwide overuse and misuse of antibiotics. It is essential to find effective alternatives in the broiler industry to improve poultry health while maintaining production efficiency and product safety. In this study, we aimed to evaluate a potential alternative: wood-derived component xylo-oligosaccharides. The objective of this research was to investigate the potential of xylo-oligosaccharides as a prebiotic feed supplement for broilers. Therefore, a pilot study was conducted to explore the optimal xylo-oligosaccharide profile by in vitro fermentation. Subsequently, xylo-oligosaccharides with an optimal profile were produced in large quantities, and an animal feed experiment was performed. During this experiment, the growth performance, feed conversion ratio, and intestinal parameters of the broilers were evaluated for 15 days. Results from the pilot study indicated that higher enzyme concentrations in the production process yield a product that leads to a higher butyric acid production during in vitro fermentation by caecal bacteria. Supplementation of the tailored xylo-oligosaccharides to the broiler diet resulted in higher wt/wt XOS, d9-d15 0.32% XOS) resulted in higher Bifidobacterium counts, beneficial to the health of birds, on d11 and d15.Although antibiotic resistance emerges naturally, this process has been accelerated by the worldwide overuse and misuse of antibiotics. It is essential to find effective alternatives in the broiler industry to improve poultry health while maintaining production efficiency and product safety. In this study, we aimed to evaluate a potential alternative: wood-derived xylo-oligosaccharides (XOS). The objective of this research was to investigate the potential of XOS prepared using enzymatic hydrolysis of beechwood xylan as a prebiotic feed supplement for broilers. A pilot study was conducted to explore the optimal XOS fraction profile by in vitro fermentation. Subsequently, a semi-continuous enzyme membrane reactor was used, allowing for the production of tailored XOS in large quantities. Given the strong bidirectional relationship between intestinal health, nutrition, and intestinal microbiota composition in broilers, an in vivo experiment was performed to explore the potential of XOS as a prebiotic feed supplement by investigating growth performance, feed conversion ratio, caecal short and medium chain fatty acid (SCFA and MCFA) concentration, and microbiological composition of the caecal content. Results from the pilot study indicated that higher enzyme concentrations in the hydrolysis process yield a product that leads to a higher total SCFA and MCFA- and butyric acid production during in vitro fermentation by caecal bacteria. Supplementation of the tailored XOS to the broiler diet (day 1 (d1)-d8 0.13%  The development of antibacterial agents has been one of the major accomplishments of modern medicine. However, although antibiotic resistance emerges naturally, this process has been accelerated considerably by the worldwide overuse and misuse of antibiotics. Antibiotic resistance rates are reaching dangerously high levels in all parts of the world. A growing number of common bacterial diseases, such as pneumonia, tuberculosis, blood poisoning, gonorrhea, and foodborne diseases, are becoming harder, sometimes even impossible, to treat as antibiotics become less effective due to newly emerging resistance mechanisms that are spreading rapidly across the world. The World Health Organization even describes antimicrobial resistance as one of the biggest threats to global health, food security, and development today . The widSince the early 1960s, global poultry meat production per capita has increased sixfold. Chicken meat, which contributes 90% of global poultry meat production, has undergone a significant transformation, evolving from a relatively scarce food product to an easily accessible, economically viable, protein-rich, and low-fat food product characterized by a favorable fatty acid profile ,12. PoulStaphylococcus aureus, Clostridium difficile, Salmonella enterica, and Campylobacter jejuni . Similarly, the total amount of WE-AX (%) was calculated as 0.88 × [(WE-L-arabinose %) + (WE-D-xylose %)]. A conversion factor of 0.88 was used to account for the release of water molecules by MS during the polymerization reaction. The purity of the XOS fraction was calculated as 0.88 × [D-xylose%] available in this fraction. Total and WE arabinose to xylose (A/X) ratios  were calculated by dividing the arabinose by the xylose content of the samples and their aqueous extracts, respectively. These A/X ratios give an indication of the complexity of the AX chain and, hence, the likelihood of the AX polymer being hydrolyzed by the microbial AX degrading enzymes and subsequently fermented by microbiota . The avDThe number of animals used in this study was calculated based on data obtained from a similar experiment conducted by Courtin and colleagues , using t2) and separated using metal fences, were covered with wood shavings as litter. Feed and drinking water were provided ad libitum. A total of 96 one-day-old male Ross 308 broiler chickens (Belgabroed NV) from the same broiler breeder flock with an age of 47 weeks were purchased and housed at the KU Leuven pilot farm TRANSfarm  under the standard housing conditions for broilers determined by the Flemish Government . The ambn = 2), and estimated FCR. Animal samples were collected on d8, d11 and d15. On each sampling day, fifteen chicks per treatment were selected at random and euthanized by decapitation. The animals were dissected to collect duodenum, jejunum, ileum, and both caeca. Duodenum, jejunum, and ileum were emptied, and their net weight was registered. The content of both caeca was pooled and divided over two 2 mL tubes: one for quantification of SCFA and one for microbiological analysis. To the latter, a 50% glycerol  solution was added to obtain a final concentration of 15% vol/vol glycerol. Samples were stored at −80 °C until further use. Upon arrival at the broiler house, the chickens were individually tagged and randomly divided into four groups (24 chicks per group): two groups that received XOS-supplemented feed (XA and XB) and two groups that received the untreated control feed (CA and CB). Groups XA and XB received 0.2% XFCF-supplemented feed during the first eight days and 0.5% XFCF-supplemented feed from d9 onwards. Two repetitions per treatment were introduced in the experiment in order to reduce the pen effect on the obtained data. On d1, d8, d11, and d15, all individual broilers and feed leftovers per pen were weighed to calculate body weight (BW), estimated feed intake , five to seven 2.0 mm Zirconia beads  per tube were added, and the entities were autoclaved. Under sterile conditions, 300–500 mg caecal content was added to the sterile microtubes, and the samples were placed on ice. Ice-cold, sterile peptone physiological salt solution , 8.5 g/L sodium chloride ) was added to obtain a concentration of 500 mg caecal content per mL PPS. In order to ensure the selective quality of the selective agar plates, bacterial strains functioning as positive and negative controls were included in the study. These controls were also prepared in sterile microtubes by adding scrapings from glycerol stocks (−80 °C) to 1 mL sterile PPS. All samples were homogenized  for ten sec at 4500 RPM. In 96-deep well plates , nine tenfold dilutions of each sample in sterile PPS were prepared, resulting in test concentrations ranging from 500 to 500 × 10Plating of the samples was performed based on a modified version of the drop plate method as described by Chen and colleagues . BrieflyBifidobacteria, anaerobic conditions were obtained by placing the plates in an anaerobic jar equipped with the Anaerocult A system . The absence of oxygen was confirmed using an Anaerotest strip  that was placed in the anaerobic jar and was regularly checked.Using a multichannel pipette, 5 µL drops of the samples were placed in a ten-by-ten grid on the plates. A schematic overview of the organization of a plate is illustrated in Following the incubation step, plates were validated on an individual basis based on three conditions: (1) growth could be observed for all PCs; (2) no growth could be detected for the NCs; and (3) no growth could be detected for the SCs. Per sample, colonies in the most adequate dilution were counted, and log10 CFU/g caecal content for each sample was determined. All measurements were performed in triplicate, and the position of each sample on the plate was randomized in order to minimize potential plate position effects. Short-chain fatty acid analysis was performed using DEE of the samples, followed by GC. DEE sample preparation and SCFA analysis of the caecal content were identical to the method described for the fermentation products in the pilot study. All measurements were performed in duplicate.t-test in case of equal variances and the Welch’s t-test in case of unequal variances. In case the data were not normally distributed, the non-parametric unpaired two-samples Wilcoxon test was used. For the in vivo experiment, two repetitions per treatment were introduced in the experiment in order to reduce the pen effect on the obtained data. Before statistical analysis of the data between treatments, repetitions of the same treatment were analyzed for pen effects. In the data sets of this experiment, no pen effects were detected, and subsequently, data sets were combined per treatment before analysis. For all performed tests, a p-value of ≤0.05 was considered statistically significant. Mean values in this work are presented as (mean ± standard deviation).All acquired data were analyzed using the statistical software package JMP . Previous to the analysis, data were screened for outliers by the ‘explore outliers’ function implemented in JMP. The normality of the data was assessed by performing a Levene test. In the case of normal distribution, homoscedasticity was tested using Barlett’s test. Data among groups were analyzed using the Student’s By varying the enzyme concentration added to 7% beechwood in a batch reaction, four XOS fractions (XF) were obtained. The reaction parameters and composition of the XF are reported in As shown in t-tests are provided in p ≤ 0.05) than for blank T24, mainly due to the increased production of acetic and butyric acid. With regard to the XFs, absolute SCFA production was highest for XF139. Production of butyric acid, an available energy source for birds, was significantly higher for XF139 compared to all other samples. Based on these results and using an EMR in semi-continuous mode, an XOS fraction with a tailored MS profile (XFCF) was prepared for the in vivo experiment. The obtained XF were evaluated using anaerobic in vitro fermentation by caecal bacteria, followed by GC analysis of the produced SCFA and MCFA. Results for the SCFA and MCFA profiles are illustrated in To assess the prebiotic properties of the produced XOS fraction, an in vivo broiler feed experiment was designed. An XOS fraction XFCF was prepared in an EMR run in a semi-continuous mode. In this reactor, the enzymatic conversion was coupled to filtration over a hollow fiber membrane module (10 kDa molecular weight cut-off). The reaction parameters and composition of the resulting xylan fractions are reported in The lyophilized powder obtained from the permeate of the EMR contained a concentration of 153.7 g/kg of X1 to X6 XOS. This powder mainly contained X3 and X4 XOS, while the concentration of X2, X5, and X6 XOS was somewhat lower. Much lower concentrations of xylose were detected, which is desirable for animal feed. Next to these X1 to X6 XOS, bigger fragments with an average Mn of 6 kDa were detected in the hydrolyzed xylan powder. wt/wt XFCF), and FXFCF0.5 (0.5% wt/wt XFCF): DM, total MS, WE MS, free MS, reducing end xylose, TOT-AX, WE-AX, and avDP.In order to obtain more insight into the chemical characteristics of the experimental diets, the following parameters were determined in the pure XFCF preparation, and the three experimental diets FCON (no XFCF supplemented), FXFCF0.2 , used for the calculation of TOT-AX and WE-AX content of the samples, are reported in As wt/wt) and the experimental diets FXFCF0.2 (0.26 ± 0.00%) and FXFCF0.5 (0.45 ± 0.01%) was observed  could be detected in the pure XFCF fraction, confirming the sample was not contaminated by arabinoxylo-oligosaccharides. The XOS purity of the XFCF fraction was estimated at 63.67%. A difference in total XOS levels between the control feed FCON  and the group that received the XOS-supplemented feed . The evolution of BW for both groups is displayed in p > 0.05) between the groups could be detected. The mortality rate of the birds was not affected by dietary treatments and was lower than 4.2% in all groups.To evaluate the effect of XOS supplementation on broiler performance, body weight (BW) and feed intake (FI) were measured. Subsequently, an estimation for feed conversion ratio (FCR) was made for both groups: the control group  were found for any parameter on any measurement day.The net weights of the duodenum, jejunum, ileum, and caeca were registered, and the sum of the four intestinal sections was used to calculate the net gastro-intestinal tract (GIT) weight and the GIT/BW ratio. The results are reported in Enterobacteriaceae, Bifidobacteria, and aerobic and aerotolerant anaerobic lactobacilli. The results are displayed in During the animal experiment, animals were dissected on d8, d11, and d15, and the content of both caeca was collected and pooled. Microbiological analysis of the caecal content was performed using selective agar plates. Three groups of caecal bacteria were enumerated: lactobacilli was significantly higher on d8 compared to d11 and d15 for both the XOS and the CON group. For Bifidobacteria, a similar evolution was observed for the CON group but not for the XOS group. For the latter, no significant differences were found between the different sampling days. On d11 and d15, the concentration of Bifidobacteria in the CON group was significantly lower compared to the XOS group. Enterobacteriaceae counts did increase for both groups during the experimental period. However, a sharper increase was noticed for broilers who received the XOS-supplemented diet compared to their CON counterparts. The amount of caecal aerobic and aerotolerant anaerobic The volatile FA profile  of the caecal content was determined by DEE of the samples, followed by GC. The results are reported in The average acetic acid concentration in the caecal samples did not differ among dietary treatment and age at sampling. The concentration of propionic- and butyric acid increased significantly in the caecal content of CON birds between d8 and d15. For XOS birds, on the other hand, the propionic acid concentration decreased significantly during this period. The propionic acid concentration was significantly higher for XOS birds compared to CON birds on d8 but not from the next sampling day (d11) onwards. The valeric acid concentration was significantly higher in CON birds as compared to XOS birds on d15. Isobutyric- and isovaleric acid concentrations on d8 were significantly higher for XOS birds compared to CON birds. No statistical differences were found in total produced FA, calculated as the sum of all quantified FA across both groups and sampling ages. Enterobacteriaceae were found to be positively correlated (p < 0.05) with caecal caproic acid concentrations (R = 0.6052). Caproic acid concentrations in CON birds increased significantly between d8 and d15 and between d11 and d15. A negative correlation (p < 0.05) was found between Bifidobacteria and propionic- (R = −0.5073), isobutyric- (R = −0.5064), and valeric acid (R = −0.5674). Caecal XOS are hydrolysis products of xylan, the second most abundant carbohydrate material in lignocellulosic biomass. As a result of the increasing wood consumption worldwide, the production of waste wood, for example, in the form of end-of-life wood-based products, is also increasing, providing an abundant source of cheap raw material . TransfoBoth absolute and relative amounts of xylose polymers per fermentation volume with a degree of polymerization lower or equal to six increased with augmenting enzyme mix Cellic CTec2 concentration. As a result, the absolute yield of free xylose was also notably higher for XF139. Free xylose, competing with glucose molecules for the same intestinal transporter systems in the duodenum and jejunum, reaches the ileo-caeco-colic section of the gastro-intestinal tract only in limited quantities and, consequently, exhibits almost no prebiotic properties . MoreoveBifidobacterium spp. and Lactobacilli spp. However, it should be noted that the higher total SCFA production in XF139 might be mainly caused by the presence of a significantly higher free xylose concentration. Free xylose, although reaching the ileo-caeco-colic section of the gastro-intestinal tract only in limited quantities in an in vivo context, can serve as a substrate for fermentation by the caecal bacteria during in vitro fermentation, resulting in a higher SCFA production. Taking these factors into account and in order to fully explore the potential of an XF obtained by enzymatic hydrolysis of BX as a prebiotic feed additive, a semi-continuous EMR system was used, allowing for the production of tailored XOS in larger quantities, and an in vivo animal experiment was designed and conducted.Viscosity was higher for the XF that were prepared with lower enzyme concentrations. Fermentation of XF050 and XF139 resulted in a significantly higher caproic acid production as compared to XF001 and XF005 . MCFA, sTo ensure feed quality, XOS profiles in the experimental diets were analyzed prior to the animal experiment. Although it has been previously demonstrated that freeze drying of XOS samples and storage at low temperatures does not result in degradation due to loss of xylose linkages by hydrolysis ,43, analn = 2), and growth of GIT. These results do not differ significantly from previous studies: Courtin and colleagues reported that XOS supplementation did not influence BW at d14 [During the animal experiment, growth performance, FCR, caecal SCFA and MCFA concentration, and microbiological analysis of the caecal content of broiler chickens were assessed. Administration of the XOS-supplemented feed did not reveal influences on the zootechnical parameters of the birds, such as growth performance, estimated FCR (W at d14 . HoweverW at d14 . In bothW at d14 . This coW at d14 ,45. Enterobacteriaceae, Bifidobacteria, and aerobic and aerotolerant anaerobic lactobacilli. Count of caecal Enterobacteriaceae, a family that comprises many known pathogenic bacterial strains such as Salmonella, Shigella, and avian pathogenic Escherichia coli, was found to be positively correlated with caecal caproic acid concentrations. These findings seem to contradict previous research from Kumar and colleagues, who reported that MCFA inhibits the overgrowth of pathogenic bacteria because of their potent antibacterial activity, resulting in an increase in beneficial bacteria [Enterobacteriaceae counts in CON-fed broilers were not significantly different between d8 and d15, suggesting that this increase for the latter group might have been slower. However, it should be noted that pairwise comparison per day does not reveal significant differences between both groups. A similar trend could be observed for butyric acid. No significant differences between the two groups were found, but butyric acid increased significantly for CON broilers between d8 and d15, whereas for XOS birds, butyric acid levels remained at the same level throughout the entire duration of this experiment. These results are in line with findings from a similar study, in which xylanase was supplemented to the experimental diet to generate XOS in vivo in the GIT, and no significant differences in caecal butyric acid proportions between broilers fed the control diet and those fed xylanase-supplemented diets were found either [The intestinal microbiome plays a pivotal role in maintaining the overall intestinal health of the host, regulating various physiological functions such as the integrity of the epithelial barrier, digestion, nutrient absorption, inflammatory balance, and mucosal immunity. These functions are intricately modulated via extensive interactions with the host, its environment, the chyme, and interactions among individual intestinal bacteria . In a stbacteria . Neverthd either . Butyratd either .Bifidobacterium, counts were significantly higher in the XOS group compared to the CON group [Bifidobacteria are considered probiotic microorganisms and play a critical role in maintaining immune homeostasis in chickens. Probiotic bacteria, via the upregulation of MUC2 in goblet cells, have the capability to enhance intestinal barrier integrity by increasing the production of mucus. Additionally, these bacteria contribute to the reduction in tight junction permeability by upregulating zonulin [Bifidobacteria, can synthesize vitamins and exhibit antioxidant properties themselves by scavenging free radicals [Bifidobacterium spp. grow more efficiently on xylobiose, xylotriose, or XOS than on xylose because they possess a specific uptake mechanism for XOS and intracellularly located carbohydrases, providing them with a competitive advantage over other strains that can only take up monosaccharides [Bifidobacterium spp., has been linked to a reduced protein fermentation, which is beneficial to the host health since bacterial protease pathways, including deamination of amino acids and decarboxylation, can produce potentially toxic compounds with carcinogenic properties [Bifidobacteria was not conducted. It is important to note that potential positive impacts on zootechnical parameters may not manifest immediately. Nevertheless, investigating these effects over an extended duration could provide valuable insights, including considerations of additional parameters such as antibiotic use, which might exhibit reductions over time.Furthermore, our results provide added support for the view that hydrolysis products of beechwood xylan stimulate bifidobacterial growth since, on d11 and d15 ON group ,33. Bifi zonulin . Certainradicals ,51. Prevcharides . Prebiotoperties ,52. In tBifidobacterium counts, beneficial to the health of the birds, on d11 and d15 compared to the control group. However, administration of an XOS-supplemented feed did not reveal influences on the zootechnical parameters of the birds, such as growth performance, FCR, and growth of GIT. Whether supplementation of XOS results in beneficial effects in the long term remains to be clarified in further in vivo work.In conclusion, XOS with a tailored MS profile prepared using enzymatic hydrolysis of beechwood xylan has the potential to serve as a prebiotic feed supplement for broilers. Results from the beechwood hydrolysis in batch set-up indicated that higher enzyme concentrations in the hydrolysis process yield a product with lower viscosity and a higher total SCFA-, MCFA-, and butyric acid production during in vitro anaerobic fermentation by caecal bacteria. Supplementation of the tailored XFCF to the broiler diet resulted in higher


Postoperative ileus (POI) is one of the main complications after colorectal cancer (CRC) surgery, and there is still a lack of effective treatment. At present, the evidence for improvement of POI by invasive acupuncture  is limited. This meta-analysis of randomized controlled trials (RCTs) aims to systematically review and evaluate the effect of IA in improving POI after CRC surgery.This meta-analysis was reported according to PRISMA statement and AMSTAR guidelines. The retrieval time was from the inception to February 2023. The RCTs were screened by searching the databases . Two independent investigators screened and extracted the data, assessed the risk of bias, and performed statistical analysis. The statistical analysis was carried out by RevMan5.3. The PROSPERO International Prospective Register of Systematic Reviews received this research for registration (CRD42023387700).p < 0.00001], shorter time to the first defecation  than the blank/sham stimulation (B/S) group. In the secondary outcome indicators: the IA group had shorter time to the first bowel motion , shorter length of hospital  than the B/S group. In terms of the subgroup analysis: IA associated with enhanced recovery after surgery (ERAS) group had shorter time to the first flauts , shorter time to the first defacation  than ERAS group.Thirteen studies with 795 patients were included. In the primary outcome indicators: the IA group had shorter time to the first flauts [stand mean difference (SMD), −0.57; 95% CI, −0.73 to −0.41, Invasive acupuncture (IA) after CRC surgery, acupuncture or electricacupuncture with a fixed number of times and duration at therapeutic acupoints, can promote the recovery of POI. IA combined with ERAS is better than simple ERAS in improving POI.https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=387700, identifier CRD42023387700. In aAcupuncture is a non-drug, safe and inexpensive treatment. Some existing clinical studies show that acupuncture and related therapies can effectively improve the POI in surgical operations . However2.2.1.The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards were followed while reporting this study. 2.2.The following databases were searched for this meta-analysis: PubMed, Ovid, Embase, Cochrane Library, China National Knowledge Infrastructure, VIP Database, Sinomed Database, and WANFANG Medical. It was reported in accordance with the PRISMA declaration and AMSTAR criteria. The search period spanned from beginning until February 2023. High-quality RCTs were gathered by two independent researchers. According to the search’s approach, full-text search was carried out .2.3.Inclusion criteria include (1) Research type: RCTs on the preventive and therapeutic effects of IA  on POI after CRC surgery; Language is not limited. (2) Research objects: Patients with CRC undergoing IA during perioperative period; Age, gender and nationality are not limited. (3) Intervention measures: The acupuncture group received manual acupuncture (MA) or electroacupuncture (EA) during perioperative period; The blank/sham stimulation group(B/S) did not receive any treatment or stimulated non-meridian points.Exclusion criteria include (1) Non-invasive acupuncture acupoint stimulation therapy, such as transcutaneous acupoint electrical stimulation, acupoint application, auricular point pressing beans, etc. (2) Intervention measures are IA combined with other Chinese medicine treatments, such as oral Chinese medicine decoction. (3) Non-colorectal cancer surgery patients or other intervention methods entered the research literature. (4) Literature with incomplete original text or ending index cannot be obtained. (5) Non-RCT, systematic review or comments, editorials, letters, meetings, and animal trials.2.4.According to the effect of IA on preventing and treating POI, the main outcome indicators are: (1) Time to the first flauts; (2) Time to the first defecation; Secondary outcome indicators: (3) Time to the first bowel motion; and (4) Length of hospital.2.5.According to the eligibility criteria above, two independent investigators preliminary screened through the title and abstract, and then the full text. The author’s name, publishing years, size of the sample, intervention methods, outcome indicators, and other data were extracted from the final screened literature. In case of disagreement, any potential disagreement shall be submitted to the correspondent for arbitration.According to the Cochrane systematic review handbook 5.1 and its suggested risk of bias assessment technique, the caliber of the included studies was assessed. Random sequence generation, allocation concealment, blinding of trial participants and staff, blinding of outcome assessors, inadequate outcome data, selective reporting, and other biases were all examined in the research. The bias assessment’s findings were “low risk,” “high risk,” and “unclear.” Two researchers independently completed the quality evaluation. Conflicts were resolved through mediation by the corresponding author.2.6.α = 0.1, and the degree of heterogeneity was observed based on 2I values  or Mean difference (MD) and its 95% CI are statistically described and the effect quantity is combined. Inter-study heterogeneity was assessed using chi-square test with a test level of ion bias .3.The GRADE evidence profiles and summary of findings table was shown in 3.1.A total of 350 relevant literatures were obtained from the search, 176 duplicates were excluded, 137 were eliminated based on title and abstract, and then 24 were excluded based on full text, resulting in the inclusion of 13 studies that met the study requirements, all in China, including one conducted in Hong Kong. There were 395 patients in the IA group and 400 patients in the B/S group, for a total of 795 patients. There of the included studies explicitly mentioned the use of open surgery, four explicitly mentioned the use of laparoscopic surgery, and the other studies described only part of the type of surgery; four studies used enhanced recovery after surgery (ERAS); nine studies used EA, four studies used MA; one study performed acupuncture 1 day before surgery; and the remaining studies were performed postoperatively. The literature screening process was shown in 3.2.(1) Random sequence generation: four papers used random number table method; two papers used computer software to generate random groupings; two papers used random zone grouping method; one paper used closed envelopes; two papers only mentioned random and did not describe the method of random sequence generation; one paper mentioned minimization; one paper did not mention random. (2) Allocation concealment: three papers used closed envelope allocation concealment; two papers mentioned allocation concealment without specific methods, and the rest did not mention allocation concealment. (3) Blinding of subjects and trial personnel: five papers mentioned blinding of subjects and investigators; one mentioned using single blinding, and the rest did not mention blinding. (4) Blinding of outcome assessors: five papers mentioned blinding of outcome index assessors, and the rest did not describe it. (5) Incomplete outcome data: one study mentioned the reason why some of the outcome indicators did not appear, but the proportion of missing outcome indicators was not enough to have a significant impact, and the rest of the studies had no missing data. (6) Selective reporting: three studies had access to the study protocol and eventually reported the expected outcome indicators, while the rest had incomplete information and it was difficult to determine whether there was a risk of selective reporting of outcomes. (7) Other bias: there was no evidence or information to determine whether there was other serious risk of bias in the included studies.Of the 13 included publications, our quality assessment using the Cochrane Risk of Bias Assessment Tool showed that the overall quality of the total literature was moderate .3.3.3.3.1.p < 0.00001, 2I = 88%) with significant heterogeneity, and sensitivity analysis was performed and three studies were excluded before heterogeneity was detected  with no significant statistical heterogeneity, low sensitivity, and good stability. The fixed-effects model combined with effect size analysis was used, and the results showed that the time to the first flauts was significantly lower in the IA group than in the B/S group , as shown in All studies reported the effect of IA vs. B/S on the time to first flauts after CRC surgery, involving 632 patients, 316 in the IA group and 316 in the B/S group. Heterogeneity was detected  with significant heterogeneity, and sensitivity analysis was performed and one study was excluded before heterogeneity was detected  with no significant statistical heterogeneity, low sensitivity, and good stability, and the fixed-effects model combined with effect size analysis was used, and the results showed that the time to the first defecation was significantly lower in the IA group than in the B/S group , as shown in Eight studies reported the effect of IA vs. B/S on the time to first defecation after CRC surgery: 380 patients were involved, 189 in the IA group and 191 in the B/S group. Heterogeneity was detected  with significant heterogeneity, and sensitivity analysis was performed and two studies were excluded before heterogeneity was detected  with no significant statistical heterogeneity, low sensitivity, and good stability, using fixed-effects model combined with effect size analysis, the results showed that the time to the first bowel motion in the IA group was significantly lower than that of the B/S group , as shown in Nine studies reported the effect of IA vs. B/S on the first bowel motion after CRC surgery: 405 patients were involved, 200 in the IA and 205 in the B/S group. Heterogeneity was detected  with significant heterogeneity, and sensitivity analysis was performed and one study were excluded before heterogeneity was detected  with no significant statistical heterogeneity, low sensitivity, and good stability, using fixed-effects model combined with effect size analysis, and the results showed that length of hospital was significantly lower in the IA group than in the B/S group , as shown in Seven studies reported the effect of IA vs. B/S on the number of days in hospital: 429 patients were involved, 214 in the IA and 215 in the B/S group. Heterogeneity was detected , with no significant statistical heterogeneity, low sensitivity, and good stability, using the fixed-effects model combined with effect size analysis, which showed that the time to the first flauts was significantly lower in the IA combined with ERAS group than in the ERAS group , as shown in Four studies reported the effect of IA combined with ERAS group on the time to the first flauts: 283 patients were involved, 141 in the IA combined with ERAS group and 142 in the ERAS group. Heterogeneity was detected , with no significant statistical heterogeneity, low sensitivity and good stability, using the fixed-effects model combined with effect size analysis, which showed that the time to the first defecation was significantly lower in the IA combined with ERAS group than in the ERAS group , as shown in Four studies reported the effect of IA combined with ERAS group on the time to the first defecation: 283 patients were involved, 141 in the IA combined with ERAS group and 142 in the ERAS group. Heterogeneity was detected  and are used to prevent and treat diseases by stimulating meridians and acupuncture points, and are used in treatment guidelines for cancer pain, post-operative pain, etc. , 25. CurA total of 24 acupoints were involved in the 13 included studies, and the four most frequently used acupoints were as follows: ST36 , ST37 , ST25 , and PC6 . ST36 and ST37 are located in the lower extremities, and ST25 is located in the abdomen. All the three acupoints belong to the stomach meridian. PC6 is located in the upper extremity and belongs to the pericardium meridian. In TCM, the points mentioned above can regulate the activities of abdominal organs, and some experiments suggested that these points can promote gastric or intestinal motility and help with inflammation: Lu et al. used a vagus used a rat model in which the vagus or sympathetic nerve was removed and found that EA stimulation of PC6 could promote vagal electrical activity to increase gastric motility . MurakamWang, Si′s study had significant heterogeneity in two meta-analyses and Meng, Niu’s study had significant heterogeneity in one meta-analysis, respectively. Among all studies, Meng’s study was the only one that reported no significant difference in POI improvement in the IA vs. blank group, which may be the source of heterogeneity. In addition, studies with negative results may have had publication omissions that tilted the final studies included in the analysis toward positive studies, leading to publication bias. The studies by Niu, Si, and Wang either only mentioned randomization or did not mention randomization when describing the randomization method, and their selectivity bias was evaluated as unclear and high risk. The remaining studies were specific in describing their randomization methods and all were at low risk of selective bias when evaluated. The selective bias resulting from the irregular randomization method may explain the heterogeneity of the three studies. In addition, the number of acupuncture points selected, the type of acupuncture points, the frequency and intensity of electroacupuncture, and the standardization of the ERAS protocols varied among the studies included in the analysis, which could be a source of heterogeneity in outcome indicators.Though a subgroup analysis was performed to adjust the bias, the following limitations and shortcomings will reduce the reliability of the results. The SMD was used for time to first flatus and length of hospital stay, which leaves the final combined results without a unit of measurement, so the results for these two should be viewed with caution. In addition, all the studies are from China and there was a lack of high-quality studies reported from different countries, which may lead to selection bias. A web of science-based bibliometric study on electroacupuncture suggested that 65.1% of the electroacupuncture literature was published in China in the last decade, compared to 16.4% in the second place . This in5.This study suggested that IA can improve POI of CRC. The implementations of acupuncture usually start from 1 postoperative day 1 until the ileus ending, 1–2 times a day, about 30 min minutes, and 2–10 acupoints are selected (ST36 is the most important acupoint). In addition, ERAS combined with the above IA treatment was more effective than ERAS alone in preventing POI. This meta-analysis was based on five high-quality RCTs and eight low quality RCTs with blinding defects, and further validation is still needed by including more high quality studies in the future.The original contributions presented in the study are included in the article/XZ and SS helped to conceive, design, analyze the data, conduct the study, and write the manuscript. JL helped to design the study and review the manuscript. XL and DZ designed, conducted, and reviewed the manuscript. YM and AH helped to design, conduct, and decide the final manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.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.


There is a large interindividual variability in cognitive functioning with increasing age due to biological and lifestyle factors. One of the most important lifestyle factors is the level of physical fitness (PF). The link between PF and brain activity is widely accepted but the specificity of cognitive functions affected by physical fitness across the adult lifespan is less understood. The present study aims to clarify whether PF is basically related to cognition and general intelligence in healthy adults, and whether higher levels of PF are associated with better performance in the same or different cognitive functions at different ages.n = 254), and the middleaged to older group . PF was measured by a quotient of maximum power in a bicycle ergometry test PWC-130 divided by body weight (W/kg), which was supported by a self-reported level of PF. Cognitive performance was evaluated by standardized neuropsychological test batteries.A sample of 490 participants (20–70 years) was analyzed to examine this relationship. Later, the sample was split half into the young to middle-aged group  and its subcomponents extracted using structural equation modeling (SEM) in the entire sample. This association was moderated by age, which also moderated some specific cognitive domains such as attention, logical reasoning, and interference processing. After splitting the sample into two age groups, a significant relationship was found between cognitive status, as assessed by the Mini Mental State Examination (MMSE), and PF in both age groups. However, apart from cognitive failures in daily life (CFQ), no other association between PF and specific cognitive functions was found in the YM group. In contrast, several positive associations were observed in the MO group, such as with selective attention, verbal memory, working memory, logical reasoning, and interference processing.Regression models showed a relationship between PF and general intelligence (These findings show that middle-aged to older adults benefit more from PF than younger to middle-aged adults. The results are discussed in terms of the neurobiological mechanisms underlying the cognitive effects of PF across the lifespan.https://clinicaltrials.gov/ct2/show/NCT05155397, identifier NCT05155397. Cognitive functions show a progressive decline beginning in the middle-age . However2 maximum test, i.e., maximal oxygen consumption  can be improved through regular physical activity, which can have different types, facets, and formats . The maisumption , or bicysumption  seem to There are several studies reporting association between PF and cognition in healthy adults in observational or epidemiological settings .Cross-sectional studies and randomized controlled trials reported consistent associations between PF and executive functions, e.g., inhibitory control , Stroop The findings presented above show a general relationship between PF and cognitive functions, but the results are inconsistent. The effects of PF on cognition may be attenuated when meta-analyses consider all age groups. Thus, little is known about possible changes in the relationship between PF and cognition across the adult lifespan, mainly in young to middle-aged adults. Indeed, most studies that showed positive effects or associations between PF and cognition were conducted with middle-aged to older adults (over 50 years), whereas studies with young to middle-aged adults are underrepresented in the literature . This shDortmund Vital Study  are healthy adults aged between 20 and 70 years, with ages distributed almost evenly across the decades. The sample and further details like eligibility criteria, methods, and procedures are described in detail in the study protocol  completed a comprehensive neuropsychological test battery and the bicycle ergometry during the baseline measurement. The study was approved by the IfADo Ethics Committee in October 2015 (A93-1). Data were collected between 2016 and 2020. Currently, the first follow-up data are collected. Thus, longitudinal data will be available in 2026 at the latest.Participants of the protocol . Four huParticipants’ current physical performance level was measured using a bicycle ergometer with a physical work capacity (PWC-130) cycle test. The PWC-130 is a version of the PWC-150 test adapted for older adults . Becauser = 0.284, p < 0.001).Subjective assessment of PF in the last two years was provided using an adapted version of the Lüdenscheid Physical Activity Questionnaire (LPAQ)  measures aspects of focused attention and psychomotor speed (from the Nürnberg Age Inventory (NAI); DS forward, from NAI; In the first part of the task, digit span forward (DS backward) the presented number sequences must be repeated in reverse order. A maximum of eight consecutive numbers can be repeated. Two successive series of numbers with the same length indicate the correct response. This version of the task assesses working memory capacity. The sum of DS forward and backward reflects the general memory capacity  and was used as dependent variable.In the second part of the task, digit span backward (Stroop 1) color words printed in blank ink are to be read as quickly as possible . The second task (Stroop 2) consists of naming the color bars. In the third task (Stroop 3) – the interference condition – the subjects are asked to name a series of the color words in which a color word is printed in colors which did not match the names of the colors . Here, word meaning, and print color are incongruent, with inhibition performance consisting of naming the color rather than reading the word as an automated response. The processing time of the interference condition as well as the difference between Stroop 3 and Stroop 2 (Stroop 3–2) are dependent variables.The color-word interference test , number of reproduced words from the interference list (VLMT I), number of words reproduced from the original list after interference (VLMT 6), number of words reproduced from the original list after 30 min (VLMT 7), loss of words reproduced from the original list after the interference list , delayed free reproduction  and the number of recognized words of the recognition list .Dependent variables were the total number of words from the learning list that the subject recalled in 5 trials  measures switch ability and divided attention. The difference between processing times for part B and A (TMT B-A) measuring components of executive functions was also included as a dependent variable in the analysis.WF Written) without repetition and rule violation was used as the test score. For the analog verbal version of the test (WF Spoken) the experimenter counted the number of spoken words beginning with the letters B, F, L. The total number of meaningful words was used as a dependent variable.The word fluency from LPS  measuresg-factor also known as general intelligence. g-factor is a construct developed in psychometric studies of cognitive abilities and human intelligence. It is based on the observation that the performance of different cognitive tasks is positively correlated, reflecting the fact that an individual’s performance of one type of cognitive task tends to be comparable to that person’s performance of other cognitive tasks  with full information maximum likelihood (FIML), including the variables d2, DST, LPS 3, LPS 7, MWT-B, WF Spoken, WF Written, VLMT Ʃ 1–5, VLMT W-F, DS forward, DS backward, Stroop 2, Stroop 3, TMT-A, TMT-B. Individual regression analyses were calculated with age, sex, age2, age*sex, and age2*sex to extract the residuals. Then, the residuals were z-standardized . The result of the exploratory factor analysis indicated four factors: attention, verbal fluency, verbal memory and working memory, including the following tests: (a) Attention: d2, Stroop 2, Stroop 3, TMT-A, TMT-B, DST, LPS 3, LPS 7, (b) Verbal fluency: WF Spoken, WF Written, MWT-B, (c) Verbal memory: VLMT Ʃ 1–5, VLMT W-F, (d) Working memory: DS forward, DS backward.The outlined cognitive measures have been used to generate the ve tasks . The g-fp < 0.001, root mean square error of approximation (RMSEA) = 0.049, comparative fit index (CFI) = 0.951, standardized root mean square residual (SRMR) = 0.041. g-factor.A second-order CFA  yielded acceptable fit indices: χ2 (82) = 198.230, β, standard error of the mean and the corresponding t-test, as well as the adjusted 2R are reported. All statistical decisions were made at p < 0.05. No adjustment of the alpha level was applied to prevent type II error, i.e., not detecting possibly relevant associations. This is a common and consented strategy in epidemiologic and exploratory studies, where the information obtained by the data prevails over the number of tests  was the continuous variable of the relative power of the PWC-130 test assessing the level of PF, and the dependent variable was the continuous scores of the cognitive test. Missing data were handled with listwise deletion. The data was controlled for normality, linearity, and independence of residuals. Unstandardized and standardized of tests . The reath percentile in younger to middle-aged group , and middle-aged to older group , relative to the median age of 46 years (See Footnote 1). The performance in the cognitive tests and subtests was analyzed in relation to PF level assessed by a quotient of maximum power in a bicycle ergometry test PWC-130 divided by body weight (W/kg). The median PF level in the YM group was 1.60 W/kg, and in the MO-group was 1.57 W/kg.The analysis was conducted in two steps: First, the relationship between PF and cognitive functions was tested in the entire sample of participants (20–70 years old) using the full range of variation in the data. To assess the modulation of the PF – cognition relationship by age, a continuous interaction term Age x PF was included in addition to the predictors Age and PF in the standard regression model. In the second step, the sample was dichotomized based on the 50g-factor: attention, verbal memory, verbal fluency, and working memory. Expectedly, PF was positively related to the reported weekly physical activity (LPAQ). General cognitive status measured by Mini Mental State Examination (MMSE) increased with the level of PF. Furthermore, working memory measured by digit span backward was positively predicted by PF. The same was true for a compound measure including digit span forward and backward . Additionally, loss of words reproduced from the original list after the interference list in the VLMT (VLMT 5–6) was lower in higher level PF individuals. Similarly, loss of words in delayed free reproduction (VLMT 5–7) was lower in higher level PF. No further associations, particularly with specific executive tests such as Stroop, TMT, or word fluency tests were found.As evident from g-factor, verbal fluency, sustained attention (d2), psychomotor speed (DST), logical reasoning (LPS-3), and the Stroop interference test.In addition to the relation between age and PF shown in MMSE). Additionally, PF predicted attentional and memory failures in daily life.MMSE). PF in MO group substantially predicted several cognitive parameters: Attention, Verbal Fluency and Memory factors constituting the g-factor which was also predicted by PF. In addition, PF was positively related to attentional endurance measured by the d2 test, digit span backward, digit span total score, logical reasoning (LPS 3), less loss of words reproduced from the original list after the interference list  and delayed free reproduction . Finally, PF was associated with less time to perform the Stroop interference list and in difference between the interreference list and the control list.The regression models for the MO group are presented in g-factor) and its subcomponents such as visual attention and verbal memory in the entire sample. A subsequent regression model including an interaction term Age x PF showed that this association was moderated by age and that age also moderates the relationship between PF and individual cognitive domains. In a subsequent step, the sample was split in two age groups (YM and OM). In the YM group, higher PF levels predicted only MMSE, and a lower risk for attentional and memory lapses leading to cognitive failures in daily life (CFQ), whereas other associations were far from being significant. In contrast, consistent associations between PF and cognitive function were observed in the MO group. Apart from a clear relationship between PF and MMSE, higher PF levels were associated with improved performance on sustained attention in the attentional endurance test (d2), digit span backward, measuring working memory capacity, reasoning (LPS 3), various aspects of verbal memory , and lower Stroop interference. In addition, the results showed that PF predicted visual attention, verbal fluency and working memory as subdimensions of the g-factor, as well as the g-factor itself. This supports the hypothesis that PF is positively related to general intelligence, at least in middle to older age.The present study aimed to investigate whether physical fitness is related to the same or different cognitive functions in younger to middle-aged and middle-aged to older adults. To this end, an objectively measured level of physical fitness assessed by bicycle ergometry was related to specific cognitive functions using a series of standardized psychometric tests. Regression models showed that PF was positive related to general cognitive performance as a proxy of general intelligence , suggesting that the screening tool is sensitive to detect already small differences in cognitive status independently on age. Indeed, the substantial association between PF and MMSE in the YM group is unexpected as one would expect a ceiling effect. MMSE was used in the present study to monitor changes and potential onset of MCI or other types of dementia over the planned 20-year study period. It includes questions regarding spatial–temporal orientation, attention, arithmetic, comprehension, and working memory reflecting crucial cognitive functions that can be positively affected by physical activity and enhanced brain metabolism or inversely some slight impairments of brain metabolism may be expressed in lower MMSE scores.Overall, no final conclusion can be drawn about the association between PF and specific cognitive functions in the YM group as the relationship was hardly observed in this age group compared to their older counterparts , but theThis age difference seems to be due to neurobiological reasons: The crucial aspect of PF on brain activity and structure is improved oxygen uptake in the blood. Since blood oxygenation is optimal in young and middle-aged people, physical activity does not additionally contribute to the improvement of brain function and cognition. In this case, PF does not have serious consequences for cognitive performance, and both seem to be independent. In other words, healthy young adults with low and high levels of PF did not differ in their cardiovascular capacity  and thus in their cognitive abilities. In contrast, older individuals have a higher risk of cardiovascular decline and lower brain oxygen saturation, which can be significantly improved by PF . Second,Dortmund Vital Study, whereas a longitudinal approach is a more conclusive way. In particular, changes in PF and cognitive functioning can be tracked over decades in the same sample. Therefore, the weak association between PF and cognitive functions in younger to middle-aged group should become stronger as participants age. This would allow to substantiate the results and to draw causal conclusions about the effects of PF on specific cognitive functions across the lifespan when the longitudinal data of the Dortmund Vital Study become available in a few years.The present study is a cross-sectional analysis of data from the Second, we did not consider in the analyses potentially confounding variables such as gender, education, sleep quality, sedentary behavior, mental health, nutrition, immunological status, type of work, social contacts, personality, quality of life, etc. c.f.,  that migDortmund Vital Study.Relevant strengths of the study include the fact that the participants were not informed about the specific questions of the present study and that test selection in this context was blind. Finally, selection bias can be largely excluded, as this study is a sample that does not differ from the general population in critical parameters, as described in the study protocol of the g-factor as a proxy of fluid intelligence and PF which was moderated by age. The findings should be replicated in a longitudinal design to draw causal conclusions about the changes of the PF – cognition relationship across the lifespan.The present study showed a positive relationship between physical fitness and cognitive functioning. However, this benefit was driven by a substantial association between PF and cognition in middle-aged to older adults, whereas only a weak association between PF and cognition was found in younger to middle-aged adults. In the middle-aged to older group, the association was stronger and concerned a variety of cognitive functions, such as attention, working memory and executive functions. Additionally, there was a general relationship between the The study data are available upon reasonable request from the authors [see the Research Data Management section in the study protocol by The studies involving human participants were reviewed and approved by Ethics Committee of IfADo (A93-1). The participants provided their written informed consent to participate in this study.PG designed the study, monitored data collection, analyzed data, and drafted the manuscript. SG designed the study, monitored data collection, and drafted the manuscript. JD and EG assisted in statistical analyses. KG, TK, and JH are responsible for the cardiovascular parameters and the corresponding data analysis. EW is the principal investigator of the study, designed the study, and supervised the organization of the measures. All authors revised and approved the manuscript.Dortmund Vital Study is funded by the institute’s budget. Thus, the study design, collection, management, analysis, interpretation of data, writing of the report, and the decision to submit the report for publication is not influenced or biased by any sponsor.The 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.


Myocardial infarction is one of the main causes of death, and cardiovascular risk factors (CVRFs) are always considered when studying it. However, although it is known that other social and psychological variables, and especially frailty, can increase the risk of infarction, their simultaneous effect has not been extensively studied. This study is based on data from the SHARE project , with a representative sample of 46,498 participants aged 50 or older , of whom 57.4% were females. Statistical analyses included a full structural equation model that predicts 27% of infarction occurrence and evidences the significant effect of well-being, depression, and social connectedness on frailty. Frailty, in turn, explains 15.5% of the variability of CVRFs. This work supports the need to study these physical, social, and mental health factors together to intervene on frailty and, in turn, improve cardiovascular outcomes. Myocardial infarction is caused by decreased or complete cessation of blood flow to a portion of the myocardium, which can be silent and go undetected, or it could be a catastrophic event leading to hemodynamic deterioration and sudden death . CardiovA substantial body of knowledge related to its biological underpinnings has been accumulated. The intricate interplay of genetic predispositions, lipid profiles, inflammatory markers, hemodynamic factors, and the decline of sex hormones have been previously discussed ,6,7,8. CFrailty is a complex age-related clinical state characterized by a decline in the physiological capacity of various organ systems. This results in an increased vulnerability to minor stressors that can increase the risk for developing adverse health-related outcomes such as dependence or death . AlthougRecent research highlights frailty as a potential risk factor for CVD. A recent meta-analysis found a significant link between frailty and prefrailty stages and a higher risk of incident CVD over around 4.4 years, even after accounting for confounders like age, gender, and cardiovascular risk factors . MoreoveIn the context of myocardial infarction, previous studies have highlighted the significance of frailty as a crucial prognostic indicator for adverse outcomes like mortality, bleeding, and rehospitalization, among others, following an acute myocardial infarction ,27,28. HResearch emphasizes the impact of psychosocial factors on physical health ,35,36. IHence, the main objective of this research was to investigate the relationship between frailty, psychosocial factors, and myocardial infarction, establishing a mediational biopsychosocial model in which several background variables affect psychosocial conditions which may exacerbate frailty conditions and cardiovascular risks; these background variables, in turn, increase the likelihood of suffering a heart attack. This is a predictive model; no assumption of causal effects is made, although the model tests the compatibility (fit) of the theoretical process with the data. Also, we aim to study the occurrence of myocardial infarction from a holistic and psychosocial approach and to address the relationship between frailty and cardiovascular risk factors, thereby evaluating frailty through a psychosocial lens. This will improve the existing information since the simultaneous effect all these variables on cardiovascular risk factors and myocardial infarction has not been extensively studied.The data for this study came from the 8th wave of the Survey of Health, Ageing and Retirement in Europe (SHARE). SHARE is a longitudinal study that started in 2004 and includes an update of the data every 2 years. For this study, we employed Wave 8, the most recent. For Wave 8, the collection of the data took place largely synchronously across countries between the end of October and the beginning of November 2019. SHARE has a probability-based method aimed at populations aged 50 or more who have their regular domicile in some of the countries included in the SHARE project (26 European countries and Israel). SHARE’s sampling protocol consists of 4 steps. First, each participating country defines a sampling frame and sampling procedure. Next, sample information is collected and processed in each country, resulting in a preliminary sample file. These files are then reviewed and approved by international coordinators at SHARE headquarters. Finally, the sample files are entered into the computer system and merged with the address data . The SHAThe Survey of Health, Ageing and Retirement in Europe (SHARE) project procedures conform to international ethical standards. SHARE is guided by international research ethics principles such as the Respect Code of Practice for Socio-Economic Research, and Wave 8 was approved by the ethics council of the Max Planck Society in Munich . In addition, SHARE country implementations were reviewed and approved by the respective ethics committees or institutional review boards. Participation in SHARE was voluntary, anonymous, and informed. The collection of SHARE data and their use are subject to the European General Data Protection Regulation. SHARE data can only be used for scientific purposes and are protected by the German Federal Statistics Act and the German Federal Data Protection Law.As exclusion criteria, we only included in our sample people aged 50 years or more, since SHARE also includes the current partners of the participants living in the same household, regardless of their age. In addition, SHARE also excludes people who do not speak the language of the country or who were incarcerated, hospitalized, or out of the country during the sample period.The present study involved 46,498 participants aged between 50 and 103 years old , of whom 19,826 (42.6%) were males and 26,672 (57.4%) were males. Many of them were either married (65.4%), widowed (18.8%), or divorced (8.1%), while the rest (7.7%) presented another marital status. It is important to bear in mind the rationale behind this specific sample size. The SHARE survey is designed to produce representative samples at each wave and for each participant country. Therefore, to achieve this objective, each country uses its own sampling scheme to obtain a representative sample and, accordingly, produces valid and generalizable conclusions for all participating countries. Frailty assessment was performed by the SHARE-Frailty Index (SHARE-FI) ,56, baseMyocardial infarction was measured with the question “Have you ever had a heart attack?” (yes/no). Additionally, several cardiovascular risk factors were assessed with being diagnosed (yes/no) with high blood pressure or hypertension, high cholesterol, and diabetes or high blood sugar.Depressive symptoms were measured with several indicators of the EURO-D scale . These wLoneliness was assessed with the UCLA scale , which cQuality of life was measured with the CASP-12 . It inclAs a measure of social isolation, we used the Social Connectedness scale. It combines the following aspects: network size, proximity , frequency of contact (number of cited persons with weekly or more contact), emotional closeness , and diversity (the different types of relationships in the network), with lower values reflecting higher social isolation. The transformed values of the scale ranged from 0 to 4. More details about how to generate this scale could be consulted at . This scFurthermore, several socioeconomic control variables were considered to minimize confounding effects including age, gender ); and economic status, measured with the question “Thinking of your household’s total monthly income, would you say that your household is able to make ends meet?” These questions were answered in a 4-point Likert scale ranging from 1 (with great difficulty) to 4 (easily).For the purposes of this study, a full structural equation model (SEM) was estimated using MPlus 8.7  to test 2(85) = 3617.87, p < 0.001; RMSEA = 0.030, 90% CI ; CFI = 0.933; SRMR = 0.044. The RMSEA and SRMR are well below the 0.08 cut-off point, while the CFI is over 0.90 and very close to 0.95.The full structural model is presented in p < 0.01) and depression , while the effect of social connectedness was significant but low , and the effect of loneliness was not statistically significant . Frailty had a moderate effect on cardiovascular risk factors ; this explained 15.5% of the variability of cardiovascular risk factors. In the end, cardiovascular risk factors increased the likelihood of having a myocardial infarction (β = 0.52). A total of 27.2% of the variability of myocardial infarction was associated with the cardiovascular risk factors.The standardized parameter estimates are presented in p < 0.01). The psychosocial factors were also correlated, however, for ease of understanding, the associations are not shown in p < 0.01); loneliness with well-being ; and depression with well-being .Regarding the correlations among the antecedents, only age and gender were significantly related to each other, but with a very low value , modification of the original scale may be altering the results. However, removing the fatigue and lack of appetite items in the EURO-D was necessary to avoid overlap with the frailty measure that also includes them. Future studies that use data where the measures do not overlap could investigate whether the results are replicated. Finally, there is a need to consider the non-inclusion of other variables that can have potential influence on this context due to the omission of its measurement in the SHARE protocol, for example, spirituality, which seems to play a key role in the adaptation of patients with cardiovascular risk and could enhance psychological health and reduce psychological disorders . Also, fIn conclusion, studying the biopsychosocial model predicting myocardial infarction is crucial for advancing our knowledge of this complex condition and developing effective strategies for prevention, early detection, and patient care. A holistic approach focused on myocardial infarction should consider the interconnectedness of psychological well-being, depression, social isolation, and frailty, leading to more comprehensive and personalized approaches to managing cardiovascular health. Strategies related to physical activity and physical and mental lifestyles could be strategies that would have an impact, but future studies in this line are needed to assess whether interventions in mental health and frailty also improve cardiovascular health. Collaboration among healthcare professionals involves sharing information, jointly formulating treatment plans, mutual education, holding team meetings, and co-monitoring patients. This approach enables a comprehensive, personalized, and effective strategy for addressing patients’ mental, physical, and cardiovascular health.Public health policies should be oriented towards community health that takes care of mental health and socialization. In addition, particularly for older people, special action regarding frailty is needed. These carefully designed actions could aim to promote cardiovascular health and prevent myocardial infarction. The evolving landscape of precision medicine regarding biomarkers of inflammation and study of the underlying mechanisms, along with community-focused initiatives, presents transformative opportunities for personalized older adult care and public health strategies.