A conventional feeding bowl is the primary method that dog owners use to feed their dogs, but this may not encourage natural behaviors and may even exacerbate unwanted behaviors. This study aimed to compare a conventional feeding bowl to a feeding toy in relation to behavior, cortisol levels, and heart rate variability (HRV).C) or the feeding toy (TC) were fed for 15 min/day for 7 days with their treatment, and serum cortisol levels measured on the first and last days of treatment. The dogs fed by the stainless bowl (BH) or the feeding toy (TH) with the owner present for 15 min for each treatment had their heart rate (HR) and HRV recorded by Polar® H10 during feedings The results were compared using a one-way analysis of variance (ANOVA), repeated measure ANOVA, and Student’s t-test.The behaviors of four dogs were recorded and analyzed while being fed using either a stainless bowl (B) or a feeding toy (T) and either alone (A) or accompanied by a dog owner (O) for 30 min with each treatment . The dogs that were fed alone with the stainless bowl (BC treatment. The dogs’ HR was higher during TH treatment than during BH treatment. All HRV parameters were decreased significantly when feeding the dog with the toys.The dogs spent more time eating and interacting with the feeding toys than stainless bowls. The activity of the dogs was higher when using feeding toys, particularly with the TO treatment. Cortisol levels were significantly lower on day 7 than on day 1 of the TThe results of this study support the idea that feeding enrichment supports the natural feeding behaviors of dogs as they mimic hunting and playing behaviors. This reduced unwanted behavior, cortisol levels, and HRV, and increased food consumption, eating duration, and active behaviors. The presence of the dog’s owner is important because it can enhance feeding and active behaviors, and feeding enrichment can improve the dog’s welfare and the dog-human relationship. Dogs are the world’s most popular pets and play an important role in human life. Dogs and pet ownership can improve physical and mental health , 2. OwniThere are multiple signs of stress in dogs, including whining, barking, yawning, drooling, licking, shedding, panting, hiding, pacing, shaking, and displacement behaviors. The best way to relieve stress in dogs is to avoid stressful situations. Physical exercise, walking, or playing can greatly reduce stress .Feeding behavior may be related to behavior problems. The primary method of feeding uses a stainless bowl. This conventional feeding technique is boring , does noet al. [Feeding enrichment, such as feeding toys, may improve natural hunting behavior, reduce unwanted behaviors, and keep dogs mentally engaged and physically indulged. Heart rate variability (HRV) is used to study sympathovagal activity related to physical and mental responses. Heart rate variability is a non-invasive technique for autonomic nervous system measurement, which plays an important role in monitoring the stress response by measuring fluctuations in the RR interval (RRI). There is increasing use of HRV in veterinary research studies and clinical practice worldwide, including in Thailand –18. The et al.  found thet al. . Polar® et al. , 23. Theet al. .This study aimed to evaluate a conventional feeding method using a feeding toy as it related to dog behavior, cortisol levels, and HRV. This study also aimed to determine whether this could enhance feeding and active behaviors in dogs and improve dog welfare or dog-human relationships.This study was approved by the Institutional Animal Care and Use Committee of Walailak University (WU-ACUC-65004).The study was conducted from January to May 2022 at the Animal Laboratory Unit, Small Animal Teaching Hospital, Akkraratchakumari Veterinary College, Walailak University, Thailand.Four healthy, mixed breed dogs were studied, aged 3.25 ± 0.50 years old, weighing 13.5 ± 3.11 kg, from a dog shelter in Nakhon Si Thammarat, Thailand. They all received annual vaccinations  and were injected with ivermectin regularly for parasite prevention. The dogs underwent physical and blood examinations, including complete blood count, alanine transaminase, creatinine, and blood urea nitrogen, performed by a veterinarian for a routine health check. Blood parasite test kit screening  was also performed since the dogs were from a shelter at risk of blood parasite infection , 25. The2 room . Experiment 1 consisted of feeding the dogs with either a feeding bowl (B) or a feeding toy (T) and either alone (A) or with the owner (O), keeping them company but without any interaction. This resulted in four treatment options: BA, BO, TA, and TO. Each option was performed and recorded by video for 30 min once daily. The next treatment option was performed on the next day in a randomized order. The dog behavior was analyzed using the Solomon coder program version Beta 19.08.02 (https://solomon.andraspeter.com/) with the ethogram, as shown in C) and feeding toy treatment (TC). There was no owner present in experiment 2. Blood was collected from the dogs at the beginning of each option on day 1 and immediately after their 15 min of treatment on day 7. Serum cortisol levels were measured using the enzyme-linked immunosorbent assay technique as previously described by Brown et al. [In the second experiment, dogs were fed in the experimental room for 15 min once a day for 7 consecutive days for each treatment option in a randomized order. The two options were conventional bowl treatment  and the feeding toy (TH). Dogs were with the owner (WB) during both feeding options; however, the owner was only there to keep the dog company and to observe the equipment. The owner had no interaction with the dogs. The dogs’ hair was clipped along the chest, ultrasound gel was applied to the area, and the Polar® H10 was strapped on. An elastic bandage was applied to cover the chest strap for stability when the dog moved. The Polar® H10 was connected through Bluetooth to Polar Beat: Running and Fitness and HR and HRV Logger 1.3.5 applications on the smartphone (Android system).In the third experiment, the dogs’ HR and HRV were measured using the Polar® H10 HR monitor  during feeding for 15 min each day during the experimental procedures. There were two treatments in experiment 3: The bowl  for statistical analysis and presented as mean ± standard deviation. One-way analysis of variance (ANOVA) and Tukey’s The dogs consumed significantly more food in the BO treatment (p = 0.023) compared with the BA treatment; however, consumption was not different between the BO and TA or TO treatments . The first approach time to the bowl or toy was not significantly different among the BA, BO, TA, and TO treatments. The dogs spent the most time eating in the TO experiment, and it was significantly comparable with the BA and BO treatments . It was similar to the frequency approach the object results . Toy interaction duration was not significantly different between the TA and TO treatments (p = 0.113). Two of the dogs in the study seemed to be right-pawed, one seemed to be left-pawed, and the other used both of its forelimbs to play with the toys. Nosing and sniffing were the longest interaction times in the TA and TO treatments , while mouthing was the shortest duration of toy interaction . Half of the dogs did not use their mouths to interact with the toys .The dogs’ passive behavior was the longest in the BA treatment option. Both feeding bowl treatments, BA and BO, had passive behavior duration significantly longer than the TO treatment . There was no significant difference in vocalizing, destructive behavior, or displacement behavior among the BA, BO, TA, and TO treatments in this study. In the BO treatment, the dogs spent 60% of the session close to the chairs where the owner sat, and it was significantly longer compared to the other treatments .C treatment option showed no difference from day 1 to day 7, (p = 0.103) while the TC group exhibited a significant decrease between day 1 and day 7 (p = 0.025) with 2.28 (ng/mL) mean difference (Serum cortisol levels in the Bfference .H treatment option than the BH treatment (p = 0.035). All HRV parameters in the BH treatment, including average RRI, standard deviation of normal sinus beats (SDNN), root mean square difference (RMSSD), and the proportion of RRI exceeding 50 ms (PNN50) were significantly higher than in the TH treatment option  (The average HR was significantly higher during the Tctively) .In this study, dogs tended to consume more food when feeding with the bowl than using feeding toys, whereas they tended to spend more time with the toys than with the bowls. Dogs spent only 2–3 min when eating with the bowl, but spent 5–10 min when eating with a feeding toy. They likely would have spent more time with the feeding toy if given more than 80 g of feed. The feeding toy elicited more interest from the dogs than the bowl, especially when the owner accompanied them. These results are similar to those of previous studies, which found that dogs preferred feeding toys , and theDomestic dog paw preference reflects the dominant limb or hemispheric functioning of the brain, which may be influenced by sex . Two femDogs respond to long-term stress with either behavioral or hormonal changes, including body shaking, yawning, stretching, vocalizing, other displacement behaviors, destructive behavior, and increasing cortisol, adrenaline, and noradrenaline levels . Reducinet al. [et al. [When the dogs played and ate with the toys, HR increased but HRV decreased. The increased HR was associated with more physical activity using their paws, nose, and mouth during toy interaction. A previous study by Wells  found thet al.  using to [et al. .Feeding enrichment may stimulate natural hunting and feeding behaviors by reducing unwanted behaviors, cortisol levels, and HRV and increasing active behaviors. This is beneficial for both the physical and mental health of dogs. The dog owner is an important factor who can positively impact feeding consumption, eating duration, and active behaviors. A feeding enrichment strategy can help improve dog welfare and the dog-human relationship.TW, NS, PS, and WB: Designed the study, prepared the materials, and edited the manuscript. WB: Performed animal experiments, coded dog behavior, collected and analyzed the data, and drafted and revised the manuscript. NW: Commented and advised on the experiment and the manuscript. PC and NT: Helped on data collection and analysis. All authors have read, reviewed, and approved the final manuscript.


Objectives: This study aims to enhance the understanding of longitudinal associations between two important facets of well-being in late life: social support and commitment to life and living (CTL). Methods: Structured home interviews were conducted with 824 Israelis ≥75 years of age, with three annual data collection timepoints. We hypothesized and tested a cross-lagged, longitudinal structural equation model (SEM) in which CTL and social support were assumed to predict each other over time, covarying for previously reported CTL and social support. Results: Social support has a positive, contemporaneous effect, predicting commitment to living at T1 and T3, while CTL predicts social support the following year . Satisfaction with relationships significantly contributes to measurement of both latent constructs at each point of data collection. Discussion: Commitment to life and living and social support are intertwined phenomena. Whereas social support has a concomitant effect on CTL, the effect of CTL on social support emerges over time. This suggests that greater social support fosters greater CTL, leading older adults to nurture social networks and relationships; the effect of which is greater social support in the future. The implications of these results warrant further research over longer periods and across cultures. Understanding of well-being in late life is of particular importance, as this stage is associated with various age-related challenges and losses . Physical, social, and emotional challenges further exacerbate the decline in psychological reserves and resources including self-esteem, self-efficacy, subjective well-being, and even interest in life ,2,3. HowPositive psychology focuses on well-being and various intrinsic and external factors that foster physical and cognitive functioning, general well-being, and longevity . ResearcWell-being in late life is composed of various factors including happiness, life satisfaction, perceived health, and will to live ,11. AssoFor this study, we set out to determine the direction and strength of both contemporaneous and longitudinal associations between core facets of personal resources and well-being in late life; specifically, we studied social support and commitment to life and living (CTL). Like all mammals, humans are born with a strong instinct to survive . Will to live (WTL), however, is a biopsychosocial phenomenon comprised of both instinctual and psychological components; that is, WTL is as an existential need, drive, or purpose ,16,17,18The WTL is generally high for most people . HoweverWTL is as an important facet of well-being in late life, significantly associated with established indices of subjective well-being such as life satisfaction, self-esteem, successful aging, and fewer symptoms of depression ,10,16,22Death is frightening because it is the end of all that people live for and understand. Societies differ widely in ways they address such issues of purpose and meaning. Homans  argued tRelated to fear of death is fear of the dying process . Due to To survive, grow, and develop, an additional basic need is support from others for much of human life, especially during periods of dependency  and often in late life . The conThe convoy model also emphasizes the importance of social support for physical and cognitive well-being in late life. Findings indicate direct and indirect effects of social support on emotional, physical, and cognitive health ,36,37,38Due to the significance of social support on human survival, people tend to live with families and within various social groups and communities, generally based on common values and beliefs. Societies incorporate such groups into larger sociocultural organizations, which also strive to foster their ongoing physical and cultural existence. This leads societies to invest considerable resources in retaining and protecting their members, values, and norms of behavior . One of Considering the theoretical significance of both CTL and social support especially in late life, we examined associations between social support and CTL measured at three time points over two years. Since social support is an important predictor of well-being, we hypothesize that it also predicts CTL, a related yet different facet of well-being that has important implications to life in late life. We also predict that older adults with a stronger CTL will have more motivation to invest in their social ties. Thus, we hypothesized that the latent constructs of CTL  and social support  are associated contemporaneously and over time. That is, we hypothesized that older adults reporting higher social support will report greater CTL concomitantly and in the future. Those reporting greater instrumental support, emotional support, and satisfaction with relationships will report higher CTL concomitantly and over time. Prospective participants were randomly identified from the population registry, stratified by gender and city of residence . We identified those ≥75 years of age living in the community, independent in activities of daily living (ADL), and without significant cognitive loss . Men weA total of 1216 older adults were interviewed at baseline, 1019 1 year later , and 892 at Time 3 (73.4%). Of those lost to attrition, 113 declined further participation, 131 became unable to participate , 60 died, and 20 could not be located despite repeated attempts. After excluding an additional 68 with missing socio-demographic data, 824 participants provided responses at each point of data collection . Those reporting a lower will to live at recruitment were more likely to be lost to attrition .Structured interviews were conducted at three annual points of data collection over 2 years. All participants were interviewed in their homes by trained research assistants, sensitive to the fatigue and concentration levels of older adults. Interviews were conducted in either one or two sessions, lasting 1.5 to 3 h. Written consent was obtained from participants. no WTL (0) to very strong WTL (5). Internal consistency of responses by older adults is high (0.81 < α < 0.90) [The Will to Live Scale (WTL)  is compo < 0.90) ,17). Forcompletely disagree (1) to completely agree (5). Adequate internal consistency for fear of death (α = 0.71) and fear of dying (α = 0.76) was initially reported with a representative sample of older Israelis ≥70 years of age (N = 1136) [The Fear of Death Scale  is compo = 1136) . For thenot true at all (1) to absolutely true (5). Internal consistency was high at each point of data collection for both emotional (0.82 < α < 0.88) and instrumental support (0.86 < α < 0.91). See The Berlin Social Support Scales (BSSS)  measure not at all satisfied (1) to very satisfied (5) and the two items were averaged. Satisfaction with social relationships was measured by two questions: “How satisfied are you with your relationships with friends, acquaintances, or neighbors?” and “How satisfied are you with your family relationships?” Responses to both were provided on a Likert scale ranging from excellent (0) to very bad (5). A socio-demographic questionnaire was created to collect descriptive information . Education was measured as primary, secondary, post-secondary, and academic. Self-rated health was assessed by a single question using a Likert scale from We hypothesized a longitudinal, structural equation model (SEM) in which social support contemporaneously predicts CTL at each point of measurement; and social support and CTL predict each other in the future . We covaried for prior measurement of both latent constructs so that additional variance explained across constructs is unique. Error was assumed to be correlated across the same item pairs over time. Various socio-demographic variables associated with social support and CTL were first examined and included as covariates if significantly associated with either latent construct. Descriptive statistics were computed with SPSS v28; the SEM was computed with AMOS v26.Consistent with convention, we report three goodness-of-fit-indices: An incremental, an absolute, and a parsimonious fit index. The Comparative Fit Index (CFI) is an incremental index representing the extent to which a hypothesized model is a better fit to data than the null model. The Standardized Root Mean Square Residual (SRMR) is an absolute index that represents the standardized difference between observed and predicted correlations within a hypothesized model. Finally, the Root Mean Square Error of Approximation (RMSEA) is a parsimony index that represents the extent to which a hypothesized model fits data relative to the population. Coefficient values greater than 0.94 for the CFI, and less than 0.055 for the SRMR and RMSEA indicate good model fit .At recruitment, participants were 80.1 years of age on average  and most were men . The plurality was born in Central or Eastern Europe  followed by Israel , Asia/Africa , the former USSR , Western Europe  and North America/Australia . Most reported Hebrew as their primary language  though a percentage continue to speak mostly Russian . A high percent of older immigrants from the former Soviet Union remain more proficient in Russian than Hebrew.Most participants had completed college  or university . Most described themselves as secular , and a minority self-described as traditional , orthodox , or ultra-orthodox . Most were widowed ; only a minority were currently married/partnered , divorced , or never married .Consistent with previous findings, education was inversely associated with social support , and per2 (df = 137) = 324.42, p < 0.01. More specifically, CFI = 0.97, SRMR = 0.053, and RMSEA = 0.041 (0.035 < RMSEA CL90 < 0.047). With 824 participants and 137 degrees of freedom, this model has sufficient statistical power (d = 0.99) to identify medium to small effect sizes (where α = 0.05) [The SEM that emerged differed from the fully cross-lagged model we hypothesized. After correcting for the correlated error between six item pairs , the goodness of fit for this model was ideal, χ = 0.05) .Each social support variable  contributed significantly to measurements at each point of data collection . The same occurred for each of the three CTL variables . However, satisfaction with relationships significantly cross-loaded between latent constructs at each point of measurement; thus, it contributed to measurements of both social support and CTL see .Social support at baseline predicted social support measured one and two years later. By contrast, CTL was predicted only by CTL measured the year prior . As hypothesized, social support concomitantly predicted CTL at baseline and T3, and CTL predicted social support when next reported (T1–T2 and T2–T3). However, the reverse longitudinal effect did not emerge. That is, CTL predicts future social support but not vice versa. The effect of social support on CTL appears contemporaneous only. These cross-lagged effects emerged while covarying for latent constructs over time. Commitment to life and living is a predictor of well-being in late life ,16. As sThose more committed to life and living reported greater social support the following year at both time points. It could be that those more committed to life are more likely to actively invest in maintaining and cultivating familial and social relationships. The benefit of this investment in social relationships is greater social support the following year. These findings are in accord with socioemotional selectivity theory , which cOur findings suggest that social support and CTL are interconnected in late life. That is, social support appears to have a positive, contemporaneous effect on CTL, indicating that those who report higher availability of emotional and instrumental support, and who are satisfied with their social relationships, are more strongly committed to life and living. This can be explained by the positive functions of emotional and instrumental support that make life easier and more meaningful, as they contribute to a sense of belonging, being cared for, and protection . In accoFurthermore, satisfaction with relationships (family and friends) contributes to measurements of both social support and CTL . That is, satisfaction with relationships is directly related to CTL. Satisfaction with relationships occurs when social networks meet one’s expectations. This appears especially important in relation to age-related losses in late life. Previous findings indicate that perceived quality of life and WTL depend on attainment of psychosocial and spiritual needs ,40. ThisAlthough previous research reports that social support from friends and family is an important resource that older adults generally value and seek to nurture and maintain , the conThese findings are in accord with qualitative research on Israeli older adults who were asked, “What strengthens your will to live?” Emerging themes were social networks, religious faith, honor versus ageism, and work/volunteering, but not health or functional ability as would be expected . CollectAlthough we initially identified a large, random sample of older Israelis, participants lost to attrition were in worse health and of lower social status. Caution should be taken when generalizing the results. Future research is needed to replicate this model with other samples and followed over longer time periods  in Israel and other societies. Results from this study highlight the complex, longitudinal associations between CTL and social support. Our findings indicate that the direction of association changes over time: Social support contemporaneously predicts CTL; and CTL predicts social support over time. An extended investigation of contemporaneous and longitudinal associations and effects among these and other aspects of general well-being is needed to further inform both theory and practice.Over-and-above, objective or instrumental and emotional support and subjective appraisal of social relationships with family and friends significantly contributes to measurements of both social support and CTL at each point of measurement. It appears that the importance of subjective evaluation of social relationships extends to social support as well as to CTL. These findings underscore the interplay between various facets of personal resources and general well-being over time. Additionally, the results of this study underscore the importance of psychosocial interventions intended to maintain and promote well-being in late life. Such interventions should strive to foster commitment to life and living, which, in addition to a direct effect of fostering well-being, can also counteract the loss of social resources that commonly occurs in late life.


The critical load concept is an important scientific guideline for acid deposition control. It was not only a crucial scientific basis to determine the emission reduction targets in Europe, but also used in China’s air pollution control, especially the designation of two control zones. Currently, critical loads of sulfur and nitrogen are still exceeded in Europe, America, and East Asia (mainly in China), and need to be continuously updated to meet the demands of further emission reductions. Critical loads of China were calculated and mapped in the 2000s, but are not sufficiently accurate due to methodological and data limitations. Here we present the latest high-quality critical loads for China, based on high-resolution basic data on soil, vegetation, and atmospheric base cations deposition, and up-to-date knowledge on important parameters. Our data, which is going to be included in GAINS-China, can be used to assess the ecological benefits of nitrogen and sulfur reductions in China at a regional or national scale, and to develop mitigation strategies in the future. It remains an important environmental problem in some developing countries such as India and Brazil, and is showing an increasing trend there3. Nitrogen and sulfur deposited into the environment may lead to acidification and eutrophication of terrestrial and aquatic ecosystems4. There have been many reports of acid deposition leading to fish kills and forest decline7. In order to effectively control the environmental impacts of acid deposition at minimal cost, the concept of critical loads was proposed, defined as the maximum amount of acid deposition that would not cause soil and surface water damage in the long term8. Critical loads are determined by the nature of the ecosystem , reflecting the tolerance of the ecosystem to acid deposition. Critical loads have been used in nitrogen and sulfur abatement around the world, even as the primary scientific guidance11. In Europe, they were used in the negotiations of the Second Sulfur Protocol and the “multi-pollutant, multi-effect” Protocol, as the scientific basis for emission reduction targets12. The US have also taken critical loads seriously, establishing the Critical Loads of Atmospheric Deposition Science Committee (CLAD) to promote the development, collaboration, and data sharing of critical loads13. Several federal agencies, such as the National Park Service , have applied critical loads to ecosystem conservation practices. Currently, acid deposition is gradually declining in Europe and the US through the reduction of SO2 and NOX, but the critical loads are still exceeded in border areas there 15. Therefore, Europe (www.icpmapping.org) and the US (http://nadp.slh.wisc.edu) are continuously updating critical loads to assess the benefits of further emission reduction.Acid deposition, consisting (mainly) of nitrogen deposition and sulfur deposition, used to be one of the most serious environmental problems in Europe, North America, and East Asia since the 1960s1. The area affected by acid rain in China once exceeded 30% of the national land area16, and the highest wet deposition of sulfur in China was significantly higher than that in Europe and North America18. In order to scientifically evaluate the status of acid deposition and to guide emission reductions, Duan et al. first mapped the critical loads in China9, which were then used in the designation of two control zones (Acid Rain Control Zone and Sulfur Dioxide Pollution Control Zone)21. In recent years, China has made great efforts to reduce nitrogen and sulfur emissions, mainly for fine particulate matter (PM2.5) control, and acid deposition seems to have been greatly alleviated as a co-benefit16. However, based on Duan et al.’s results, Zhao et al. found that the critical load exceedance of sulfur remained at 2.5 Mt in 2015, and that of nitrogen was 1.1 Mt22. Furthermore, the particulate matter abatement reduces the tolerance of ecosystems to acid deposition, and reduction of ammonia also brings uncertainty in acid deposition control23. Therefore, the available critical load data in China  cannot meet the need for an accurate assessment of acid deposition impacts currently in China. More importantly, Duan et al.’s critical loads were mapped more than two decades ago, thus the accuracy and resolution were limited by basic data and methods. For instance, they calculated denitrification and soil weathering rates based on soil type without localized parameters; vegetation uptake was roughly determined according to vegetation type. Generally, current critical load data has low spatial resolution and accuracy, and can no longer describe the latest situation of ecosystems due to changes in deposition, vegetation, and other environmental factors.Since the late 1970s, acid rain has gradually become one of the most concerning environmental issues in East Asia. And southern China is a hot spot for acid rain in East Asia25, including the maximum critical load of sulfur (CLmax (S)), the minimum (CLmin (N)) and maximum (CLmax (N)) critical load of nitrogen, and the critical load of nutrient nitrogen (CLnut (N)). Our results used high-resolution geographic, vegetation, and meteorological data, and up-to-date knowledge from literature, to update and refine the key parameters. The data calculation methodology is shown in Fig. To meet the demand for assessment of acid deposition status in China, we developed a high-resolution (1 km × 1 km) critical load dataset for soils, based on the Steady-state Mass Balance (SMB) model26. It has to be noted that the SMB model is a steady-state model, i.e. all inputs and outputs considered are stable over time24, so finite reservoirs such as ion exchange are not included.Our calculation method refers to the European manual on modelling and mapping critical loads, which are based on the principles of conservation of mass and chargemax (S) , which is given by:Q is the runoff, [H] ([Al]) is the equivalent concentration of H+ (Al3+) in the runoff. Further calculation will be introduced in “Critical chemical criteria”.The maximum critical load of sulfur, CL(S) Fig. , was calmin (N)  Fig. , is defimin (N), some of the excess nitrogen would be denitrified, and the rest would leach and cause acidification. Therefore, the maximum critical load of nitrogen, CLmax (N)  Fig. , is definut (N)  Fig.  as:5\docThe parameters of the available critical loads were mainly determined by soil and vegetation types, while the characteristics of soil and vegetation  vary widely in space and are related to many factors. Therefore, the accuracy needs to be improved urgently. Instead, we used the latest high-resolution digital maps Fig. , and com27 to calculate the baseline weathering rate at standard conditions  for each soil type. Mineralogical composition data for typical soil types was compiled by Duan9. The 1 km × 1 km map of soil types in China was taken from Resource and Environment Science and Data Center (https://www.resdc.cn). Some soils in China contain calcium carbonate (CaCO3) especially in arid areas, but that was excluded in the calculation when the content was lower than 0.5% since it might be depleted during the long-term acid deposition. The weathering rate was calculated as CaCO3 content (%) times 0.82 keq/ha/yr when the CaCO3 content was higher than 0.5%. The soil CaCO3 content was from the Harmonized World Soil Database (HWSD)28.Soil weathering rate is determined based on the mineralogical composition, the physical properties , and environmental factors  Fig. . First, w0 is the baseline weathering rate, Csw is a correction factor for soil moisture, A is a constant (3600 K as recommended) for temperature correction, and T is the soil temperature. Soil temperature data was from the National Tibetan Plateau Data Center30. Csw ranges from 0.7 (soil moisture < wilting moisture) to 1.3 (soil moisture > water holding capacity) and linear interpolation were used to determine it in areas of moderate moisture. The soil moisture data was from the National Earth System Science Data Center31. The numbers 1.1, 1.2, and 281 in Eq. , and soil temperature:1 in Eq.  means thXsand, Xsilt, Xclay, and S mean the fraction of sand, silt, clay, and gravel in the soil; ρsoil is the soil bulk density; fclay is a correction factor32:SSA in Eq.  was esti28.Soil bulk density and texture  data were from HWSDpi is the proportion of biomass in the considered plant part , and CN (CBc) is the nitrogen (base cation) content of plants. The annual NPP data modelled by Global Production Efficiency Model from 2000 to 2010 was from Resource and Environment Science and Data Center and was averaged to represent long-term NPP. Biomass proportion and elemental content data were collected by Duan et al.33 and linked to the vegetation map of China, which is from National Cryosphere Desert Data Center34.Net uptake by plants means the net removal of nitrogen and base cations from the ecosystem Fig. . The nit26. The soils were divided into three categories, Skeletol Primitive Soils, Ferralisols, and others, whose ages were set to 1500 years, 130000 years, and 5000 years, respectively, according to measurements and soil type35. Soil nitrogen content was from National Tibetan Plateau Data Center37.Nitrogen immobilization refers to the conversion of inorganic nitrogen to stable organic nitrogen in the soil Fig. . The lonfde based on the observation data on denitrification for main forest types in China39 crit is the molar critical base cation to aluminium ratio. Kgibb was determined according to the soil organic matter content crit for each ecosystem type was taken from Duan9 and the manual26.To protect plants from the damage of aluminium, we set a limit to the base cation to aluminium ratio (Bc/Al) for each ecosystem type. Critical ANCe in Eq.  is then entclass1pt{minimale, crit in Eq. . The dataset consists of four TIF files and a ‘readme’ file. The TIF files give the critical loads (CLmax (S), CLmin (N), CLmax (N), and CLnut (N)) of China. The ‘readme’ file explains the units and additional information for critical loads.The data are freely available at National Tibetan Plateau Data CenterThe SMB model has been extensively used around the world, and we calibrated the model parameters with reference to the latest research. However, critical loads are long-term attributes of ecosystems, which is difficult to validate by experiments. Therefore, quality control of the input data is the main approach to ensure the reliability of output at present.The high-resolution maps we used  are peer-reviewed data or data from authoritative data repositories , which have high quality. For some other data , we obtained them from literature or manuals, which can also be considered reliable.fde is very complex and related to many factors besides forest type, there is no widely accepted model to calculate fde yet. We summarized the observations on fde from literature for different forest type, which can better represent the actual situation in China compared to commonly used empirical relationships.Although 9, a uniform soil age was used for all soil types because the available data for soil ages was very limited.Soil ages were determined by soil type base on literature. Since the contribution of nitrogen immobilisation to critical loads is negligible, our rough estimation of soil ages would not cause large errors. In previous research47. Generally, this study provides high quality estimation of critical loads in China under existing conditions.The main uncertainty arises from the estimation of soil weathering rates, as the mineralogical composition of soils is poorly studied and fragmented. However, weathering rates of the same soil type are relatively close due to the similar soil formation process and therefore the method we currently used is acceptable


Shen-Song-Yang-Xin Capsule (SSYX), a Chinese patent medicine, combined with antiarrhythmic drugs (AADs) in the treatment of atrial fibrillation (AF) has been widely applied in clinical practice, but the results are controversial. This study aims to conduct a network meta-analysis (NMA) based on data from the randomized controlled trials (RCTs) to evaluate the efficacy and safety of SSYX combined with ADDs in the treatment of AF.A comprehensive systematic literature search will be conducted in Cochrane Library, PubMed, Web of Science, EMBASE, Chinese Biomedical Literature Database (SinoMed), Chinese National Knowledge Infrastructure (CNKI), and WanFang database for RCTs about SSYX combined with ADDs. The primary outcomes will be the frequency of AF attack and P-wave dispersion, and the secondary outcomes will be the symptom improvements, left atrial diameter, and adverse events. Statistical analyses will be conducted by using WinBUGS software (version 1.4.3), Stata software (version 14.0) and RevMan software (version 5.3).The results of this NMA will provide a high-quality evidence for the efficacy of SSYX combined with ADDs in the treatment of AF, and a ranking of the therapeutic classes will also be presented.The protocol will provide updated evidence for the application of SSYX for AF.https://inplasy.com/inplasy-2020-8-0075/) and INPLASY registration number is INPLASY202080075.The protocol of this systematic review and meta-analysis was registered on the INPLASY website ( The high incidence of AF is associated with increased rates of mortality and disability. The risk of stroke is 4 to 5 times higher in AF patients than non-AF ones, which leads to a nearly 20% mortality rate and nearly 60% disability rate. One percent of the annual medical expenditure in the UK and up to $26 billion in US medical expenditure are related to AF, most of which is hospitalization costs.,8 AF has become a major public health problem that hinders the improvement of national health and social development.Atrial fibrillation (AF) is the most common clinical arrhythmia characterized by the high-frequency electrical activity of the atrium and unsynchronized atrial contraction.,10 In addition, heart rate control and heart rhythm control can effectively improve AF-related symptoms and cardiac function. For paroxysmal AF patients who have failed to respond to drug therapy, the guidelines recommend radio frequency ablation. But for persistent AF and other types, the success rate of postoperative sinus rhythm recovery is not high, and the long-term follow-up results are not satisfactory. Surgical AF ablation such as maze surgery is mostly used for AF patients undergoing cardiac surgery simultaneously, but patients with simple AF have a low acceptance of it.In recent years, significant progress has been made in the clinical treatment of AF. New oral anticoagulant drugs and vitamin K antagonists can remarkably reduce the risk of stroke and death in patients with AF.–15 As a part of it, Chinese medicine has been used to prevent and treat arrhythmia in China for thousands of years. Shen-song-yang-xin Capsule (SSYX) is a traditional Chinese patent medicine, it is composed of 12 kinds of Chinese herbal medicines, including Ginseng (ren shen), Radix Ophiopogonis(mai dong), Fructus Corni (shan zhu yu), Salvia Miltiorrhiza (dan shen), Semen Ziziphi Spinosae (suan zao ren), Herba Taxilli (sang ji sheng), Nardostachys Chinensis (gan song). The formula of SSYX is based on the traditional Chinese medicine (TCM) theories of tonifying Qi, nourishing Yin, promoting blood circulation to remove the obstructions to calm the mind. It has been widely used in the treatment of patients with various types of AF, and proved by a large number of evidence-based medicine that SSYX has a significant effect and can greatly reduce the side effects that may occur by using the AADs.The results of many clinical randomized controlled trials (RCTs) have indicated that complementary and alternative medicine has similar antiarrhythmic effects to AADs and has fewer adverse events.In the past, although some RCTs have compared the clinical efficacy of SSYX combined with AADs, but there were no studies comparing different combinations. In addition, although many positive outcomes have been demonstrated, however, the optimal threshold, the treatment regimens, and the efficacy and safety of using SSYX combined with AADs remain to be determined. Therefore, we are going to conduct this network meta-analysis (NMA) to confirm the clinical efficacy and safety of SSYX combined with AADs, to determine the optimal threshold and treatment regimen, and to provide evidence that individualized TCM therapy is beneficial in the treatment of AF.22.1 The protocol of this systematic review and meta-analysis was registered on the INPLASY website (https://inplasy.com/inplasy-2020-8-0075/) and INPLASY registration number is INPLASY202080075.This meta-analysis will be performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-NMA) statement.2.2In this study, we will search 7 commonly used databases: Cochrane Library, PubMed, Web of Science, EMBASE, Chinese Biomedical Literature Database (SinoMed), CNKI, and WanFang database. The retrieval time begins on the database's build date and ends in December 2019. The references of included studies will be tracked and those meeting the inclusion criteria will be supplemented. The search strategy will be adjusted according to the characteristics of different databases. Table 2.32.3.1RCTs regarding SSYX combined with AADs for AF will be included without language restriction.2.3.2 and the AHA/ACC/HRS 2019 guidelines for the management of patients with AF.All adult patients diagnosed with AF  will be included in the study. We will follow the 2016 European Society of Cardiology preliminary criteria for the clinical diagnosis of AF2.3.3Both the experimental group and the control group routinely treated for basic cardiovascular diseases, including antihypertensive, anticoagulant, lipid-lowering, diuretic and other treatments. According to the literature, the intervention methods were designed into following groups: SSYX with Amiodarone; SSYX with Propafenone; SSYX with Metoprolol; SSYX with Bisoprolol; others: alternative AADs.2.3.4Patients in the control group are those who only have received AADs treatment without SSYX.2.3.5The primary outcomes will be the frequency of AF attack and P-wave dispersion, which will be measured by electrocardiogram or 24 hours dynamic electrocardiogram result.The secondary outcomes will be: Symptom improvement, including palpitations, chest tightness, dizziness, blackness, fatigue, and other symptoms; left atrial diameter that measured by echocardiography; adverse events.2.4Three reviewers  will independently select the studies according to the inclusion criteria, then removing the duplicate and unqualified articles by reading the titles as well as abstracts. For the articles that meet the inclusion criteria, we will read the full texts to determine their eligibility. In addition, the reference list of eligible articles will be manually retrieved. If there is any inconsistency between the 2 reviewers, the corresponding author (YH) will make the final decision. The reviewers participating in the search are experienced clinical AF experts or evidence-based medicine methodology experts. The literature retrieval process of this study will use the PRISMA flowchart, as shown in Figure 2.5The 2 review authors (SS and GY) will independently extract the data of the included studies according to the data extraction table. The extracted information includes: author, year of publication, type of study, sample size, and follow-up time. If the data that needs to be extracted is not available in full text, we will contact the corresponding author. The multiarm test will be split into a double-arm test to ensure that the results can be combined.2.6 The evaluation contents include random sequence generation, allocation concealment, participants and personnel blindness, outcome evaluation blindness, incomplete outcome data, and selective reports. The risk of bias will be classified as “high risk,” “low risk,” and “unclear risk.”The quality of the included studies will be assessed according to the Cochrane collaboration's risk of bias tool.2.72.7.12 test and the Higgins I2 test for heterogeneity will be used.Standard pairwise meta-analysis will be performed using Stata V.14.0 software. Odds ratio (OR) will be used as the effect size for enumeration data, mean difference will be used for measurement data, and 95% confidence interval (CI) will be used for interval estimation. To explore between-study variability, the Cochrane Q statistic with the χ2.7.2 in which the posterior parameters will be calculated by Markov chain Monte Carlo methods. After an initial burn-in of 50,000, we will operate another 100,000 iterations. Surface under the cumulative ranking probabilities (SUCRA) values will be applied to rank the examined treatments, with SUCRA values of 100% and 0% assigned to the best and worst treatments, respectively.WinBUGS 1.4.3 will be used for network statistical analysis,,25 Besides, a comparison-adjusted funnel plot was used to test for the publication bias.The network geometry will be drawn by Stata 14.0. The larger arm indicates a larger amount of basic data of the intervention, and the larger circle area indicates a better effectiveness of the intervention.2.7.3 We will use local and global methods to assess whether there is statistical inconsistency in the data. Specifically, we will use the loop-specific approach to detect loops of evidence that might present important inconsistency as well as the node splitting approach to detect comparisons for which direct estimates disagree with indirect evidence from the entire network.Transitivity is the fundamental assumption of indirect comparisons and network meta-analysis, and its violation threatens the validity of the findings obtained from a network of studies.2.7.4To assess the impact of covariates and areas  of heterogeneity in our sample, we will explore subgroup analysis and/or use meta regression.We will conduct a sensitivity analysis to exclude each study sequentially and combine the remaining studies to identify the impact of each study on the overall outcome.2.7.5Publication bias will be assessed using funnel plots and the Egger test for direct comparisons with 4 or more studies. In the funnel plots, if the points representing the included studies are evenly distributed, it means that the publication bias is small.2.7.6It is not necessary for ethical approval because it is based on published studies. The protocol will be disseminated in a peer-reviewed journal or presented at a topic-related conference.3,31AF, as an arrhythmia disease with high prevalence, high disability rate, and high mortality rate, however, has poor clinical treatment effect. This network meta-analysis will conduct a detailed summary and analysis of SSYX combined with AADs in the treatment of atrial fibrillation to find the best treatment plan. Although the comparison of therapies in a network meta-analysis is conducted based on the direct comparisons of treatments and the indirect comparisons based on a common measurement, some factors may affect the outcomes of the analysis such as the number of articles included in the network, so we use the heterogeneity test, the inconsistency test, and several approaches to deal with those factors.However, there are still limitations in this network meta-analysis. Some studies of low quality may decrease the significance of the results in network meta-analysis. Moreover, heterogeneity of different studies may affect the final results of this study. Despite the limitations, a systematic review with the newest data should be conducted to show such combination of therapeutic method with better atria conduction and quality of life. Therefore, it is worthy to display this protocol for a systematic review. We hope our work will provide more convincing evidence to the clinicians about the treatments for patients with AF.The authors acknowledged Mr Kang Ren for his contribution to edit the English text of a draft of this manuscript.Conceptualization: Shuqing Shi, Qiu lei Jia.Data curation: Shuqing Shi, Jingjing ShiMethodology: Shuai ShiProject administration: Yuanhui HuWriting – original draft: Shuqing Shi.Writing – review & editing: Qiu lei Jia, Guozhen Yuan.


Scorpion stings in Brazil represent a major public health problem due to their incidence and their potential ability to lead to severe and often fatal clinical outcomes. A better understanding of scorpionism determinants is essential for a precise comprehension of accident dynamics and to guide public policy. Our study is the first to model the spatio-temporal variability of scorpionism across municipalities in São Paulo (SP) and to investigate its relationship with demographic, socioeconomic, environmental, and climatic variables.This ecological study analyzed secondary data on scorpion envenomation in SP from 2008 to 2021, using the Integrated Nested Laplace Approximation (INLA) to perform Bayesian inference for detection of areas and periods with the most suitable conditions for scorpionism.From the spring of 2008 to 2021, the relative risk (RR) increased eight times in SP, from 0.47 (95%CI 0.43–0.51) to 3.57 (95%CI 3.36–3.78), although there has been an apparent stabilization since 2019. The western, northern, and northwestern parts of SP showed higher risks; overall, there was a 13% decrease in scorpionism during winters. Among the covariates considered, an increase of one standard deviation in the Gini index, which captures income inequality, was associated with a 11% increase in scorpion envenomation. Maximum temperatures were also associated with scorpionism, with risks doubling for temperatures above 36°C. Relative humidity displayed a nonlinear association, with a 50% increase in risk for 30–32% humidity and reached a minimum of 0.63 RR for 75–76% humidity.Higher temperatures, lower humidity, and social inequalities were associated with a higher risk of scorpionism in SP municipalities. By capturing local and temporal relationships across space and time, authorities can design more effective strategies that adhere to local and temporal considerations. Scorpions cause approximately 3,000 deaths every year worldwide, second only to snakebites in terms of venomous animal-related human accidents due to the potency of their toxins. Natural habitat extinction combined with accelerated urban expansion have promoted greater contact between humans and many species of wild animals, and consequently increased the number of accidents and fatalities caused by these animals. Recognizing which environmental conditions are most associated with accident hotspots can help design better strategies for the control and distribution of anti-scorpion serum, for example. Here we show that scorpionism occurred more frequently in spring, and it decreased in winter. The areas with higher temperatures, lower humidity, and social inequalities were also associated with a higher risk of scorpion envenomation. Accidents caused by venomous animals pose a threat to public health. Among these accidents, those provoked by scorpions are becoming more frequent in many parts of the world. Owing to their high incidence and lethality, these fatalities are currently considered a global medical-sanitary threat . ApproxiTityus, and Tityus serrulatus (yellow scorpion) is the most dangerous species, causing many fatalities [Tityus serrulatus are typically nocturnal creatures and can be located in a variety of habitats, including rock crevices, tree bark, decaying tree trunks, beneath rocks and leaves, and within burrows and caves. The presence and abundance of these scorpions in a given area is largely dependent on factors such as temperature, humidity, and the availability of prey [Over the last decade, there has been a wide increase in scorpionism reports, particularly in Brazil, representing a leading cause of fatalities caused by venomous animals in the country . The maitalities . Due to talities . Tityus  of prey .Natural habitat extinction combined with accelerated urban expansion have promoted greater contact between humans and wild animals of many species, and consequently increased the number of accidents and fatalities caused by scorpions ,5,6. RecWe previously conducted a descriptive study of scorpionism in the state of São Paulo (SP) , where wThe present study was developed using secondary data provided by the CVE . The data form which was anonymized without names or addresses, and scorpion accidents were aggregated by municipality and year. The protocol for the present study was submitted for approval by the institutional ethics review board of the University of São Paulo School of Public Health  and no consent was required because we used anonymized secondary data.2, a population of around 45 million (21.8% of Brazil’s population), and accounts for 33.5% of the national GDP. The median monthly income per capita in 2021 was around US$ 348, but there is huge variation between municipalities reflecting the inequalities present in the state. Currently, 19.28% of the state is covered with native vegetation remnants [Eucalyptus plantations, sugar cane, and cattle pastures are the predominant agricultural land uses, accounting for approximately 39% of the state’s area [São Paulo is located in the southeastern region of Brazil, has an area of around 248,210 kme’s area . RegardiWe analyzed data on scorpionism reported between 2008 and 2021 in 645 municipalities of SP which are aggregated into 17 Regional Health Departments (RHDs) . Data onGeographic and demographic information on the municipalities were obtained from the Brazilian Institute of Geography and Statistics (IBGE), including the shape files of the study regions. In terms of environmental variables, we chose those most related to the scorpion life cycle according to previous literature ,13: totaThe observed data on scorpion envenomations were aggregated by sex and age for each season in each year and municipality. Then, using indirect standardization and the entire study region over the whole period as a reference population, we obtained the expected values after adjusting for age and sex . The ratOur response variable was the observed number of accidents in each municipality, season, and year, which we considered to be Poisson distributed. We included the log of the expected values in these models as an offset; therefore, the estimates were expressed as log relative risks (RR). On the log RR, we first specified a disease mapping model to estimate the spatiotemporal variability in scorpion envenomations for the 645 municipalities and each season over the 14 years considered. The model included a global intercept and spatial, temporal, and spatiotemporal random effects. As a second step, we ran an ecological regression model, including covariates, while retaining the random effects. The models were framed from a Bayesian perspective, and statistical inference was performed using the Integrated Nested Laplace Approximation approach (INLA) . The priThe incidence rate of scorpion envenomation in SP was 30.8 cases per 100,000 inhabitant-years over the entire period from 2008 to 2021, corresponding to more than 250 thousand notifications in SINAN. Among the covariates, there were outliers in the percentages of natural vegetation and rural population, and these were transformed using the square root. Maximum temperature, total precipitation, and relative humidity did not exhibit a linear relationship with the response variable. Using VIF and considering all covariates, we obtained values for total precipitation, relative humidity, and seasonal effects above 3.00, which is the suggested threshold to check for collinearity. While removing relative humidity did not improve the VIF, we found that removing total precipitation resulted in a VIF value below 3; therefore, we used this model specification.First, we ran the disease-mapping model, and the one with the lowest WAIC is the model with RW1 as the structured temporal random effect . We thenThe curve of the disease mapping model shows that the relative risk of occurrence of scorpion envenomation increased continually from 2008 to 2021 in SP, rising from 0.47 (95%CI 0.43–0.51) to 3.57 (95%CI 3.36–3.78) in natural scale; in general, higher values were seen in spring and lower values (except in 2021) in autumn . The temConsidering the disease-mapping model and the entire period, the values showed large spatial variability across the municipalities of SP, ranging from 0.0 to 18.9, with some presenting the risk of occurrence of scorpionism almost 19 times the average value for the entire period and state . MunicipOur ecological regression model suggests that the spring and summer seasons are risk factors, showing a 31% and 23% increase in scorpionism risk compared to autumn, respectively . In wintThe Gini index was the only socioeconomic variable that showed a positive association with the response variable, with an increase of one standard deviation corresponding to a 11% increase in accident risk. The purpose of the Gini index is to demonstrate the distribution of income within an economy . In otheOur data revealed a significant increase in the risk of scorpion accidents between 2008 and 2021, with spring being the season with the highest risk, and the western, northwestern, and northern regions of SP being the most affected areas . RegardiT. serrulatus for altered environments, as its modeled distribution was highly correlated with human population density in Brazil. The preference of this species for anthropically modified environments appears to be related to its parthenogenetic reproduction, as this type of reproduction is frequent in uniform environments such as urban areas [SINAN reported a progressive increase in the number of notifications related to venomous animals each year in Brazil ,32. Our an areas . The groOur results showed that RR increased continually from 2008 to 2018; however, since 2019, there has been an apparent stabilization in the number of cases. One hypothesis that can be raised is the underreporting of cases due to the COVID-19 pandemic, especially in 2020 and 2021 . The effOur findings showed that the spring and summer seasons were the periods with the highest risks, showing, respectively, 26% and 19% increase in scorpion accident risks compared to autumn, while winter showed a decrease of 13% in accident risks. The state of SP is located in a tropical area, and the four seasons of the year are not well defined. Nevertheless, spring tends to exhibit high temperatures. Related findings have been reported in other Brazilian regions ,40 and oMunicipalities with higher risk were located in the western, northern, and northwestern parts of SP. The most affected RHDs were Araçatuba, Barretos, Franca, Presidente Prudente, and São José do Rio Preto, as described previously ,9. OtherIn our model, the Gini index showed a positive association with scorpionism since an increase of one standard deviation represented a 13% increase in accident risk. The higher the Gini coefficient, the greater the income inequality, and consequently, the greater the differences in housing conditions and access to healthcare. Poor housing conditions and a lack of basic sanitation were found to be associated with an increase in scorpionism in Sergipe, Brazil . The assThe other variables investigated  did not show evidence of an association with accident risks. However, caution is needed when interpreting these results, as this is an ecological study, and an ecological fallacy could have been induced. Commonly, the “ecological fallacy” refers to the error of assuming that statistical relationships at a group level also hold for individuals in the group . HoweverRegarding the limitations of this study, we highlight the use of secondary data, which has already been collected and recorded by health facilities. A possible bias could be associated with this issue; the notification system is susceptible to underreporting, which can show incidences lower than real occurrence numbers. Nevertheless, the system has been enhanced over time, which is reflected in both the increase in notifications and in the requirements for health care . DespiteThe Brazilian Ministry of Health  suggestsOur results indicate that reducing the negative effects of scorpion envenomation requires a collaborative effort from multiple teams, such as environmental management, healthcare workers, researchers, and the general public. Destoumieux-Garzón et al.  have staThis study showed that the RR of scorpion accidents in the state of São Paulo increased eight-fold between 2008 and 2021. Municipalities with higher risk were in the western, northern, and northwestern parts of the SP. The most affected RHDs were Araçatuba, Barretos, Franca, Presidente Prudente and São José do Rio Preto. Accidents occurred more frequently in spring, while winter showed a protective effect, with a decrease of 13% in accident risk. In our model, the Gini index, which captures income inequality, shows a positive association with scorpionism. Other variables such as higher temperatures and lower humidity were also associated with a higher risk of accidents in the municipalities, corroborating what has been found in other surveys in Brazil and other countries. Future studies based on individual scorpionism, such as cohort or case-control approaches, should be conducted to confirm whether the variables analyzed here are actual risk factors. Additionally, future studies also should address issues related to the process of land occupation as well as the economic functions performed by municipalities and relate them to socio-environmental determinants.S1 Appendix(DOCX)Click here for additional data file.S1 Database(XLSX)Click here for additional data file.S1 MapPlease open with some Geographic Information System software.(ZIP)Click here for additional data file.S1 Code(R)Click here for additional data file.S1 TableWe considered three types of structured temporal random effects—RW1, RW2, and AR1, and two types of non-linear effects for the climatic covariates: RW1 and RW2.(DOCX)Click here for additional data file.S1 Fighttps://www.ibge.gov.br/geociencias/organizacao-do-territorio/malhas-territoriais/15774-malhas.html?=&t=acesso-ao-produto.Maximum temperatures of the municipalities of the state of Sao Paulo by seasons, for 2008 and 2021. Base layer of map: (PNG)Click here for additional data file.S2 Fighttps://www.ibge.gov.br/geociencias/organizacao-do-territorio/malhas-territoriais/15774-malhas.html?=&t=acesso-ao-produto.Relative humidity of the municipalities of the state of Sao Paulo by seasons, for 2008 and 2021. Base layer of map: (PNG)Click here for additional data file.S3 Fighttps://www.ibge.gov.br/geociencias/organizacao-do-territorio/malhas-territoriais/15774-malhas.html?=&t=acesso-ao-produto.Gini index of the municipalities of the state of Sao Paulo, 2010. Base layer of map: (PNG)Click here for additional data file.


The aim of this study was to assess the global burden of disease from non-communicable chronic diseases (NCD) due to diet low in fruits from 1990 to 2019.Based on data from the Global Burden of Disease (GBD) 2019, the global burden of disease due to diet low in fruits was analyzed for each country or region, disaggregated by disease type, age, sex, and year. The number of deaths and disability-adjusted life years (DALYs), population attributable fraction (PAF), age-standardized mortality rate (ASMR) and age-standardized DALY rate (ASDR) were calculated, and the average annual percentage change (AAPC) was calculated to describe trends in ASMR and ASDR from 1990 to 2019.p < 0.05) and −0.56 , respectively. For GBD regions, high PAF occurred mainly in South Asia, Oceania, and sub-Saharan Africa. Age-specific PAF for stroke and ischemic heart disease death attributable to diet low in fruits was significantly negatively associated with age. Diet low in fruits related ASMR and ASDR showed an M-shaped relationship with the socio-demographic index (SDI), but with an overall decreasing trend.From 1990 to 2019, the number of deaths and DALYs due to diet low in fruits increased by 31.5 and 27.4%, respectively. Among the tertiary diseases, ischemic heart disease, stroke, and diabetes and kidney disease were the top three contributors to the global increase in deaths and DALYs. However, both ASMR and ASDR showed a decreasing trend. The fastest decline in ASMR and ASDR was in stroke, with AAPC of −2.13 (95% CI: −2.22, −2.05, The number of deaths and DALYs due to diet low in fruits continues to increase. Therefore, early nutritional interventions should be implemented by the relevant authorities to reduce the burden of diseases caused by diet low in fruits. SuboptiFruits contain nutrients that benefit human health and are an important part of a healthy diet. Studies have shown that vitamin C in fruits can destroy cancer cells and inhibit tumor growth, so humans can supplement vitamin C and thus reduce cancer risk by consuming appropriate amounts of fruits  Figure . In addiDiet low in fruits is receiving increasing attention worldwide as important dietary risk factors. However, the burden of NCD attributable to diet low in fruits has not been systematically and quantitatively assessed. In this study, we counted the age-standardized mortality rate (ASMR) and age-standardized rate of DALY (ASDR) for diseases attributable to diet low in fruits in 204 countries and territories from 1990 to 2019. The mean annual percentage change (AAPC) of ASMR and ASDR was also calculated using a log-linear regression model to analyze trends from 1990 to 2019. And Pearson correlation coefficient was used to explore the relationship between socio-demographic index (SDI) and ASMR, ASDR attributable to diet low in fruits. This study provides a foundation for developing effective health strategies for dietary habits to reduce the future burden of disease attributable to diet low in fruits in different regions.2.2.1.Diet low in fruits is one of the risk factors in the Global Burden of Disease (GBD) Study 2019 database . The GBDAnnual cases and corresponding age-standardized rate and a population-attributable fraction (PAF) of disease burden due to diet low in fruits by disease, sex, age, and location from 1990 to 2019 were collected from the Global Health Data Exchange query tool,2.2.To assess the burden of disease and its trends during a specific period, we calculated ASMR/ASDR for mortality and DALYs, and their corresponding AAPC. ASMR/ASDR was calculated by aggregating measures of the rate that a population would have if it had a standard age structure. The weights are taken from the overall distribution of the standard population. The expression was:αi: specific age ratio, wi: number (or weight) of selected standard population. Estimated value was used to describe the burden of disease due to diet low in fruits by age, sex and year. To avoid effects due to the age composition of the populations, we chose the age distribution of the world population from the GBD 2019 study to standardize mortality and DALYs per 100,000 person-years for diseases caused by diet low in fruits.T is calendar year, a is the constant term, β is the regression coefficient, and ε is the random error term. If both the AAPC and the lower limit of 95% CI were higher than 0, the index was considered to have an upward trend. If both the AAPC and the upper limit of 95% CI were less than 0, the estimated was considered to have a downward trend. Otherwise, the index was considered stable over time , 459.33 thousand  for female and 586.69 thousand  for male . The numAt the SDI region level, the middle SDI region had the highest number of deaths attributable to diet low in fruits (325.58 thousand) and the highest number of DALYs (876.18 thousand), but the region with the highest ASMR and ASDR were low-middle SDI region. Among the 21 GBD regions, East Asia and South Asia ranked the top two in terms of deaths or DALYs attributable to diet low in fruits, but the top two ASMR occurred in Central Asia and Oceania, and the top two ASDRs occurred in South Asia and Oceania .Among the five tertiary diseases, the top three diseases in terms of the number of mortality and DALYs attributable to diet low in fruits were: ischemic heart disease, stroke, and diabetes and kidney disease, accounting for 87.7 and 89.2% of the total, respectively . In addiAt the country or territory level, the top three deaths attributable to diet low in fruits were in India, China and Russia , while I3.2.The global number of deaths caused by diet low in fruits increased from 795.57 thousand  in 1990 to 1046.01 thousand  in 2019, an increase of 31.5%. However, ASMR showed a decreasing trend overall, males and females with AAPC of −1.70 , −1.62  and −1.83 , respectively . From 19At the SDI region level, ASMR and ASDR decreased in all five SDI regions, with the fastest decrease in ASMR in the high SDI region with AAPC of −2.67  and the fastest decrease in ASDR in the high-middle SDI region with AAPC of −2.29 . Regarding the GBD region, ASMR in Sub-Saharan Africa and ASDR in Oceania were the fastest growing with AAPC of 0.09  and 0.09 , respectively. The ASMR and ASDR in Southern Latin America were the fastest de-creasing with AAPC of −3.73  and −3.65 , respectively . At the Among the 5 level-three diseases, ischemic heart disease, stroke, and diabetes and kidney diseases were the top three contributors to the global increase in deaths due to diet low in fruits, contributing 88.6% of the total increase in deaths from 1990 to 2019. ASMR decreased significantly in patients with stroke and ischemic heart disease, with AAPC of −2.13  and −1.57 , while ASMR did not change much in patients with diabetes and kidney diseases, with AAPC of 0.02  . Similar3.3.The PAF of ASMR for five tertiary diseases varied significantly between different regions . In 5 leTrends in PAF for deaths attributable to diet low in fruits varied with age across the 5 level-three disease types . Age-spe3.4.The ASMR and ASDR showed an overall “M” relationship with SDI, with a negative correlation, reaching the first peak at SDI = 0.4 and the second peak at SDI = 0.7 . AAPC of4.Using GBD study 2019 data, we systematically estimated trends in the burden of NCD due to diet low in fruits from 1990 to 2019. Globally, from 1990 to 2019, the number of deaths and DALYs attributed to diet low in fruits in-creased. But ASMR and ASDR decreased slightly, mainly in ischemic heart disease, stroke, and diabetes and kidney disease. Compared to females, the males had a more severe disease burden. The ASMR and ASDR caused by diet low in fruits were more significant in areas with low SDI and high-middle SDI, mainly in South Asia and Eastern Europe. Furthermore, PAF for ASMR or ASDR varied significantly between regions and age groups in the five tertiary diseases. These results help guide public health programs and inform strategies to change eating habits and improve health.In this study, it was found that the mortality rate and DALYs rate of elderly individuals due to diet low in fruits were higher than those of young individuals. This trend may be attributed to the weakened metabolism of elderly, which makes them less effective at absorbing and utilizing the nutrients in fruits within the timeframe when adverse effects of low fruit intake occur . In addiBetween 1990 and 2019, the burden of disease due to diet low in fruits in-creased in both males and females, with age-wide increases in the number of deaths and DALYs, but corresponding ASMR/ASDR decreased. This may result from the rapid growth of the global population . This stAround the world, ASMR or ASDR attributed to diet low in fruits showed an M-shaped association with SDI, showing an overall downward trend, while low SDI and high-middle SDI regions had higher disease burdens than other regions. The causes of death from NCD in low SDI regions include poor living environment, infection, inadequate resources and lack of access to health care . The disIn addition, this study found that the number of deaths and DALYs attributable to diet low in fruits were the largest in middle SDI regions, and the middle SDI regions were represented by countries such as China, Albania and Brazil. Studies have shown that young people in China prefer to eat fruit, consuming about twice as much fruit as elderly . China hper capita fruit intake in countries represented by Russia, Ukraine and Belarus in Eastern Europe is less than 300 g/d, while the per capita fruit intake recommended by WHO is 400 g/d . The reason may be the low fruit intake caused by the traditional diet culture in Eastern Europe . The per 400 g/d . The str 400 g/d . In all  400 g/d . The gro 400 g/d . In addi 400 g/d . We also 400 g/d . The dieper capita fruit intake in the Solomon Islands has decreased, and the consumption of sugar-sweetened beverages is the lowest, but the prevalence of hypercholesterolemia has increased significantly , the Shihezi University self-funded project (ZZZC202125), the Shihezi University College students’ innovation and entrepreneurship training program (SRP2022084), the Major Public Health Special Project of Xinjiang Production and Construction Corps (20100409), Science and Technology Project of the 8th Division of Xinjiang Production and Construction Corps (2018YL11), the seventh batch of “3152” Young Backbone Teacher project of Shihezi University.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The findings revealed a non-significant decrease in the surface roughness of EC, EP, and LP groups (p > 0.05), and both LP and EP have the lowest surface roughness values  after brushing, respectively. Toothbrushing showed a decrease in the microhardness of the three groups: EC and LP, p < 0.001; EP, p = 0.012). EP showed the lowest hardness value after brushing (862.45 ± 273.83). No significant changes (∆E) were observed in all groups (p > 0.05); however, the EC group was found to be considerably affected by color changes, in comparison to the EC and LP groups. Toothbrushing had no effect on surface roughness and color stability of all tested materials, but it decreased the microhardness. Material type, surface treatments, and glazing of ceramic materials contributed to the surface changes in the ceramic materials, necessitating further investigations in terms of the toothbrushing effect with different glazing as variables.Pressable ceramic restorations have been introduced and investigated, and found comparable to CAD/CAM ceramic in terms of mechanical properties; however, the effect of toothbrushing on the pressable ceramic has not been thoroughly investigated. The objective of the current study was to assess the effect of artificial toothbrushing simulation on the surface roughness, microhardness, and color stability of different ceramic materials. Three lithium disilicate-based ceramics , and LiSi Press [LP] ) were examined. For each ceramic material, eight bar-shaped specimens were prepared and subjected to 10,000 brushing cycles. Surface roughness, microhardness, and color stability (∆E) were measured before and after brushing. Scanning electron microscopy (SEM) was used for surface profile analysis. The results were analyzed using one-way ANOVA, Tukey’s post hoc test, and paired sample  Dental ceramics are inorganic, non-metallic materials used as dental prostheses to replace missing teeth and restore defective dental structures. Ceramics are the material of choice for long-term esthetics and stability . CeramicMany techniques have been reported for fabricating dental ceramic restorations. The conventional layering technique was designed to be used with the feldspathic porcelain, where the porcelain particles are mixed with glycerin or distilled water and are to be added in layers, mainly for metal-ceramic restorations. The limitations of this technique are that it is time-consuming, technique sensitive, and unpredictable . CeramicToothbrushing, as an example of surface wear, is another main factor that might influence the surface properties of ceramic materials. Many studies ,13,14,15The study of the effect of toothbrushing on restorations can lead to the development of new materials and techniques that are more durable and stable, improving the quality and longevity of dental restorations, as well as assisting in the selection of appropriate materials and techniques for fabrication. To our best knowledge, few studies have examined the influence of toothbrushing on different pressable and machined lithium disilicate ceramics. Therefore, this current study was conducted to assess and compare the effect of toothbrushing on the surface roughness, microhardness, and color stability of different ceramic restorations. The null hypothesis stated that toothbrushing has no significant effect on the surface roughness, microhardness, and color stability of tested ceramic materials.3. The materials’ information, compositions, and fabrications are summarized in G*Power ((Version 3.1.9.4) 5% alpha error, effect size = 0.59) was used for the sample size calculation . The cal3 were obtained, as per the International Organization of Standards (ISO standards 178:2010) 12  (color c−b*)2]12 .t-test was also used to compare mean differences before and after toothbrushing. A non-Gaussian distribution of color change (ΔE) data was found, so a non-parametric Kruskal–Wallis test was applied as an alternative to the ANOVA test. A post hoc Mann–Whitney U test was performed. A statistically significant difference was set at p-value ≤ 0.05. SPSS v.22.0  was used for data analysis.Numerical data based on measurements of Ra, microhardness, and color change were tabulated as mean and standard deviation (SD). A normality test (Kolmogorov–Smirnov test) showed normal data distribution for Ra and microhardness. A one-way ANOVA was used to compare the tested properties between the different study groups and post hoc Tukey’s test. A paired sample p = 0.993) and after toothbrushing . The paired differences of means within the study group for comparison of mean surface roughness before and after toothbrushing were also non-significant in each group, at a 5% significance level , though the difference was significant after toothbrushing . The paired differences of means within the study group for comparison of mean surface roughness before and after toothbrushing were found significant in each group at a 5% significance level  but non-significant after thermo-cycling . Paired differences of means ΔL* within materials EP and LP were non-significant (p > 0.05); however, it was significant in EC (p = 0.012). The results of mean Δa* between materials before and after toothbrushing were non-significant, respectively  and . Paired differences of means within each material revealed significance in EC (p = 0.012) and LP groups (p = 0.017). The results of mean Δb* between materials before toothbrushing  and after toothbrushing  were found highly significant. However, the paired differences of means of Δb* within each material before and after toothbrushing were non-significant  were performed by employing one-way ANOVA between the materials. The results of ΔL* showed a significant difference of means between the materials before thermo-cycling . A post hoc Mann–Whitney U-test for pairwise comparisons of color change (ΔE) between the materials is presented in The mean color change ΔE in EP, EC, and LP was 4.2 ± 1.55, 7.86 ± 4.13, and 11.67 ± 3.20, respectively, and was found to be non-significant when employing the Kruskal–Wallis test following a non-Gaussian distribution , and microhardness of CAD/CAM and pressable lithium disilicate dental ceramic materials was examined. The null hypothesis of this current study was rejected for the EC, EP, and LP groups for surface microhardness; however, the null hypothesis was not rejected for the surface roughness and color changes for all groups. With the increased demand for monolithic restorations, ceramic materials with various compositions have evolved to be applied in monolithic restorations, mainly for mimicking natural tooth shade and achieving comparable strength . IPS EmaOne of the various laboratory aging protocols is toothbrushing simulation , which sp value = 0.842). This is in accordance with previous studies that showed a non-significant change in the roughness (Ra) of extrinsically stained pressable and CAD/CAM lithium disilicate ceramics after toothbrushing [The current study aimed to assess the impact of toothbrushing simulation on different CAD/CAM and pressable lithium disilicate ceramics in terms of surface roughness, microhardness, and color change. Based on our findings, the Emax CAD, Emax Press, and LiSi Press groups showed a decrease in the surface roughness (Ra) after an equivalent of 1 year of toothbrushing; however, the decrease was insignificant, which may be explained by their excellent physicomechanical stability ,30. Addibrushing ,31,32. Obrushing ,34.SEM analysis showed a variation in surface roughness after brushing, as some faint serration lines started to appear, compared to the glazed specimens. However, it was observed that Ra values were non-significantly decreased for all materials. This may be attributed to the glaze effect the samples showed when received from the laboratory; glaze film may show peaks and valleys, resulting in a rougher surface. Toothbrushing affects these glazed materials and shows that the material substrates with smooth surfaces are related to the inherent surface properties of each material . This fiThis finding supports the findings made by Meng et al., who reported that different aging conditions did not influence the surface roughness of lithium disilicate glass-ceramic . MoreoveSurface hardness is an important property that compares dental materials’ resistance to surface penetration through the effect of brittle fractures and plastic flow, collectively. It can identify the wear resistance of materials, in addition to their abrasion effect on the opposing materials, which can directly influence materials’ finishing and polishability attributes . MicrohaMoreover, another reason behind the significant decrease in the microhardness of EC, EP, and LP after a simulation of 1 year of toothbrushing is the glaze on the ceramic surface ,43. The Esthetics is one of the essential aspects to be considered in the selection of a restorative material. The CAD/CAM and pressable lithium disilicate ceramics investigated in the current study are clinically used to construct anterior or posterior fixed restorations. Recent data have shown their excellent optical characteristics . These mThese findings coincide with Yuan et al., who found no significant color changes between CAD/CAM lithium disilicate ceramics after simulated toothbrushing . AdditioRegarding our findings on Emax CAD, the change in the shade was higher than the acceptable threshold (NBS = 3.89). Still, it was the lowest, compared with Emax Press (NBS = 7.23) and LiSi Press (NBS = 10.73), and as such might be advocated for its improved clinical color stability. Another reason is the difference in the firing temperatures, which might affect the glaze layer on the Emax CAD ,55. ThesOur results contrast with a previous study, which showed that the ΔE values of the CAD/CAM ceramics increased, and these changes were clinically acceptable . The varIt should be mentioned that while surface roughness is associated with ceramic color change, it is not the only reason for staining. One possible justification is that the pigmentation of ceramics is related to both extrinsic and intrinsic factors . For exaThe current American Dental Association (ADA) recommendation is to replace the toothbrush every 3–4 months. This rate might modify the findings of the current study. In the current study, the toothbrushes were changed after 5000 simulated toothbrushing cycles ,29 becauDespite the limitations of the current study, tooth restorations using these ceramic materials can be recommended for permanent use in patients with moderate tooth wear. One of the limitations is that it was an in vitro laboratory experiment with a short simulated toothbrushing time, which might have limited effects on the ceramic surface. Increasing the toothbrushing cycle time could influence the clinical preference for pressable and CAD/CAM lithium disilicate ceramics materials. Furthermore, the ceramic specimens were glazed on both sides, which differs from the clinical condition, in which the ceramic restoration is bonded to the surface of the tooth. The influence of surface roughness on the color stability of the CAD/CAM ceramics should be investigated and related to the spectrophotometer recordings. Various data should be obtained with various types of porcelain and polishing techniques . More exLittle evidence was reported on the influence of toothbrushing on the color stability and surface properties of pressable and machined lithium disilicate ceramics. Therefore, this current study was conducted to assess and compare the effect of toothbrushing on the surface roughness, microhardness, and color stability of different ceramic restorations. Based on the findings of present study, the following conclusions could be drawn:The surface roughness of Emax CAD, Emax Press and LISI Press are relatively resistant to 1 year equivalent toothbrushing. Emax CAD, Emax Press and LISI Press showed a decrease in the microhardness after 1 year equivalent toothbrushing. Emax CAD, Emax Press and LiSi Press are relatively resistant to color change. However, the Emax CAD ceramics exhibited considerable color change values with an equivalent to 1 year of simulated toothbrushing, compared to the pressable ceramics (Emax Press and LiSi Press). Regardless of material type, the change in tested properties is mainly attributed to the glazing, which improves the surface properties, especially after surface adjustment; therefore, further investigations focusing on glazing type and methods are recommended.