Self-concept (AF-5), Isolation (UCLA), Attitude towards Physical Education (CAEF), and Family Functioning (APGAR) were analyzed. (3) Results: Good fit was obtained for all evaluation indices included in the structural equation model, which was significantly adjusted (χ Lack of physical activity (PA) in the 21st century, both in children and in adults, has become a topic of interest worldwide in developed countries. The increase in sedentary habits as a consequence of technological advances has provoked a rise in physical inactivity within the population. This has negative consequences for physical health and mental wellbeing ), and mePA during infancy and adolescence is associated with physical health, and psychological and social benefits over both the medium and long term . DespitePhysical education (PE) in the educational setting provides a tool for these learnings ,12. AmonIn adolescents, engaging in physical and sporting activity contributes to the promotion of a positive personality and emotional empathy, which improves interpersonal relationships between participants ,15. LeveRecent studies have added a new risk factor for mental health and anti-social conduct in adolescents. This is the rise in screen time , which tThe school setting and, specifically, school physical activity, provides an ideal setting for the prevention of inactivity and promotion of PA. Nonetheless, schools by themselves cannot cover the daily recommendations that will bring an end to the health problems generated by inactivity; however, they can influence the acquisition of healthy habits ,3. TogetDue to the scarcity of studies that approach self-concept, loneliness, physical activity and family, the following study states the objectives of defining and contrasting an explanatory model of self-concept, isolation, physical activity, and family. In addition, it will analyze the existing associations between variables through multi-group structural equation analysis. The present research is descriptive and cross-sectional in nature. A total of 2388 adolescents participated who reported being aged between 11 and 17 years . The sample included 1036 (43.39%) males and 1352 (56.61%) females. All participants were enrolled on the third year of primary school, or the 1st or 2nd year of compulsory secondary education (CSE) in Andalusia. Sample selection took place through a convenience sampling strategy, attending to the criteria of being enrolled on the third year of primary education, or the 1st or 2nd year of CSE. All participants had informed consent from their parents or legal guardians and did not suffer from any type of pathology that impeded their ability to participate in the research. This formed the inclusion and exclusion criteria. The sample was obtained from eight Spanish cities, with participation being requested from all centers who voluntarily agreed to participate. It is necessary to indicate that 281 questionnaires were excluded after it was detected that they had been incorrectly completed or had missing data. Ad hoc questionnaire: For the selection of descriptive variables, various aspects were considered which could establish differences at some stage of the research process. These included sex, school year, population, engagement in PA outside of school hours, and the place in which individuals engage in PA. Self-concept Questionnaire: Data is collected through the original questionnaire “Autoconcepto Forma-5 [Self-concept Form] (AF-5)” of García and Musitu . It measIn the study conducted by García and Musitu  reliabilLoneliness Scale (UCLA): This scale is based on the original created by Russell, Peplau, and Cutrona , and theQuestionnaire on attitudes towards physical education (CAEF): The original questionnaire of Moreno, Rodríguez, and Gutiérrez  will be Family Functioning Scale (APGAR): This test is extracted from the original version “Family APGAR” developed by Smilkstein, Ashworth, and Montano  and adapEducational centers were contacted from the University of Granada in order to inform them about the nature of the study, with the centers that voluntarily agreed to participate then being selected to participate in the research. Informed consent packs were given out to students at the center, requesting collaboration from their parents or legal guardians. Next, questionnaires were administered to the group during lesson time. Anonymity of participants was guaranteed, clarifying that collected data would be used purely for scientific purposes. Researchers were present during data collection in order to guarantee the correct development of processes and to resolve any doubts. The present research study received approval from the Ethics Committee of the University of Granada with code641/CEIH/2018.® in its version 23.0  for Windows was used for the analysis of basic descriptive data. The program IBM AMOS® 23 ) was employed with the aim of analyzing the existing relationships between the constructs included in the structural model. After developing the theoretical model, a path analysis was carried out considering matrix associations through a multi-group analysis which grouped participants as a function of whether or not they regularly participated in physical activity. Finally, a path model was constructed which constituted nine factors . Likewise, parameter estimation was carried out through the maximum likelihood method (ML) as this method is coherent, unbiased, and invariant to scale type. Error terms were established for all of the endogenous variables. Model fit was examined with the aim of verifying compatibility of the model to the empirical data obtained. Analysis of the reliability of model fit was performed according to goodness of fit criteria established by Marsh , p. 785.With regards to the descriptive data referred to in With regards to attitudes towards physical education, the most highly rated dimension is agreement with EF management (M = 3.01). All of the other dimensions were found to have values lower than 3, with the lowest mean pertaining to usefulness of PE (M = 2.06).With regards to self-concept, the academic dimension received the highest rating (M = 3.61), followed by the physical (M = 3.54), social (M = 3.48) and family (M = 3.39) dimensions, and finally, emotional self-concept (M = 3.02). In reference to the variable describing isolation, the highest score was achieved for the dimension describing subjective evaluations of the social network (M = 2.94), followed by general isolation (M = 2.00), and finally, emotional isolation (M = 1.95).p = 0.000). These are reflected in higher ratings of the subject and of the teacher on behalf of students who have highly functioning families (M = 2.76), relative to those who have moderately dysfunctional families (M = 2.59). The dimension describing difficulty of PE (p = 0.010) is more highly scored by students who report moderate family dysfunction (M = 2.49) and scored less highly by those with families with severe dysfunction (M = 2.32). With respect to the usefulness of PE, this dimension is more highly scored by students with families with moderate dysfunction (M = 2.21), in comparison to those with highly functional families (M = 2.02). Those who proportion higher scores to the dimension of empathy with the teacher and subject (M = 2.45), and agreement with subject management (M = 3.03) also reported good family functioning. Further, for preference for PE and sport (p = 0.005), the highest score was also obtained for those who have high family functioning (M = 2.33) relative to serious dysfunction (M = 2.10).p = 0.000 ***) reflects higher scores for those who have a highly functional family (M = 3.69), with scores being lower when family dysfunction is serious (M = 3.06). Social self-concept reaches higher scores amongst those with highly functioning families (M = 3.54) relative to those who present serious (M = 3.10) or moderate dysfunction (M = 3.26). However, in the case of emotional self-concept the highest scores are obtained for those from families with moderate dysfunction (M = 3.12) and the lowest scores relate to those with serious dysfunction (M = 2.99). Finally, it must be highlighted that both family self-concept (M = 3.45) and physical self-concept (M = 3.62) achieve their highest mean values in students from highly functional families, this value being lowest in students from families with serious dysfunction (M < 3).p = 0.000 ***) in all of its dimensions , empathy towards the teacher and subject r = 0.229 **), agreement with subject management (r = 0.210 **) and preference for PE and sport (r = 0.236 **).The positive correlation is weakest in relation to the dimensions describing the difficulty presented by PE (r = 0.153 **) and PE as sport (r = 0.060 **), whilst a low negative correlation is seen with usefulness of EF(r = −0.046 *).r = −0.170 **). In contrast, when this emotional isolation is greater, perceived difficulty of this subject is also higher (r = 0.066 **). In the same way, a medium correlation is produced between the dimension of isolation and usefulness of PE (r = 0.323 **), however, when this emotional isolation is greater, agreement with subject management decreases (r = −0.191 **). Attending to the dimension of emotional isolation in relation to attitudes towards Physical Education, it is observed that when emotional isolation is higher, ratings of the subject and the teacher imparting it are lower (r = 0.107 **), and with PE as sport (r = 0.085 **).In addition, a slight agreement is maintained regarding preference for PE and sport , although we must bear in mind that this statistic, as an index, has no upper limit. Further, problems arise as it cannot be interpreted in a standardized way and is sensitive to sample size. In addressing this, other indices of standardized fit are employed which are less sensitive to sample size. The comparative fit index (CFI) showed a value of 0.913, this being acceptable. The normalized fit index (NFI) specified a value of 0.917 and the incremental fit index (IFI) was 0.906, both being acceptable. Analysis of the root mean square error of approximation (RMSEA) obtained an acceptable value of 0.072.Good fit was obtained for all evaluation indices of the structural equation model. Chi-squared analysis revealed a significant p < 0.001. These were positive and direct in all cases except for the association between COA and UEF (r = −0.110). r = 0.127; p < 0.001), COA , and EPA , whilst the association between VPEF and UEF was negative . On the other hand, if the associations between PEFD and the exogenous variables are considered, statistically significant relationships are shown with DEF , UEF , and EPA . No statistically significant associations were obtained between COA and PEFD (p = 0.544). Approaching the second level, it can be observed that VPEF is positively associated with DEF , and between VPEF and physical self-concept , whilst this variable was negatively related with emotional isolation . Along similar lines, PEFD was directly associated with physical self-concept  and emotional isolation , although in this case an association was not found with family functioning (p = 0.544). Following this, the endogenous variables in the second level of the model are related with emotional isolation, family functioning, and physical self-concept. In the first instance, a positive relationship can be observed between VPEF and family functioning , whilst this association was negative and indirect with emotional isolation . Finally, it is highlighted that family functioning maintains a positive and direct relationship with physical self-concept (The present study, conducted with students in the 3rd year of primary education or the 1st year of CSE from the eight provinces of Andalusia, pursues as its principal objectives the analysis of existing relationships between the attitudes towards physical education of schoolchildren and their physical self-concept, level of emotional isolation and family functioning. These premises are of great interest when it comes to developing and adapting concrete teaching methods and strategies, which favor the development of programs that incentivize students’ participation in AF and assume a positive role in the psychosocial development of students . Analyzing the family context, it is deduced that eight out of every ten students belong to a family with good family functioning, with very few students coming from families with severe dysfunction. This type of family functioning will facilitate engagement in PA , althougIn reference to attitudes towards PE, the most highly rated dimension is agreement with subject management relating to PE , in contAnother significant fact uncovered by the study is that self-concept, in all of its dimensions, achieved a higher level amongst individuals who engaged in PA. This confirms the positive effects of PA at a physical and mental level, on social relations, and on academic performance , this beWith regards to family relations and engagement in PA, data from both the present study and other research studies indicate that the level of family functioning does not have a significant relationship with engagement in PA and/or sport . NeverthGood family functioning is also related with a high academic and social self-concept , in contWith respect to the variables of isolation according to family functioning, we found that emotional isolation predominates above all within those students who belong to severely dysfunctional families. High scores are obtained within functional families for the subjective evaluation of the social network, with this instead being low within those who live within a seriously dysfunctional family. In the same way, students who present greater general isolation are those who belong to seriously dysfunctional families. Research conducted by other authors collaborate these results , whilst Analysis of bivariate correlations performed with the variables of physical self-concept, emotional isolation and attitude towards PE, demonstrated that students who have a good physical self-concept present scant levels of isolation at a general or emotional level. These data are in agreement with data produced by other studies and reflect that the lower the level of isolation in students, the greater their physical self-concept and security of the social relationships they establish with their social environment. All of this facilitates greater engagement in PA . In the Attending to the dimensions of isolation in relation to those pertaining to attitudes towards physical education, it is observed that when emotional isolation increases in students, the rating that they attribute to the subject and teacher is lower ,78, and With regards to the dimensions pertaining to attitude towards PE, students who rate the subject as more difficult also tend to perceive it as being more useful . Those wFrom the structural equations carried out it can be seen that an increase in the perceived difficulty of physical education goes hand in hand with an increase in reports of its usefulness, coherence in the way it is managed and empathy towards the teacher who imparts it . It can This study presents some limitations. The first of these is due to the fact that it deals with a cross-sectional study and so is not able to establish causal relationships. A second limitation is that this study does not enable generalization of the data obtained to other populations. This being said, the explanatory model developed does enable a better understanding of the associations between variables. Further, we consider the sample to be broad and representative of the targeted population. For this reason, the present research permits development of a future line of research, providing a base from which we can evaluate, compare, and replicate the study with other groups of students. Findings will also be used for the planning and design of future research in a classroom setting.The main conclusions of the present study confirm that the physical dimension of self-concept is high in students who maintain low percentages in all of the dimensions of isolation. Those families in which functionality is good engage regularly in AF. At the same time, it is also reflected that students who rate the subject and teacher more highly, whilst also demonstrating empathy towards both, tend to be those who present relatively high family functioning. The same can be seen to occur in reference to subject management, and preference for PE and sport. With regards to the theoretical model of self-concept, isolation, family functioning and attitude towards PE, it presented good fit. The data indicate that engagement in PA is not determined by the other variables measured in the model. Results also suggest that family functioning intervenes to a large extent on self-concept and its dimensions, in addition to the isolation demonstrated by students. It is concluded that attitudes towards PA are positive when levels of isolation are low and when an adequate self-concept is present. All of this is typically generated in students who, in the majority of cases, come from families with high levels of functioning.


Elaboration and internal validation of the Quality of Life in CardiovascularSurgery (QLCS) questionnaire adapted to the reality of Braziliancardiovascular surgery.Cross-sectional pilot study of a prospective cohort included in theDocumentation and Surgical Registry Center (CEDREC) for internal validationof the QLCS questionnaire. Four hundred forty-five patients submitted tocardiovascular surgery and who answered a QLCS questionnaire 30 days afterhospital discharge were included. It was applied via telephone. To verifythe questions' internal consistency, Cronbach's alpha was used. The totalQLCS score was calculated as the sum of 5 questions, ranging from 5 to 25points. Mann-U-Whitney test was used to relate the symptoms with the qualityof life (QoL). Level of significance was 5%.P=0.002), chest pain(P<0.001), shortness of breath(P<0.001), and return to physical activity(P<0.001) were statistically significant.After 30 days of surgery, about 95% of the patients had already returned tonormal routine and 19% of them were already performing physical activity. Inthe evaluation of the QLCS's internal consistency, a Cronbach's alpha of0.74 was found, suggesting that this was probably an adequate questionnaireto evaluate QoL in this population. In the comparison between the presenceand absence of symptoms and the median of QoL, the presence of pain at theincision (The process of elaboration and validation of questionnaires includes a seriesof steps. The QLCS questionnaire is probably an adequate tool for theevaluation of QoL in the postoperative patient of cardiovascular surgery, inthis first stage of internal validation. It is a broad ranging concept affectedin a complex way by the person's physical health, psychological state, personalbeliefs, social relationships, and his/her relationship to salient features ofhis/her environment. Although the most important indicator of healthstatus is the clinical outcome, QoL and patient satisfaction are key indicators forthe adequate understanding and treatment of pathologies. The QoL related to cardiovascular disease and theimpact of the treatment on each patient's life have been researched, contributing tothe clinical decision-making process, as well as improving patient care, aiming at amore integral approach to health .The impact of any event or health status on a person's QoL depends to a large extenton his/her personal projects, desires, and history, andits short version 12 (SF-12), orThe World Health Organization Quality of Life Assessment (WHOQOL-100), and its summary version(WHOQOL-BREF), orspecific questionnaires, developed for a particular pathology, such as the KansasCity Cardiomyopathy Questionnaire (KCCQ) for heart failure.To evaluate QoL, you can choose to use generic questionnaires, which do not specifythe disease itself, such as the Medical Outcomes Study 36-Item Short-Form HealthSurvey (MOS SF-36 or SF-36). Another meta-analysis published in 2013 selected 15 articles on QoL inthe postoperative period of cardiovascular surgery, and most of the analyzed studiesshowed a significant improvement in QoL in the evaluation instruments; the SF-36 wasthe most used questionnaire in 43% of the studies.Improving QoL is one of the main objectives for cardiovascular surgery, so a reviewon this subject was published in 2011, which included 29 articles published betweenJanuary 2004 and December 2010, but only nine studies presented data on pre andpostoperative QoL, and that was a limitationTherefore, QoL measurement of the postoperative period of cardiovascular surgery iscrucial to evaluate the patients' treatment, and the creation and validation of acurrent questionnaire which is more adequate for these patients' reality is offundamental importance. The objectives of this study were to create, based on anadaptation of the main existing QoL questionnaires, and to validate a current andadequate questionnaire, easy to apply, which can be performed via telephone, for thereality of the postoperative period of cardiovascular surgery in Brazil.This is a pilot study for initial validation of the Quality of Life in CardiovascularSurgery (QLCS) questionnaire, using as sample the population included in theDocumentation and Surgical Registry Center (CEDREC) of a hospital specialized inCardiology. CEDREC is a computerized database specifically for patients undergoingcardiovascular surgery in our hospital. Patients who were operated on and acceptedto participate in the database were included and monitored prospectively.This cross-sectional study taken from a prospective cohort included patients whounderwent cardiovascular surgery, from July 2016 until October 2017, who accepted toparticipate in CEDREC, and who properly answered a QoL questionnaire (the QLCS)after thirty days of hospital discharge. Only patients under 18 years old wereexcluded. All the other patients were included in the sample.The questionnaire was created by a group of medical specialists, based on the mainexisting QoL questionnaires , and adapted tothe current reality of Brazilian medicine. It is a simple and fast questionnaire,easy to perform, and feasible to be applied via telephone. The questionnaire used byCEDREC had 21 questions , being f. Internal consistency is commonly estimated using thealpha coefficient, also known as Cronbach's alpha.After the creation of any questionnaire, it must go through an initial validationstep with a pilot sample. In this pilot test, the questionnaire's final version isadministered to a large representative sample of respondents for whom thequestionnaire is intended. At this point, it is important to evaluate thequestionnaire's reliability. This is accomplished by assessing the internalconsistency and testing-retesting reliability. Internal consistency reflects theextent to which the questionnaire items are intercorrelated or whether they areconsistent in measurement of the same constructFor statistical analysis, Cronbach's alpha was used to verify the questionnaire'sinternal consistency and to validate the questionnaire. Assuming a standarddeviation of approximately 6 units and a detectable difference of 3 points, with 5%of alpha error and 95% of power, it would be required a total of 63 cases. Thequantitative variables were described by mean and standard deviation in the presenceof normal distribution, or median and interquartile range in the presence ofasymmetric distribution. The qualitative variables will be presented by absolutefrequencies (number of patients) and relative frequencies (percentages). TheMann-U-Whitney test was used to relate the symptoms  with theQoL (quantitative variable). Level of significance was set at 5%.Four hundred forty-five patients submitted to cardiovascular surgery, from July 2016to October 2017, and who had a QoL questionnaire answered 30 days after hospitaldischarge were included. The mean age of the sample was 60.20 years (±13.29),of which 58.43% were males and 41.57% were females.The initial characteristics of the sample are summarized in About the surgeries performed, the largest part consisted of valve surgeries, with atotal of 198 (44%) cases, followed by coronary artery bypass grafting (CABG) with164 (37%) cases, aortic surgeries with 39 (8.7%) cases, and congenital anomalycorrection surgery with 19 (4.2%) cases. The remainder comprised of 6 (1.3%) casesof heart transplant surgeries, 7 (1.5%) cases of pericardiectomies, 4 (0.9%) casesof myectomies, 3 (0.6%) cases of tumor removals, and 9 (2%) cases of reshaping andcleaning. It is noteworthy that in some cases more than one type was performed atthe same surgery time .After 30 days of surgery, 35% of the patients had incision pain, 17% wound infection,23% chest pain, 22% lack of air, 1% fainting, 5% palpitation, and 43% othersymptoms. However, 95% of the patients had already returned to normal routine and19% were already performing physical activity.In the evaluation of the QLCS's internal consistency, a Cronbach's alpha of 0.74 wasfound, proving this to be a questionnaire with adequate internal consistency. Thismeans that, in the evaluation of the degree of variation of these questions, it wasdemonstrated that the items are appropriately related to each other.P=0.002). The same was also observed for patients with chestpain, with a median of 18.50 , when comparing with those withoutchest pain, with a median of 20.0 ; significant difference(P<0.001). The presence of shortness of breath also affectedthe QLCS score, with a median of 18.0 , compared to its absence,with a median of 21.0 ; (P<0.001). So, in theevaluation of symptoms and QLCS scores, the presence of pain at incision(P=0.002), chest pain (P<0.001), andshortness of breath (P<0.001) negatively affected QoL. On theother hand, other symptoms (P=0.075), fainting(P=0.50), palpitations P=0.52), and infection(P=0.48) weren't related to QoL. The return to physicalactivity was also significant, the group that performed physical activity had ahigher median in the QLCS questionnaire  than the sedentarygroup , improving QoL (P<0.001). Whencomparing the median of the group that returned to the routine  with the median of those who hadn't returned , itwasn't significant (P=0.85). The comparison between the presenceand absence of symptoms and the median obtained in the QLCS questionnaire is shownin box-and-whisker plots in When comparing between patients with and without incision pain after 30 days ofsurgery, we observed that patients with this symptom presented a median of 19.0 inthe QLCS questionnaire, with lower quartile (LQ) of 16.0 and upper quartile (UQ) of22.0, while those without incision pain presented a median of 20.0 .When using the Mann-U-Whitney test, this observed reduction was significant, whereas, when it is 1, it reflects perfect internal consistency. In practice, Cronbach's alpha of at least 0.70 has been suggested toindicate adequate internal consistency. A low Cronbach's alpha value may be due to poorinter-relatedness between items; as such, items with low correlations with thequestionnaire total score should be discarded or revised. On the other hand, analpha value that is too high (more than 0.90) suggests that some questionnaire itemsmay be redundant, and investigators may consider removing items that are essentiallyasking the same thing in multiple ways.The present study represents an important advance to facilitate the assessment of QoLin postoperative cardiovascular surgery patients in Brazil and other countries. TheQLCS is a new questionnaire with an internal consistency of 0.74 ,being probably a good questionnaire to evaluate QoL in this population in a fast,easy, and objective way. Thus, it is possible to measure QoL in a practical way,even in countries where there aren't many resources and incentives for research,making possible a greater diffusion of QoL assessment by society, which contributesto the universality of knowledge. When Cronbach's is 0, it indicates no internalconsistency . The same result ofimprovement in QoL with CABG was also demonstrated by Dal Boni et al. and Gois et al.. In another study, Takiuti etal. compared clinicaltreatment, percutaneous coronary intervention, and CABG in 483 patients withcoronary disease; there was an improvement in QoL in all domains and in the threetherapeutic options, but the surgery offered better results after four years offollow-up.The QoL in the postoperative period of cardiovascular surgery has been much studiedin the international literature, which justifies even more the creation of thisquestionnaire. When referring to CABG, Aydin et al.In a Brazilian prospective cohort study with 44 elderly patients between 60 and 80years of age, of both sexes, diagnosed with coronary artery disease, and undergoingCABG, from June 2010 to June 2011, a significant increase was observed in SF-36scores between the pre and postoperative periods (three and six months) for thedomains: functional capacity, pain, general health, vitality, and emotionalaspect. found that in thepostoperative period of surgery for valvulopathy correction, the improvement of thegradient resulted in an improvement in the QoL. Another study, conducted by Ferreiraet al., showed that patientswith cardiovascular valvar disease have a better QoL three to six months aftersurgery, compared to those awaiting surgical intervention.Albert et al., whichanalyzed 111 patients in pre and postoperative periods and the health status of thepatients one year after discharge, showed a statistically significant improvement,and the group of high-risk patients had the best benefit (EuroSCORE 6). Koch etal., in a study of5581 patients, demonstrated that a lower socioeconomic status of the patient isassociated with a lower QoL, while Noyez et al. concluded that QoL in cardiovascular surgery isoverestimated, certainly for the elderly and those patients with preoperative lowQoL.Some studies addressed cardiovascular surgeries as a whole; a study published in 2008by Colak et al.Several authors, as described above, have already performed studies about the QoLassessment in the postoperative period of cardiovascular surgery, but a Brazilianstudy with a questionnaire created in Brazil, adapted to our reality, hasn't beenconducted yet. In addition, this questionnaire was created to facilitate theacquisition of data, not only via personal contact, but also via telephone. Byfacilitating the way to obtain information about QoL, more people may be interestedin using this parameter in the assessment of individuals' health, especially in theBrazilian context, where research isn't valued and resources are scarce.The present study has some limitations. The first, it is a cross-sectional analysisof a cohort. This was done only for the QLCS questionnaire's initial validation, thework with longitudinal analysis of the patients is already being elaborated and thetest-retest reliability will be made. The second, it is an unicentric study. On theother hand, once validated, we hope that many other scientific centers can takeadvantage of this questionnaire. The third refers to the limited number of patients,however, because it is a prospective study using the CEDREC registry, which began inJune 2016, it was not possible to recruit a larger sample. Still, it was enough toperform the internal validation of the questionnaire, since only 63 patients wererequired. A fourth limitation is the possible bias associated with any questionnaireconducted via telephone. But it was created to be simpler and more objective toreduce this bias, and all phone calls were made by the same researcher. A fifthlimitation could be the fact that we haven't chosen to create stricter exclusioncriteria, excluding patients with lung diseases or neurodegenerative diseases. TheQoL of these individuals would be invariably affected by these other conditions, andthe insertion of these patients could provide a bias for the misunderstanding ofadequately representing the impact of cardiovascular surgery on QoL. However, thiscould be done in a future research.Finally, this is only the first validation step of this questionnaire, which presentsadequate internal consistency. Subsequent steps will be performed to ensure theadequate use in the clinical practice of postoperative cardiovascular surgerypatients.The QLCS questionnaire is probably a good tool for the evaluation of QoL in thepostoperative period of cardiovascular surgery, with adequate internal consistency,besides being an easy-to-apply instrument, which can even be done via telephone. Thepresence of chest pain, incision pain, and shortness of breath seems to be relatedto QoL, making it worse, while return to physical activity seems to improve QoL.


Brassica vegetables are a significant component of the human diet and their popularity is systematically increasing. The interest in plants from this group is growing because of numerous reports focused on their pro-health properties. However, some consumers are not enthusiastic about these vegetables because of their specific bitter taste and sharp, sulfurous aroma. In this study, the volatile composition of 15 Brassica cultivars , both raw and cooked, was analyzed by solid phase microextraction and comprehensive two-dimensional gas chromatography with time of flight mass spectrometry (SPME-GC×GC-ToFMS). Differences were found between the analyzed vegetables, as well as different cultivars of the same vegetable. Moreover, the influence of cooking on the composition of volatile compounds was evaluated. All the vegetables were frozen before analyses, which is why the impact of this process on the volatile organic compounds (VOCs) was included. The most abundant groups of compounds were sulfur components (including bioactive isothiocyanates), nitriles, aldehydes and alcohols. Cooking in general caused a decrease in the abundance of main volatiles. However, the amount of bioactive isothiocyanates increased in most cultivars after cooking. The effect of freezing on the volatile fraction was presented based on the Brussels sprout cultivars. Most of the changes were closely related to the activity of the lipoxygenase (LOX) pathway enzymes. These are characterized by a marked reduction in alcohol contents and an increment in aldehyde contents. Moreover, important changes were noted in the concentrations of bioactive components, e.g., isothiocyanates. This research included a large set of samples consisting of many cultivars of each analyzed vegetable, which is why it provides a considerable body of general information concerning volatiles in Brassica vegetables. Brassica vegetables due to their characteristic flavor, which is genetically related [Brassica vegetables are sold as frozen florets or cubes, often found as ingredients in vegetable mixes, thus ensuring their supply year-round in a convenient form. Raw vegetables are rich in aromatic compounds, which usually are produced as a result of enzymatic reactions. Their storage in the frozen form can significantly alter biochemical reactions occurring in vegetables, thus influencing flavor also after cooking. However, there are practically no studies on the comparison of volatile compound profiles of frozen, fresh and cooked Brassica vegetables. In the case of the analyzed plants, the specific interest focused on bioactive molecules is particularly high and they have been extensively studied recently, mainly due to the presence of isothiocyanates. These are the products of enzymatic hydrolysis of glucosinolates and their beneficial influence on human health has been widely examined [Broccoli, Brussels sprouts, cauliflower and kohlrabi are members of the Brassicaceae family, which is widely cultivated throughout the world. Some consumers reject  related . The con related , while aexamined ,5,6,7,8.Brassica volatiles have been collected using simultaneous distillation-extraction (SDE) [A wide array of analytical techniques have been used to analyze volatile compounds in plants, including fruit and vegetables. on (SDE) ,10, sorbon (SDE) , solventon (SDE) , as wellon (SDE) ,14. The on (SDE) ,16.Brassica vegetables. Thanks to the results obtained for 15 different cultivars of kohlrabi, broccoli, cauliflower and Brussels sprouts, generalized conclusions may be drawn in terms of changes in volatile compounds in the main representatives of Brassica vegetables. The volatile compounds were analyzed using solid phase microextraction and comprehensive two-dimensional gas chromatography with time of flight mass spectrometry (SPME-GC×GC-ToFMS).The aim of the present study was to evaluate differences in the profiles of volatile compounds in fresh and cooked To compare the profiles of volatiles for the investigated vegetables, the compounds were isolated using headspace analysis, where the volatiles were adsorbed using SPME fiber and then separated by comprehensive two-dimensional chromatography-mass spectrometry (HS-SPME-GC×GC-ToFMS). This approach allows for the specific separation and (tentative in this case) identification of volatile compounds, thus, it is widely used in volatilome fingerprinting and profiling ,18. As tBrassica vegetables using principal component analysis (PCA) based on the profiles of volatile compounds. Each point represents a mean of three replicates analyzed for a given cultivar. One can observe obvious differences in the profiles of particular vegetables, both raw and cooked. However, there are also significant differences between particular cultivars of some investigated vegetables, which is especially noteworthy for raw broccoli and Brussels sprouts. Examination of the PCA graphs shows a similarity between cauliflower and broccoli volatiles in raw vegetables, despite the between-cultivar differences for broccoli, while kohlrabi and Brussels sprouts differ substantially in terms of their volatile compound profiles. When the data are compared for cooked vegetables, the similarities between cauliflower and broccoli can still be observed (close distance between clusters), whereas the other vegetables form distant clusters. Interestingly, after cooking, the differences between cultivars are much less pronounced. This would indicate the more uniform profile of the main volatiles. A detailed list of main compounds for all the examined cultivars is provided in Very small amounts of isothiocyanates were detected in all of the raw broccoli cultivars . Additionally, the nitrile levels were relatively low (<5%), which confirms very low concentrations of myrosinase hydrolysis products in the gas phase. The diversity of isothiocyanates was also very limited, barely four different isothiocyanates were identified using GC×GC. Both 2-methylbutyl isothiocyanate and isobutyl isothiocyanate were found in the cultivars Malibu and “2970”, while cyclopentyl isothiocyanate and n-hexyl isothiocyanate were present in all the analyzed broccoli samples. The composition of isothiocyanates was different in cooked vegetables, as propane, 1-isothiocyanato-, butane, 1-isothiocyanato-, 1-butene, 4-isothiocyanato- and benzene, (2-isothiocyanatoethyl)- were detected in all the analyzed cooked vegetables, instead of most isothiocyanates present in raw vegetables. The most interesting result was found in the cooked cultivar “2970”, where all the described isothiocyanates were present, along with a significant amount of allyl isothiocyanate (which was not present in the raw broccoli). This unexpected finding was connected with the absence of sulforaphane, one of the most explored isothiocyanates present in broccoli. Because of the health benefits of sulforaphane , interesThe concentration and diversity of isothiocyanates was much greater in the cooked broccoli. The amounts were almost two times higher than in the raw vegetables. It was reported that myrosinase in the broccoli matrix is inactivated after 20 min at 60 °C [In cauliflower, the major isothiocyanate was allyl isothiocyanate, representing 2–4% of the total volatile fraction, resulting from the high concentration of sinigrin, its precursor, in cauliflowers . Allyl iThe third group of analyzed plants comprised four varieties of kohlrabi: Kolibri, Kordial, Konan and Konmar. The percentage concentration of isothiocyanates in the raw vegetables was unexpectedly varied, as it was 4.16% for Konan, 18.96% in Kolibri, 6.15% Konmar and 3.71% in Kordial. The content slightly exceeded that in cauliflower. This fact was also correlated with high nitrile concentrations . In cooked kohlrabies, this amount increased in the Konmar and Kordial cultivars. Benzene, (2-isothiocyanatoethyl)-, which is present in uncooked vegetables at significant levels, almost disappeared in the cooked kohlrabies. The increase in isothiocyanate concentrations  in the KThe uncooked Brussels sprout cultivars contained mostly nitriles in their volatile fractions. Isothiocyanates constituted the second most abundant group. In the cooked plants, the isothiocyanates accounted for more than 50% in the Maximus, Marte, Ajax and Neptuno cultivars. However, the percentage contents of isothiocyanates increased, while their summary peak area changed significantly only in the Maximus cultivar. In the case of nitriles, the summary peak area decreased almost two-fold when compared with the raw varieties. Only in the Profitus cultivar did the levels of nitriles remain practically unchanged.Brassica vegetables and the detection of glucosinolates, which are biologically non-active molecules. Still, a higher glucosinolate content does not always guarantee an increment of desirable isothiocyanates after tissue mastication. The formation of beneficial isothiocyanates depends on a variety of factors, such as the activity of myrosinase and nitrile specific proteins or domestic processing. It is worth mentioning that even if glucosinolates are not degraded, their consumption is beneficial, since they can be hydrolyzed by a healthy intestinal microbiome [The important issue described in this part of the study is related with the high concentration of nitriles in some of the analyzed samples. This fact suggests that after tissue disruption in raw, defrosted vegetables, the hydrolysis of glucosinolates occurs in favor of the formation of nitriles instead of bioactive isothiocyanates. This seems to be important from a biological point of view. This is because of the health-promoting nature of isothiocyanates, which are bioactive molecules that are known for having many positive effects on human health. These isothiocyanates are found as a minority in the volatile fraction with respect to nitriles. Based on the actual in vitro data, nitriles have less beneficial health potential ,22,23, ocrobiome . Studiescrobiome , allyl icrobiome  and benzcrobiome , while aS-alk(en)yl-l-cysteine pathway compounds occurred very frequently in the volatile fraction in all analyzed vegetables. In all raw kohlrabi cultivars, sulfides formed the most abundant group of volatile components. They accounted for more than 50% of all the volatiles present in the analyzed kohlrabies , 2,4-heptadienal and benzaldehyde. According to , those aPrior to cooking, all samples were stored at −20 °C, which is why the impact of freezing needed to be evaluated. The comparison of the volatile composition in raw, fresh and frozen-thawed vegetables was performed based on Brussels sprouts. Three cultivars of fresh broccoli , three cultivars of cauliflower , four of kohlrabi  and five cultivars of Brussels sprouts  were used for analysis. They were harvested during the same 2016 autumn season: Broccoli, cauliflower and kohlrabi were harvested in September and the Brussels sprout cultivars were harvested in December. The vegetables were delivered to the laboratory within 24 h after harvest and stored at −20 °C until analysis (approximately 4 weeks).All vegetables were cooked in the same way. After washing and chopping, about 200 g of plant material was placed in 1 L of boiling pure water with 7 g of salt. Cooking times differed among vegetables. It was 5 min for the broccoli, 7 min for the cauliflower and 10 min for the kohlrabi and Brussels sprouts.Brassica vegetable samples were isolated using headspace solid phase microextraction (HS-SPME) and analyzed using SPME-GC×GC-TOFMS for the comparative, semiquantitive (peak area percentage) analysis only. The SPME fiber carboxen/polydimethylsiloxane (DVB/CAR/PDMS) was used for volatile extraction . The vegetables were cut into approximately 0.5 cm pieces with a kitchen knife and 4 g of each was placed in a separate SPME vial. The samples were pre-incubated for 5 min at 60 °C, then the fiber was exposed for 30 min at the same temperature to adsorb volatiles. The volatile compounds isolated by SPME were desorbed in the injector port on the GC×GC–ToF-MS system . The GC was equipped with a DB-5 column  and a Supelcowax 10  as the second column. The injector temperature was set at 250 °C and injection was performed in a splitless mode. The gas flow was set at 0.8 mL/min. The primary oven temperature was programed as follows: 40 °C for 1 min, then rising at 6 °C/min to 200 °C, where it then was reduced at 25 °C/min to 235 °C, where it was held for 5 min. In the secondary oven, the following programming was used: Held at 65 °C for 1 min, then rising at 6 °C/min to 225 °C, where it then decreased at 25 °C/min to 260 °C, where it was held for 5 min. The transfer line temperature was 260 °C. The modulation time was 4 s. The time-of-flight mass spectrometer was operating at a mass range of m/z 38–388 and detector voltage −1700 V at 150 spectra/s. Total analysis time was 34.07 min. All analyses for any particular cultivar and preparation method were done in triplicates.The volatiles of the Data were collected using the LECO ChromaTOF v.4.44 software . Tentative identification was accomplished using the National Institute of Standards and Technology (NIST) library (version 2.0) of mass spectra. The calculations and basic statistical analysis were performed using Excel 2010 and Microsoft Office 2010. The principal component analysis (PCA) was performed by the SIMCA software, v. 14.1.0.2047 .Brassica vegetables. This fast and efficient technique allowed for the determination of volatile compounds in different cultivars of broccoli, cauliflower, kohlrabi and Brussels sprouts. SPME is a method that provides a relatively fast volatile profiling of numerous samples. Despite many advantages of this technique, there are some issues which need to be mentioned here. First of all, there is no possibility to store volatile extracts (isolates), thus we face the problem of vegetable storage to analyze large sets of fresh raw vegetables. As presented, the freezing process caused some changes in the volatiles profile. Moreover, this is a non-exhaustive extraction method, so components with a low partition coefficient might be undetected, even if they are present in the sample in a relatively high concentration. Additionally, non-stable, easily reactive compounds can disintegrate, mainly due to high temperatures during thermal desorption from the fiber. The technique is very good for comparative purposes, pertinent for quantitative analysis; however, in the case of an external standard method used for quantitation, the impact of the matrix cannot be ignored, or alternatively, isotopomers of analyzed compounds could be used. Components from the following chemical groups were identified in those plants: Alcohols, aldehydes, isothiocyanates, nitriles, sulfides and others (unspecified). The proportions between the different groups were dependent on the vegetable type/species. The volatiles analyzed in raw and cooked vegetables showed changes occurring in the volatile fraction in cooked vegetables in comparison with raw ones. One of the most important differences in the volatile compounds concerned was a marked decrease in the contents of aldehydes and alcohols. The total amounts of sulfides decreased after cooking in all vegetables, except for broccoli. Isothiocyanate concentrations unexpectedly increased in most analyzed vegetables, while in the case of nitriles, a decrement was observed. Because all vegetables were frozen before analysis, the influence of freezing on the volatile fraction composition was also investigated. It was found that postharvest freezing of the Brassica vegetables induces biochemical changes that give rise to a significant modification of the compounds responsible for the aroma properties of those plants. Most of the changes are closely related to the activity of the LOX pathway enzymes. They are characterized by a high reduction in alcohol contents and an increase in aldehyde contents. Moreover, important changes were noted in the concentrations of bioactive components, e.g., isothiocyanates. The comparison of volatiles between fresh and thawed raw and cooked Brussels sprouts showed that after freezing, it is suggested to cook vegetables before consumption to maximize their beneficial properties.The HS-SPME-GC×GC method was proposed for the identification of a large spectrum of volatiles from selected


BC was measured at whole-body absolute and regional levels by dual-energy X-ray absorptiometry in eighteen players at the beginning and at the end of the competitive period. The ST was organized into three different session types: ST in the gym, specific ST on the field, and individual ST (weak points). The results of the present study indicated that fat-free mass (FFM) was substantially higher following the competitive period (5.1% ± 1.2%), while percentage of fat showed no changes during the competitive period. At the regional level, arms’ and legs’ FFM increased at the end of the season, and bone mineral content (BMC) and density (BMD) increased in arms, legs, pelvis, thoracic spine, and lumbar spine. In conclusion, within the limitation of the potential positive impact of growth and/or maturation, present results seem to indicate that an ST program that supplements football-related training sessions could be an effective option to increase FFM, BMC, and BMD at both whole-body and regional level across the competitive season in young male professional football players. The present prospective cohort study investigated changes in body composition (BC) in young male football players ( The central goal of strength training (ST) in football is to improve the players’ specific activities inherent to the sport , as wellMany different methods to improve strength and power have been suggested throughout the years. Certain ST methods in football combine different exercise modes, such as weight training and ballistic exercises, plyometric training, and sports-specific force-based actions. A training method that has increased in popularity in the past two decades is flywheel training, especially among professional football players ,8,9,10. BC is a key fitness element relevant to football player performance , and in The present prospective observational cohort study employed controlled repeated measures to analyze in-season BC changes after a combined football and ST program for 26 weeks in young male professional football players. Throughout the season, players usually had five training sessions , plus the ST program. BC was assessed using DXA in September (at the beginning of the in-season period) and in June (at the end of the season). Players did not perform any heavy exercise 48 h before the BC assessment.n = 18, 16.1 ± 0.8 years; 181.0 ± 0.1 cm; 71.3 ± 4.9 kg).Data were collected from a group of male young football players belonging to the third team from a professional football club (playing in Europa League). Players spent ~7 h in training plus one official match per week, and the team competed at the highest level for this age group. Our data came from routine testing over the season; therefore, ethics committee clearance was not required. The study conformed, nevertheless, with the current national and international laws and regulations governing the use of human subjects (Declaration of Helsinki II) and was approved by the Ethics Committee of the involved institutions . Written consent was obtained from the participants before the start of the study, or their legal representatives if the player was younger than 18 years old, after being fully informed about the experimental procedures, purpose, and potential risks. Only the data from players who completed >85% of the strength training sessions were included  and stature with a stadiometer . Body composition (fat-free mass (FFM), fat mass (FM), bone mineral content (BMC), and bone mineral density (BMD)) were assessed by DXA  using Hologic APEX software , and according to the manufacturer’s recommended procedures. Participants were presented in a rested, fasted, and hydrated state and were instructed to avoid strenuous exercise for 24 h prior to testing. Subjects wore only shorts and removed any metal and jewelry prior to assessment. Before any measurements, the DXA was calibrated each day with phantoms, as per the manufacturer’s guidelines. The participants assumed a stationary, supine position on the scanning table, with hands level with the hips and feet slightly apart, as in a recent study . All scaSubjects participated in a weekly football training program with one day of rest (Monday), and the players were involved in an official game once a week . The entire squad complemented the football training with an ST program for almost the entire in-season period (26 weeks). The complete ST program was organized into three different session types: (i) ST in the gym; (ii) specific ST on the field; and (iii) individual training.ST in the gym was usually organized as circuit training before the football drills in the field. Players performed one or two laps of a circuit consisting of 10–12 exercises mainly focusing on the lower limbs, combining free weights with non-gravity dependent flywheel inertial devices (Kbox® and Versa-Pulley®), and including some functional exercises for upper-body and core muscles. In addition, complementary ST sessions were prescribed with exercises for upper-body, core, and lumbopelvic stability. ST sessions in the gym lasted 25–35 min each, while complementary sessions lasted ~20 min. Specific ST on the field lasted 20–25 min each and consisted of different combined football drills with goal-shooting (finishing), including high-intensity actions such as plyometric jumps, resisted sprint, duels, different change of directions, or high-speed running, among others. Individual training consisted of ST sessions in the gym focusing on the player’s weak points for injury prevention, and these sessions were usually planned after the football training on the field and lasted 10–15 min. During the 26 weeks of ST, only data from players who completed >85% of the ST sessions in the gym and on the field were included. In addition to the 26 weeks of ST, the players did not perform the complete ST program for ~9 weeks due to friendly games, international weeks, or because there was a reduction in training load. In those cases, players only completed the individual ST.Data in the text and tables are shown as means with standard deviations (SD) and 90% confidence limits. All data were first log-transformed to reduce bias arising from non-uniformity error. For players, individual differences in BC from the initial values were compared with the smallest worthwhile difference (SWD), which was set as 0.2 of the typical error of the estimate . For indPlayers´ height showed no substantial changes during the in-season period ).BC variations after the in-season period are presented in Variations in left and right arms after the in-season period are presented in Variations in the left and right legs after the in-season period are presented in Variations in the trunk, pelvis, spine, and ribs after the in-season period are presented in The purpose of this study was to investigate the impact of combined football and ST on BC in young male professional football players. The major findings of the research were that (a) whole-body FFM increased after the competitive season; (b) at regional levels, lean muscle mass for arms and legs increased at the end of the season, as well as BMC and BMD in arms, legs, pelvis, thoracic spine, and lumbar spine.Assessment of BC is regularly undertaken when players are being monitored during the regular season. Previous studies investigated BC changes during a full season ,25 or onThe results of the present study showed substantial whole-body increases in FFM (5.1%) after the in-season training period. A recent previous study with professional football players showed lower increments in FFM (2.5%) during the competitive period after an eccentric-overload ST program . DiffereOur results showed that when FFM was analyzed at regional levels, increases in FFM were identified in the arm and leg regions. Similar results were shown in the arms and trunk, but not in the leg FFM after a similar in-season combined football and eccentric-overload training with professional football players . IncreasPrevious research has indicated that football training is associated with positive changes in BMC and/or BMD ,32. OnlyOne of the limitations of the current research is that our study assessed young professional players from an elite professional football club, and this group of participants did not allow us to have a control group . Additionally, the influence of diet on BC was not exhaustively controlled throughout the season. Some players had breakfast, lunch, and dinner at the club , but there was not a daily diary of food intake. Other players were instructed to follow a similar balanced diet at home. Finally, the statistical approach used in the present study was magnitude-based inference. Several statisticians have criticized magnitude-based inference due to theoretical problems with the method . Within the limitations of the absence of a control group and the potential positive impact of growth and/or maturation, the present results seem to indicate that an ST program that supplements football-related training sessions in young professional soccer players could be an effective option to increase FFM, BMC, and BMD at both whole-body and regional level through the competitive season. Furthermore, neuromuscular training may help players to reduce muscular damage following match-play, as shown in previous studies ; such tr


Attention impairments are frequent in stroke patients with important consequences on the rehabilitation outcomes and quality of life. The aim of the study was to perform a comprehensive assessment of selective and intensive attention processes in a large population of brain-damaged patients, evaluating the influence of the side and site of the brain lesion, the time from stroke, and the concomitant presence of aphasia or neglect. We assessed 204 patients with a first unilateral brain lesion and 42 healthy individuals with three subtests of the Test of Attentional Performance (TAP): Alertness, Go-No Go, and Divided Attention. 44.4% of patients had an impairment in both intensive and selective aspects of attention, 5.6% had deficits only in the intensive component, and 31.8% had deficits only in selective tasks. More than 80% of the patients fell below the cut-off point on at least one task. Patients with a right hemispheric lesion (RHL) were more impaired than patients with a left hemispheric lesion (LHL) especially in tonic and phasic alertness. Patients with total anterior infarcts (TACI) presented the worst profile compared to other stroke subtypes, with a difference between total and lacunar subtypes in the Alertness test, independent of the presence of warning. Patients in the chronic phase had shorter RTs than acute patients only in the Alertness test. In patients with LHL, the presence of aphasia was associated with a greater deficit in selective attention. In patients with RHL, the presence of unilateral neglect was associated with impaired alertness and selective attention. Attention deficits are common after a unilateral first stroke. In keeping with the hierarchical organization of attention functions, results confirm the important role of the right hemisphere for the intensive components of attention, also highlighting the involvement of left hemisphere functioning for the selective aspects, possibly indicating a role of its linguistic functions. Attention can be divided into two broad subsystems : intensiAlertness refers to the condition of general wakefulness that enables a person to respond quickly and appropriately to any sudden given request for action. It is a prerequisite for effective behavior and, in this respect, is the basis of every attention performance. Alertness can phasically increase efficiency for a short period by both bottom-up  and top-down processes . IntrAs it regards the selectivity aspects of attention processes, the model of van Zomeren and Brouwer  is distiAttention deficits are quite common stroke-related deficits, and their occurrence is documented in several clinical studies. Attention deficits in stroke survivors are reported with a variable incidence ranging from 46% to 92% in different studies . The impThe presence of attention disorders in stroke patients has important implications for the everyday functioning of these patients. In particular, these disorders constitute a serious obstacle to rehabilitation , 9. TheyOverall, the assessment of attentional deficits and the understanding of their clinical correlates are important in stroke survivors. However, although there is converging evidence on the high prevalence of attention deficits, it is not easy to draw a definite profile of attention deficits in stroke patients. Differences related to sampling variables  or tasks (tapping the intensive or selective aspects of attention) may explain in part this variability. Furthermore, association to critical neuropsychological symptoms may also modulate attention performance.As numerous studies have shown, attention functions can be selectively impaired as a function of the side of the lesion , 11–15. While there has been a sizeable amount of research on the laterality of attention, clinical studies examining the intrahemispheric correlates of different attention deficits are much fewer. A useful classification to this aim, the Oxford Community Stroke Project classification (OCSP), was proposed by Bamford et al. . The OCSMoreover, the time from onset is an important variable that influences attention deficits. Patients with a longer time between stroke onset and assessment may have a better performance in some attention tasks  althoughThere is some evidence that attention deficits covary with other neuropsychological deficits, particularly aphasia and neglect. As to language deficits, Murray , 25 founPatients with neglect commonly have low general arousal  with defOverall, the results of these studies show a complex picture with several different factors contributing to the individual performance in attention tasks. The aim of the present study was to provide a comprehensive evaluation of these factors within the same sample of patients. Thus, the presence of attention deficits, both in selective and in intensive aspects, was examined in a large sample of first stroke patients, relative to age-matched healthy adults, evaluating the role of lesion characteristics (such as the side of the hemispheric lesion and site of lesion), time from stroke, and the copresence of critical neuropsychological deficits .Neurological criteria: all patients were suffering from the consequences of a unilateral cerebral ischemic stroke, documented by computerized tomography or magnetic resonance imaging data. We excluded patients with bilateral lesions, with a previous stroke, noncerebral involvement, or patients who had undergone surgery . Patients with other chronic disabling pathologies  or other central nervous system diseases were also excluded. Finally, patients were excluded if they had prior psychiatric/substance abuse historiesNeuropsychological criteria: all patients presented adequate sufficient levels of awareness, linguistic ability, and abstract reasoning to carry on the experimental tasks (see the following paragraph). Patients with severe anosognosia (as assessed by a structured questionnaire), severe comprehension deficit [performance on Token test < 10 (corrected score)], or cognitive decline [performance on Raven's Progressive Matrices test < 1 ] were excluded.This was a multicenter study, enrolling all stroke patients consecutively admitted to two neurorehabilitation Units in the center and south of Italy . The neurological and neuropsychological criteria for inclusion (or exclusion) in the study were as follows:A total of 204 stroke patients fulfilled these criteria over a two-year period and were enrolled in the study. All patients were tested between two and twelve months after the onset of stroke. Dividing the patient's groups according to the side of hemispheric lesion, 108 (39 F and 69 M) had a RHL and 96 (39 F and 57 M) had a LHL.Patients were compared to a group of 42 healthy controls (20 M and 22 F). They were recruited out of hospital and, as a group, were matched with stroke patients for gender, age, and education . For this group, the exclusion criteria included prior neurological or psychiatric disorders and recent reduction of cognitive efficiency, carried out by a careful neuropsychiatric evaluation done by a neuropsychologist. The study was conducted according to the principles of the Helsinki Declaration and was approved by the local Ethical Committees of the participating centers. Each participant signed a consent form.The Oxford Community Stroke Project classification (OCSP)  was usedF = 51.35, p < .0001), with patients with LHL showing greater impairment in verbal comprehension . In Raven's Progressive Matrices, patients with RHL showed lower scores than patients with LHL  = 11.91, p < .001). As to the FIM total score, patients with RHL showed more functional impairment than patients with LHL  = 6.40, p < .01).The Functional Independence Measure (FIM)  was usedNeglect and language disorders were detected by a specific neuropsychological examination.In patients with LHL, language disorders were analyzed by two standardized batteries for the examination of language deficits  : AlertneThis subtest measures the RTs to simple visual target with or without a warning signal (tone). A cross appears in the middle of the computer screen, and the subject has to press a button as rapidly as possible. The order of block presentation is ABBA, in which A is the block without a tone and B is the block with a warning signal. A total of 80 trials were presented to each participant. The median RTs of the subtests with and without warning were considered dependent measures.This subtest measures selective attention. One three by three cm square appears in the middle of the screen. There are two target and three nontarget stimuli  with seven little “x's” are displayed on the screen see . The subParticipants were tested individually in a quiet room. Stimuli were presented on the screen of a PC computer about 60 cm away from the patient. Patients responded by pressing one button connected with the PC, thus allowing the measurement of RTs and errors . Instructions for each test were given aloud, and a brief sequence of practice trials preceded each test.Note that, due to technical problems, accuracy data  were missed for 37% of patients with LHL and 32% of patients with RHL.Following the indications of the TAP battery, the median RTs of the Alertness, Go-No Go, and Divided Attention tests were corrected for age and education. The general form of this formula is shown as follows:Correction values vary for the different tests . LimitedFirst, we examined the percentage of patients unable to perform the different attention tests. Then, we computed the proportion of patients with a pathological performance, i.e., performing at or below the fifth percentile according to Zimmermann and Fimm's  normativUnivariate analyses of variance were carried out to compare RTs and errors as a function of lesion laterality , lesion classification , and time from stroke and presence of concomitant neuropsychological deficits (aphasia or neglect). To more directly test the effect of age and education on patient's performance, analyses were carried out on raw (uncorrected) data taking into consideration age and years of schooling as covariates. However, for the sake of presentation, the mean values reported in the text always refer to corrected scores. To evaluate the effect of distance from stroke, we divided the overall group in subacute (<90 days) and chronic (>90 days) patients. There were 123 patients in the subacute phase and 81 in the chronic phase.In the whole sample, 44.4% of patients had impairment in both intensive and selective aspects of attention, with a pathological speed performance in all tasks; 5.6% had deficit in only intensive component (Alertness with and without warning) and 31.8% only in selective tasks (Go-No Go and Divided Attention). Thus, overall, 81.8% of patients fell in at least one attentional measure while 18.2% showed no attention deficits. Incidence of pathological speed performances was similar in intensive vs. selective attention tests: nearly half of the patients fell below the cut-off point on the Alertness test with and without warning (45% and 44%) and on the Go-No Go (47%) and Divided Attention (40%) tests. Regarding error data, 71% of patients displayed omissions in the Divided Attention test and 41% made false reactions in the Go-No Go test.p < .001 and p < .0001, respectively), and a comparable proportion of patients with impaired RTs in the Go-No Go and Divided Attention tests in the two groups. Regarding error data, the percentage of patients displaying a pathological rate of omissions in the Divided Attention test was higher in patients with RHL than in patients with LHL (p < .0001); the two groups did not differ in the proportion of patients with a pathological rate of false responses in the Go-No Go test.Comparisons between patients with LHL and RHL  revealedF = 7.78, p < .001), indicating slower RTs in patients with RHL with respect to controls (p < .001) and patients with LHL (p < .05). Patients with LHL and controls did not differ from each other. The main effect of warning approached a significance  = 2.68, p = .10), with shorter RTs in the warning condition (339 ms) with respect to the no-warning condition (353 ms). The group by warning interaction was not significant (F < 1), indicating no group difference in the warning effect in the two groups. As for covariates, only the age by warning interaction was significant  = 7.52, p < .01).F = 8.34, p < .001) and false responses  = 4.81, p < .01). With regard to RTs, healthy controls were faster than both patients with RHL (p < .0001) and LHL (p < .0001), while the two groups of patients did not differ from each other. With regard to false alarms, patients with RHL differed from healthy subjects (p < .0001), while patients with LHL did not differ from patients with RHL or healthy controls. As for covariates, only years of schooling modulated the performance in the Go-No Go test: the effect was significant in the analysis on false alarms  = 9.86, p < .01) and approached significance in the analysis on RT data  = 3.66, s).In the Go-No Go test, the main effect of the group was significant for both RTs  = 12.04, p < .0001) and omissions  = 27.96, p < .01). Healthy controls were faster than both patients with RHL (p < .0001) and LHL (p < .01); there was a tendency for patients with RHL to react more slowly than patients with LHL (p = .052). With regard to errors, patients with RHL committed more omissions than healthy controls (p < .0001) and patients with LHL (p < .0001), while patients with LHL made a comparable number of omissions than controls. The years of schooling covariate influenced the performance in the Divided Attention test: the effect was significant in the case of omissions  = 27.96, p < .0001) and approached significance in the case of RT data  = 3.05, p = .08).In the Divided Attention test, the effect of the group was significant for RTs  were slower than healthy controls independent of the presence of warning. This pattern held true both in terms of mean performance and incidence of individual patients performing below the cut-off. RTs in performing the Go-No Go and Divided Attention tests were impaired not only in patients with RHL but also in patients with LHL; again, this pattern emerged both at a group and at an individual level. In the Go-No Go test, the two groups did not differ. However, it should be noted that several LBD patients with LHL were unable to carry out this test while this occurred quite rarely among patients with RHL. In the Divided Attention test, incidence of pathological performance was similar but patients with RHL showed more omissions than patients with LHL and also tended to be slower. Note that a sizeable proportion of patients with both RHL and LHL was unable to perform this test..Overall, both mean data and individual analyses highlighted a specific pattern of attention impairment, with patients with RHL suffering from more severe and frequent deficits in intensive attention as well as divided attention and patients with LHL presenting frequent failures in selective attentionPerformance on each attention measure was examined as the function of laterality and OCSP classification. As shown in Figures The role of lesional variables was analyzed with ANOVAs with lesion side (RHL and LHL) and lesion site  as unrepeated factors, separately for each attention measure.F = 7.66, p < .001), indicating that patients with LACI had shorter RTs (300 ms) than those with PACI  and TACI  who did not differ from each other. The lesion side effect approached significance  = 2.99, p = .08), indicating shorter RTs for patients with LHL (341 ms) than patients with RHL (386 ms). The warning effect approached significance  = 3.13, p = .08), indicating shorter RTs in the warning with respect to the no-warning condition . As for covariates, only the age by warning interaction was significant  = 8.21, p < .01).In the case of Alertness, the lesion site effect was significant  = 4.09, p < .05), with faster RTs in patients with LACI (660 ms) with respect to the other groups . None of the covariates are proven significant. In the analysis on false alarms, no main effect or interaction are proven significant, except for the year of schooling covariate  = 7.66, p < .01).In the Go-No Go test, the analysis for RTs indicated the significance of the lesion site factor  = 5.27, p < .01), indicating shorter latencies for patients with LACI (778 ms) with respect to patients with PACI  patients; patients with TACI had intermediate RTs (835 ms) not differing from either of the other two groups. None of the covariates are proven significant. The analysis on omissions indicated both a main effect of the lesion side  = 10.14, p < .001) and site  = 4.01, p < .05) factors. The lesion side by lesion site interaction approached significance  = 2.35, p = .09). In patients with RHL, the number of omissions was higher for patients with PACI (13.11) than for patients with LACI  but not for patients with TACI ; in patients with LHL, omissions were generally low and did not vary as a function of the lesion site  = 5.44, p < .05).In the Divided Attention test, the ANOVA on RTs indicated a significant main effect of the site see . Only thComments: patients with lacunar infarcts presented generally better performance in all tests while patients with partial or total anterior circulation infarcts showed more severe deficits. Patients with PACI and TACI were slower in each attention measure while not differing from each other. The same pattern of results (with better performance in patients with LACI with respect to those with PACI or TACI) was found in terms of omissions in the Divided Attention test but only in the group with RHL; for patients with LHL, no difference was found as a function of the lesion site. For false responses in the Go-No Go test, neither lesion site nor laterality affected the performance.F = 2.04, n.s.), as well as the warning factor  = 2.53, n.s.): patients in the subacute phase employed on average 334 ms while patients in the chronic phase 296 ms. The age by warning covariate was significant  = 6.78, p < .01).In the Alertness test, the stroke onset factor was not significant  = .27, n.s.), with very similar RTs in the two groups  and for number of false response  = 1.64, n.s.) (4.6% in the subacute group and 3.0% in the chronic one). As for covariates, years of schooling were significant only in false response data  = 8.55, p < .01).In the Go-No Go task, the stroke onset factor was not significant for RTs  = 2.76, n.s.) and omissions  = 1.46, n.s.): in the subacute phase, patients had mean RTs of 695 ms with 8.0% of omissions while, in the chronic phase, patients had mean RTs of 644 ms with 8.7% of omissions. Covariates were significant only in the case of omission data  = 5.79, p < .05; years of schooling: F = 7.69, p < .01).The stroke onset factor was not significant in the case of the Divided Attention test for both RTs  and for the Go-No Go test (p < .01). In terms of group data  in attention functioning which was impaired in both patients with total and partial anterior strokes. These data reflect the literature relating OCSP stroke subtypes to outcomes, which states that TACI have the worst outcomes with regard to mortality, quality of life, participation, and activity limitations.For what regards distance from stroke, data did not indicate sizeable differences between subacute and chronic patients for both intensive and selective attention functions. These findings are in line with the results of Hyndman  who repoWe also examined the possible association of attention deficits to key neuropsychological symptoms. Results showed that the presence of aphasia was associated with deficits in selective attention. In particular, patients with aphasia were more impaired in selective functions than patients without aphasia. A review of the literature showed a cooccurrence of attention deficits and aphasia –53, evenIn our study, we paid attention to select attention tasks including only nonverbal stimuli and then should be not influenced by language disease of LBD patients. However, the patients with aphasia in the Go-No Go test were more impaired than patients without aphasia. Furthermore, many researchers showed that even the short-term retention of abstract shapes is sensitive to verbal distraction . High leThe present study also examined attention skills in relation to neglect. Our data are in agreement with previous studies indicating a close association between nonspatial attention deficits and neglect following RHL . In facOverall, the present data highlight the role of the right hemisphere for the basic aspects of attention, such as alertness and vigilance and the involvement of both right and left hemisphere for more complex and capacity-demanding dimensions of attention selectivity. These behavioral data are in keeping with the evidence of anatomical studies . The inIn conclusion, the results of our study underscore the importance of a comprehensive assessment of attention functioning in stroke survivors and shield some light on different clinical and lesional variables that modulate the severity and phenomenology of attention deficits in this population.


In poor settings, where many births and neonatal deaths occur at home, prediction models of neonatal mortality in the general population can aid public-health policy-making. No such models are available in the international literature. We developed and validated a prediction model for neonatal mortality in the general population in India, Nepal and Bangladesh.Using data  from rural and urban surveillance sites in South Asia, we developed regression models to predict the risk of neonatal death with characteristics known at (i) the start of pregnancy, (ii) start of delivery and (iii) 5 minutes post partum. We assessed the models’ discriminative ability by the area under the receiver operating characteristic curve (AUC), using cross-validation between sites.At the start of pregnancy, predictive ability was moderate {AUC 0.59 [95% confidence interval (CI) 0.58–0.61]} and predictors of neonatal death were low maternal education and economic status, short birth interval, primigravida, and young and advanced maternal age. At the start of delivery, predictive ability was considerably better [AUC 0.73 (95% CI 0.70–0.76)] and prematurity and multiple pregnancy were strong predictors of death. At 5 minutes post partum, predictive ability was good [AUC: 0.85 (95% CI 0.80–0.89)]; very strong predictors were multiple birth, prematurity and a poor condition of the infant at 5 minutes.We developed good performing prediction models for neonatal mortality. Neonatal deaths are highly concentrated in a small group of high-risk infants, even in poor settings in South Asia. Risk assessment, as supported by our models, can be used as a basis for improving community- and facility-based newborn care and prevention strategies in poor settings. To our knowledge, this is the first prediction model of neonatal mortality in the general population in low- and middle-income countries published in an English-language international peer-reviewed journal.Using data on 49 632 live births and 1742 neonatal deaths from population surveillance sites in South Asia, we were able to develop good performing prediction models based on characteristics known at (i) the start of pregnancy, (ii) the start of delivery and (iii) 5 minutes post partum.Especially at 5 minutes post partum, predictive ability was high and strong predictors were multiple birth, prematurity and a poor condition of the infant.Risk assessment, as supported by our models, can be used as a basis for improving community- and facility-based newborn care and prevention strategies in poor settings.Our findings suggest that improved (community or facility-based) management of high-risk infants, combined with population-level strategies to reduce the prevalence of important risk factors, can substantially reduce neonatal mortality.Worldwide, every year, nearly 3 million infants do not survive the first 28 days of life.Prediction models of neonatal mortality are largely restricted to high-income countries, which account for only 1% of neonatal deaths. These models focus on infants in neonatal intensive-care units.,,,Whereas prediction models for neonatal mortality are scarce, there is quite a good understanding of the causes of and risk factors for neonatal death in low- and middle-income countries. Preterm birth, neonatal infections and birth asphyxia account for around 80% of neonatal deaths.The advantage of prediction models is that they formally combine risk factors, allowing more accurate risk estimation.We aimed to develop and validate a prediction model for neonatal mortality in the general population in low- and middle-income countries, with specific reference to South Asia, using data from four surveillance sites.We used prospectively collected data from surveillance sites in rural Nepal  and Bangladesh  and rural  and urban  India.Lancet Neonatal Survival series,,Our outcome of interest was neonatal death, i.e. death in the first 28 days of life among live-born infants. All characteristics known to influence neonatal mortality as reported in the Most predictors were available for over 90% of deliveries . Some va2 test statistic minus twice the degrees of freedom was relatively small (below 10).We modelled possible non-linearity of the association between mother’s age and the risk of neonatal death with restricted cubic splines.We assessed the discriminative ability of each model by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve. The AUC can be interpreted as the probability that the risk prediction of a randomly chosen neonatal death is higher than the risk prediction of a randomly chosen neonatal survivor. We determined the AUC of the models within each of the four sites (‘apparent AUC’). We also used a cross-validation approach between sites to obtain a more realistic presentation of the AUC in independent settings . Cross-validation means that the model is consecutively fitted in three of the four sites and validated—with the AUC—in the site that was left out when fitting the model. To obtain overall AUCs—both apparent and cross-validated—we used random-effects meta-analyses of the four site-specific AUCs.,For calculation of an individual’s probability of neonatal death, we present the prediction models with nomograms.Approval for the trials of which we used the data for our secondary analysis was received from the Research Ethics Committee at the UCL Institute of Child Health and appropriate national Ethics Committees.Across the sites, 1742 neonatal deaths occurred in 49 632 live births, with the neonatal mortality rate (NMR) varying from 58.8/1000 in rural Jharkhand/Odisha (India) to 36.9/1000 in Nepal, 34.6/1000 in Bangladesh and 8.6/1000 in informal settlements in Mumbai (India) .IJE online]: breech delivery, premature birth, mother died, multiple birth, small size at birth, looking abnormal, not immediately crying or breathing, poor condition at 5 minutes, and infant had floppy or stiff arms and legs. The other included characteristics were also associated, though less strongly, with neonatal death in most sites.The following characteristics were very strongly associated with neonatal death ; cross-validated AUC 0.58 [95% CI 0.56–0.59]}.At the start of delivery, prematurity was a very strong predictor of neonatal death . Less strong, but still predictive, were health problems during pregnancy and delivery in the cold season. Low maternal socio-economic position and short birth interval were also important predictors. Predictive ability at the start of delivery was considerably better than at the start of pregnancy [AUC: 0.72 (95% CI 0.68–0.75)]. Multiple pregnancy was a strong predictor of neonatal death . When information about multiple pregnancy was available at the start of delivery, the predictive ability improved .At 5 minutes post partum, prematurity , a poor condition of the infant  and multiple birth  were highly predictive of neonatal death. Less predictive, but still important, were low maternal education, short birth interval, floppy or stiff arms and legs of the baby, small or large infant size at birth, breech delivery, male infant, health problems during pregnancy and delivery in the cold season. The predictive ability of this model was high . A substantial proportion of deaths was associated with the three risk factors with the highest ΔAIC at time of delivery (60.1% of deaths and 9.3% of births had any one of these risk factors).IJE online). Using The prognostic nomograms corresponding to the three models are presented in the nomograms of We developed and validated prognostic models for neonatal mortality in the general population in low- and middle-income countries, with specific reference to South Asia, on the basis of risk factors known at (i) the start of pregnancy, (ii) the start of delivery and (iii) 5 minutes post partum. At the start of pregnancy, prediction of neonatal death was difficult, although infants born to women of lower socio-economic position and to women with certain demographic characteristics  were at a higher risk of neonatal death. Predictive ability improved at the start of delivery, where multiple pregnancy and a premature start of delivery were highly predictive of neonatal death. Predictive ability was high at 5 minutes post partum, where prematurity, multiple birth and a poor condition of the infant were strong predictors of death. The models can be used to inform population-based prevention and more narrowly targeted interventions for high-risk infants.Our models are based on large datasets from sites in which the full population was prospectively followed up and detailed information on predictors of neonatal death was collected, allowing precise prediction. Yet, recall bias is a potential problem, as information was based on the mother’s report at approximately 6 weeks post partum. Whereas we reduced this problem by using broad categories for variables such as size at birth, random error may remain substantial for such variables. Furthermore, the mother’s report may have been biased by the outcome , with worse conditions reported for neonatal deaths, leading to inflated ORs for characteristics that mothers associate with death (e.g. infant condition at 5 minutes). Yet, for other predictors, such as multiple birth, such recall bias is probably minimal. Finally, whereas the high number of missing values in some predictors in particular sites may be considered a limitation, we were able to develop our models based on multiple imputation of missing values using the substantial amount of available data. Nevertheless, this may have led to an under-estimation of the discriminative ability of the models. Despite these problems, we arguably used some of the best data available for general populations in poor settings (i.e. prospectively collected data from some of the largest networks of linked demographic surveillance sites in South Asia) where home births without skilled care are common and reliable vital registration systems are non-existent.Our models are arguably generalizable to rural and poor urban South Asia. Our study sites ranged from informal settlements in megacity Mumbai, with a comparatively low NMR, to tribal areas in some of the poorest states in India, with a high NMR. The discriminative ability of the models—measured by the apparent and cross-validated AUC—was stable across sites, implying that the models are generally applicable across our study population. Our models are possibly less applicable to the top layer of South Asian society with a different cause-of-death pattern. Furthermore, their wider generalizability to other world regions needs further examination.To our knowledge, our study is the first to formally combine known risk factors for neonatal mortality into a prediction model for the general population in low- and middle-income countries. We developed models for three time points, i.e. onset of pregnancy, onset of delivery, immediately after birth—something we rarely encountered in the literature.,,,We found that three risk factors—preterm birth, multiple birth and poor condition at 5 minutes post partum—were associated with a very high risk of neonatal death. A substantial proportion of deaths was associated with these risk factors. Secondary prevention  can play an important role in preventing these deaths. Facility-based interventions to improve management of high-risk infants exist for poor settings.,Combining the above strategies with population-level primary prevention to reduce the incidence of risk factors, e.g. by improving maternal nutrition, reducing indoor pollution and increased use of family planning, will help to further reduce neonatal mortality.We developed good performing prediction models for neonatal mortality in the general population in South Asia. We conclude that neonatal deaths are highly concentrated in a small group of high-risk infants, even in poor settings in South Asia. These high-risk infants can be identified based on characteristics available before or shortly after birth. Our models suggest that improved management of high-risk infants can substantially reduce neonatal mortality. Where health systems are weak, a high-risk approach should arguably include population-level strategies to raise awareness about important risk factors and empower community-based care-givers to take action. This should arguably be complemented with health-system strengthening to improve the uptake of facility-based care and quality of maternity and newborn care and action on the social determinants of health to reduce mortality in low-risk, as well as high-risk, infants.This work was supported by the Economic and Social Research Council and the Department for International Development (grant number ES/I033572/1) and a Wellcome Trust Strategic Award (award number: 085417MA/Z/08/Z). T.A.J.H. was supported by an Erasmus University Rotterdam Research Excellence Initiative grant. D.v.K. was supported by the Netherlands Organization for Scientific Research (grant number 917.11.383). J.V.B. was supported by fellowship grants from the Netherlands Lung Foundation and the Erasmus University Medical Center. The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. T.A.J.H. and D.v.K. had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.Conflict of interest: None declared Supplementary TablesClick here for additional data file.