The lung is the most common distant metastatic organ in patients with endometrial cancer (EC) but is rarely reported. This study examines the association between clinical characteristics and overall survival (OS) in EC with lung metastasis.Patients with EC who had accompanying lung metastasis were selected from the Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2017. Univariate and multivariate Cox regression were used to estimate hazard ratios (HRs) and 95% confidence intervals (95% CIs) and assess OS outcomes related to EC with lung metastasis. A Cox proportional hazards nomogram model for OS was constructed and validated. The calibration plot, receiver operating characteristic (ROC) curve and decision curve analysis (DCA) were used to evaluate the discriminative ability and clinical benefit of the novel nomogram. Kaplan–Meier curves and scatter diagram analysis were used to investigate the risk stratifications of the nomogram.https://endometrialcancer.shinyapps.io/DynNomapp/. Additionally, patients in the high-risk group had a significantly worse OS than those in the low-risk group.Overall, 1542 EC patients with lung metastasis between 2010 and 2017 were included and randomly divided into training and validation cohorts. A nomogram model was constructed using the clinical characteristics of tumor grade, histological type, surgery, adjuvant chemotherapy, adjuvant radiation, brain metastasis and liver metastasis. The concordance indexes (C-indexes) were 0.750  and 0.743  for the training cohort and validation cohort, respectively. Calibration plots and DCA showed good clinical applicability of the nomogram. The areas under the curves (AUCs) were 0.803 and 0.766 for 1-year and 3-year OS, respectively, indicating that the nomogram model had a stable discriminative ability. An online calculator of our nomogram is available on the internet at An easy-to-use, highly accurate nomogram was developed for predicting the prognosis of EC patients with lung metastasis. Endometrial cancer (EC) is the most common gynecologic malignancy in developed countries, with approximately 66,570 new cases in the United States in 2021, and the incidence continues to increase by approximately 1% per year  have a poor prognosis. The incidence of stage IVB disease is approximately 5–10%, with a 5-year overall survival (OS) of less than 10%, despite the quality of multimodality therapy available , 4.Survival is dependent on other predictive factors. Abu-Rustum devised a nomogram based on five simple criteria  to predict the OS of EC patients with a high concordance probability . Lymph nThe data of women diagnosed with EC were obtained from the statewide SEER Program of the National Cancer Institute and queried using SEER*Stat software (version 8.3.5). The SEER database is the largest population‐based tumor registry in the United States, and nearly 97% of all incident cancer cases are captured within the registry area . PatientIn this study, clinical and pathological variables included age at diagnosis, race, histological type, tumor size, tumor grade, marital status, lymphadenectomy and distant metastasis . Adjuvant treatment included radiotherapy, chemotherapy, and surgery of the primary site recorded by program coding as defined by SEER. Tumor grades were defined as I (well differentiated), II (moderately differentiated), and III/IV (poorly differentiated or undifferentiated). For survival analyses, we collected information regarding the survival months, cause of death and cancer-specific mortality.All eligible patients were randomly divided into training and validation cohorts at a ratio of 7:3. The distribution of demographic and clinical variables was compared in the two cohorts using chi-square tests, and medians with interquartile ranges (IQRs) are used to describe continuous variables.In the follow-up statistics, we observed that among the 1542 enrolled patients, the numbers of death cases attributable to any cause and to EC were 96 and 1274, respectively; therefore, the primary outcome measure was OS in our study. OS was defined as the time interval between EC with lung metastasis diagnosis and death from any cause . Univariate Cox regression was used to estimate the hazard ratios (HRs) and 95% confidence intervals (95% CIs) to determine the statistically significant risk factors related to OS. Variables with a P value <0.05 in univariate analysis were incorporated into multivariate Cox regression analysis using a stepwise selection process with the Akaike information criterion (AIC).Next, the model with prognostic factors was used to construct a prognostic nomogram. The calibration curves based on the bootstrap method and decision curve analysis (DCA) curves at 12 and 36 months were used to validate the predictive accuracy and clinical applicability of the nomogram. The discrimination of the nomogram was quantified using time-dependent receiver operating characteristic (ROC) curve analysis for 12 and 36 months in the training and validation cohorts. The area under the curve (AUC) is a widespread metric used to evaluate classification models, especially in medical science. In addition, according to the median risk score by using the nomogram, all patients were divided into high- and low-risk groups. Kaplan–Meier and scatter diagram analyses were used to plot survival curves for group comparisons and to assess the significance of differences in event rates with the log-rank test in the training and validation cohorts .P < 0.05 was considered statistically significant.All statistical analyses were conducted with R software (version 3.6.1). Two-sided hypothesis tests were used for statistical analysis, and P > 0.05). A total of 1274 patients died after the follow-up cutoff date, and only 96 patients (7.53%) died due to causes other than EC. Notably, the prognosis of EC patients with lung metastasis was very poor, and the median survival time in these patients was only 8 months (IQR 2–19), with 1-year and 3-year OS rates of 38.06% and 9.86%, respectively.Overall, 1542 EC patients with lung metastasis between 2010 and 2017 from the SEER database were included. Patient demographic and clinical characteristics are summarized in P < 0.05). According to multivariate Cox regression analysis, histological type that was non-endometrioid, high tumor grade, absence of surgery, absence of radiotherapy, absence of chemotherapy, and presence of brain and liver metastases were all poor predictors of OS. However, age, race, marital status, bone metastasis and lymph node resection were no longer risk factors for EC patients with lung metastasis.As shown in We constructed a nomogram model Figure 1The concordance indexes (C-indexes) were 0.750  and 0.743  for the training cohort and validation cohort, respectively, which showed the good discriminative ability of this nomogram. Moreover, the AUCs of the time-dependent ROC curves in the training cohort were 0.803 and 0.766 for 1-year and 3-year OS, respectively, and those in the validation cohort were 0.785 and 0.746  and low-risk (risk score <150) groups according to the nomogram score. Kaplan–Meier survival curves were plotted and showed that patients in the high-risk group had significantly worse OS than those in the low-risk group  appeared to worsen long-term OS. This study also found that patients with non-endometrioid subtypes had shorter survival times than those with endometrioid subtypes, which is consistent with the findings of several retrospective studies , 8, 20. The C-indexes of the training and validation cohorts were 0.750 and 0.743, respectively. The training and validation cohorts, combined with the calibration plot, show that our nomogram has good discrimination and calibration capabilities. DCA curves are a new method for assessing whether nomogram-assisted decisions improve patient outcomes based on the threshold probability , 28. DCAThis study has several limitations. The main limitation is that T stage and M stage, overriding prognostic factors in EC, were not included in the nomogram since nearly half of the data were not available. Second, The Cancer Genome Atlas (TCGA) identified four molecular subtypes of EC , and thehttps://endometrialcancer.shinyapps.io/DynNomapp/. Overall, our nomogram is an easy-to-use, highly accurate tool to predict the prognosis of EC patients with lung metastasis.In conclusion, our study suggests that tumor grade, histological type, surgery, adjuvant chemotherapy, adjuvant radiation, brain metastasis and liver metastasis are independent prognostic factors. A nomogram was developed and validated for predicting the survival for EC patients with lung metastasis. To facilitate clinical use of this nomogram, an online calculator is provided at Publicly available datasets were analyzed in this study. This data can be found here: the SEER database.GY and YL designed the study and wrote the manuscript. YD collected the data from SEER database and contributed to the statistical analysis. XM performed figures and tables. YX and XZ contributed to the final data and manuscript revision. All authors contributed to the article and approved the submitted version.This study was supported by the Science and Technology Project of Hennan Province (LHGJ20210436) and Higher Education Key Scientific Research Plan of Henan Province(22A320007).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.


Heart Failure (HF) is a growing epidemic with a similar prevalence in men and women. However, women have historically been underrepresented in clinical trials, leading to uneven evidence regarding the benefit of guideline-directed medical therapy (GDMT). This review aims to outline the sex differences in the efficacy of pharmacological and non-pharmacological treatment of HF with reduced ejection fraction (HFrEF).via Medline from inception to 31 January 2022, including all randomized clinical trials published in English including adult patients suffering HFrEF that reported data on the efficacy of each drug. Baseline clinical characteristics, primary outcomes, and sex-specific effects are summarized in tables. The systemic review has been conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. In total, 29 articles were included in the systematic review. We observed that the proportion of women enrolled in clinical trials was generally low, the absence of a prespecified analysis of efficacy by sex was frequent, and the level of quality of evidence on the efficacy of GDMT and implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy (CRT-) in women was relatively poor.We conducted a systematic review Sex influences the response to treatment of patients suffering from HFrEF. All the results from the landmark randomized clinical trials are based on study populations composed mainly of men. Further studies specifically designed considering sex differences are warranted to elucidate if GDMT and new devices are equally effective in both sexes. Heart failure (HF) is a global epidemic that is growing every year, with a similar prevalence and incidence in men and women , 2. DuriHowever, women have been underrepresented in every landmark study, preventing us from concluding if the benefit of these therapies is unequivocally observed in both sexes . There aThe purpose of this systematic review is to describe the sex-specific differences in the efficacy of pharmacological and non-pharmacological treatment of HFrEF.This review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement .An electronic systematic review of the literature was conducted in the Medline database . The keywords used were chosen according to the MESH terminology:  AND . These terms were restricted to “Title/Abstract” and “English” (Language). The search was conducted from inception to 31 January 2022. In addition, we conducted a hand-searching of reference lists of all included studies and guidelines to identify further studies.The inclusion criteria were the following: (i) randomized clinical trials including adult patients (≥18 years of age) suffering from HFrEF and (ii) studies that reported data on the efficacy of each drug. There was no restriction on the publication date. We excluded animal studies, abstracts, editorials, commentaries, systematic reviews, and narrative reviews. Once duplicates were removed, all authors independently screened titles and abstracts to ensure the capture of all relevant studies. Disagreements were resolved by discussion to achieve consensus.p-value for interaction when available. The primary outcomes of interest were all-cause mortality or the combined endpoint of mortality and HF hospitalization. This systematic review was restricted to data published in manuscript or abstract form. We expressed study results as relative risk (RR) or hazard ratio (HR) with 95% confidence intervals (CI) when available.Data were extracted by the authors into predetermined tables using a standardized protocol. The data extracted were drug name, study name, year of publication, characteristics of the study population, number of included patients, number of women included, left ventricular ejection fraction (LVEF), efficacy primary endpoint, sex-specific outcomes, and Our electronic search retrieved 23,938 articles. After the removal of duplicates and those which did not fulfill inclusion criteria, 17 articles were identified. After hand-searching, 12 articles were identified. Finally, 29 articles were included in our systematic review. Two studies were reviewed according to the inclusion criteria , 13. TheTwo meta-analyses including the CONSENSUS and SOLVD study populations together with smaller studies showed that the mortality benefit of ACEI showed only a trend for benefit in women, without reaching statistical significance , 15.post-hoc analysis, bisoprolol reduced the mortality rates for both men and women after adjustment for baseline differences   . In the = 0.044) . The pri= 0.044) . The CarRR 0.69; 95% CI 0.51–0.93) and men   .post-hoc analysis adjusted for NYHA class, LVEF, use of ACEI and beta-blockers, and HF etiology, valsartan reduced the adjusted RR for the combined endpoint in women , but not in men  (Three studies were reviewed according to the inclusion criteria –26. The = 0.053) . The Can= 0.053) , 26. Thi= 0.053) .Three studies met the established search criteria for drugs –31. The HR 0.82, 95% CI 0.75–0.90, p < 0.0001) in 6,505 patients  with symptomatic HF and LVEF ≤ 35%, in sinus rhythm and with heart rate ≥70 beats per minute (bpm)  and deaths due to HF . This lower rate of the composite endpoint with ivabradine was similar in both sexes .The Systolic Heart failure treatment with the If inhibitor ivabradine Trial (SHIFT) study reported a significant reduction in the composite endpoint of cardiovascular death or HF hospitalization with ivabradine vs. placebo (te (bpm) . The effOnly the Prospective Comparison of Angiotensin receptor neprylisin inhibitor (ARNI) with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure Trials (PARADIGM-HF) met the inclusion criteria . This waHR, 0.74; 95% CI 0.65–0.85; p < 0.001). Moreover, a total of 276 patients (11.6%) in the dapagliflozin group and 329 patients (13.9%) in the placebo group died from any cause . In a prespecified subgroup analysis of the DAPA-HF, dapagliflozin reduced the risk of worsening HF, CV death, and all-cause death and improved symptoms, physical function, and health-related quality of life similarly in men and women with HFrEF. In addition, dapagliflozin was safe and well-tolerated irrespective of sex . The effect of empagliflozin on the primary outcome was consistent in patients of both sexes.Two clinical trials met the search criteria , 35. Thee of sex . The EmpIn total, 12 clinical trials were reviewed according to inclusion criteria –48. TablSeveral randomized trials have proven the efficacy of ICD to prevent all-cause death. As in most HF drug therapy trials, women were underrepresented in these studies, accounting for less than one-third of the total population –43. Overp for interaction = 0.01) , but less than one-third of them were women. The subgroup analysis of most trials did not show a significant difference in outcomes between men and women –48. An e = 0.01) .In this systematic review including 28 randomized clinical trials evaluating pharmacological and non-pharmacological treatment of HFrEF, we observed that: (1) the proportion of women enrolled was generally low, (2) the absence of a prespecified analysis of efficacy by sex was frequent, and (3) the level of quality of evidence on the efficacy of GDMT and ICD or CRT in women is relatively poor.Over the last 30 years, many significant advances have been made in the treatment of patients suffering from HFrEF. Thus, the main HF guidelines that have been recently published recommend starting neurohormonal drugs and SGLT2 inhibitors at the same level to achieve the maximum mortality risk reduction , 5. OnceHowever, this “foundational therapy” approach is not supported by the same level of quality of evidence when sex is considered. After reviewing the principal landmark trials involving drugs, we observed that women were repeatedly underrepresented and prespecified sex-based analyses were not performed. Only in the case of the most recent families, sacubitril-valsartan and SGLT2 inhibitors, we should be confident that the sex interaction was not significant when assessing the efficacy of the drug –36.This uneven supporting evidence is particularly relevant when epidemiological, physiological, and pharmacological differences by sex are known. The HF incidence increases over time with aging in both sexes and the overall lifetime risk for developing HF is also similar , 51. NevIn relation to devices, women are less likely to receive an ICD than men, but they have higher rates of device implantation-related complications. Instead, women are more likely to respond favorably to CRT than men, which can result in an improvement of survival rates. The reasons for this are not clear still but include differences in vascular access, higher hemorrhagic risk, QRS duration cutoff, and less ischemic HF origin .Our systematic review has some limitations. First, we only included randomized clinical trials in our study. Although publication and selection bias may arise because we selected those published in English, the main pivotal studies are usually published in this language. Second, since only aggregated data were available, it was not possible to perform a more granular analysis of clinical outcomes.Sex influences in the response to treatment of patients suffering from HFrEF. All results from the landmark randomized clinical trials are based on study populations composed mainly of men. Further studies specifically designed to consider sex-differences are warranted to elucidate if GDMT and new devices are equally effective in both sexes.The original contributions presented in the study are included in the article/supplementary materials, further inquiries can be directed to the corresponding author/s.MS and JÁ-G drafted the work. All authors made substantial contributions to the conception, design of the work, data acquisition, analysis, and interpretation of data for the work. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Studies conducted in the health sector have determined a positive relationship between job satisfaction and work engagement. However, this paper reveals that this relationship turns into a negative or non-significant relationship during the COVID-19 pandemic. We explore the reasons for inconsistency in research findings in this critical period through a meta-analysis.This study was conducted according to the PRISMA guidelines and PICO framework. Online databases including Web of Science, Scopus, PubMed, ProQuest, Google Scholar, and additional records from other databases were searched without any time limitation, and all studies published in English that reported the correlation between work engagement and job satisfaction were included in the analysis. In total, 36 individual correlation coefficients were synthesized. R statistical language was used to analyze the data.r = 0.57 (95% CI [0.50–0.64]). While the moderating effect of national culture was not statistically significant, presence of COVID-19 as the significant moderator explained 37.08% of effect size heterogeneity. Such that the presence of COVID-19 has transformed the positive relationship between work engagement and job satisfaction into a negative but statistically non-significant relationship.A total of 36 studies with a sample size of 16,087 were synthesized. The overall effect size was found as This study empirically challenges the existing assumptions about the positive link between work engagement and job satisfaction. The results of the research can be a guide for managers and policymakers. Specifically, based on these results, different mechanisms can be put in place to support work engagement and, in turn, job satisfaction in the COVID-19 process. The ongoing COVID-19 pandemic has caused radical changes in the ordinary routines of life. Undoubtedly, health sector workers are the worst hit in the COVID-19 pandemic  model  specify the overall effect size of the correlation between study variables and (b) analyze the moderating effect of the presence of COVID-19 on the overall effect size. The study reveals counterintuitive findings that challenged the previously established relationship between WE and JS, showing that the COVID-19 pandemic had an adverse impact changing the relationship between WE and JS to negative. We explain why this is and suggest future research directions in the conclusion section.Work engagement (WE) is one of the most critical drivers of positive organizational behavior outcomes. Leiter and Bakker  defined One of the positive and vital consequences of WE is JS  model  among the studies was calculated   framework, which is widely used in systematic literature reviews in the health field, was used ,Outcomes: Quality of the relationship between study variables .Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) followed the reporting of the process and results of this meta-analysis  The publication must be written in English.(2) The publication must have reported the correlation coefficient WE and JS.(3) If there is no correlation coefficient, it must have reported the values  to calculate the correlation coefficient.(4) The publication must have been done on healthcare workers.(5) The concepts must have measured with measurement tools in accordance with the definitions in the literature.On the other hand, research that did not meet the following criteria was excluded from the study:(1) The publication is written in other languages.(2) The publication has not had sufficient statistics .(3) Publications whose authors were reached by e-mail, but the necessary data were not provided.(4) Publications in which the sample does not only consist of healthcare professionals,(5) Studies that have not been handled with a quantitative method such as a book, book chapter, editorial, content analysis, or qualitative studies.r = 0.85, which is robust. Further, to evaluate the quality of the coded studies, we used Cicolini et al.'s (k = 32), medium (k = 4), and low (k = 0), respectively  healthcare professionals who primarily work in hospitals. As illustrated in I2 = 75% categorized as a high level of heterogeneity  . Based on these explanations results were considered as robust.Findings showed that 36 studies' amount of heterogeneity is above z = 16.612, p < 0.0001) , Fisher's r-to-z transformed correlation coefficients of individual studies ranged from −0.1851 to 0.9097. As a result of the meta-analysis run by choosing the random effect model, the average effect size was found to be μ =0.57 (95% CI: 0.50–0.64), which is positive and differed significantly from zero (001) see . Based o001) see .As can be seen in (35) = 358.78, p < 0.01, τ2=0.04, I2 =94.07%] for the correlation between study variables. To explain overall effect size heterogeneity moderator and subgroup analyses were run. Moderator analysis showed that the moderating effect of national culture was found as non-significant . On the other hand, it was found that presence of covid 19 significantly moderated the link between WE and JS . Because the total number of studies is 36 which is above K > 9 we conducted subgroup analysis  and Yes (during COVID-19) (k = 2). When the overall effect size  was compared with the subgroups effect sizes namely No (before COVID-19)  and Yes (during COVID-19) , the difference between the subgroups effect size was statistically significant (p < 0.001). Such that, while the correlation is small and negative (p > 0.05) during COVID-19, it is higher and positive before the COVID-19. Presence of COVID-19 explained 37.08% of effect size heterogeneity.There was a high heterogeneity in the included effect sizes [Q r = 0.57, the average sample size is 447, and a large level of heterogeneity (I2 = 94.07%), the estimated statistical power was calculated as 1 out of 1 is robust. Additionally, the power of moderator analysis was calculated based on the effect sizes of two groups namely before COVID-19  and during COVID-19 . Power of the moderator analysis is 0.99 out of 1. Lastly, power of the subgroup analysis showed that the minimum effect size difference required for sufficient power is 0.393. Accordingly, power for subgroup difference test (two-tailed) indicated that the power of subgroup analysis is 100% (Because most of the meta-analyses were conducted on a small number of individual studies calculating and reporting the power statistic of the meta-analysis is important in terms of minimizing Type 1 error (Borenstein et al.,  is 100% . Taken tThe relationship between WE and JS has been the focus of many studies. There has been consistent academic and policy interest in this relationship. Theoretically, the relationship between WE and JS is often considered settled to be positive. Yet, most studies that find such a positive relationship examine relatively stable and supportive work environments. There is a need for exploration of this relationship in different turbulent, dynamic, and adversarial contexts. The COVID-19 pandemic provides such a toxic context specifically for healthcare workers. In the volatile context of the COVID-19 pandemic, we question whether the positive relationship between WE and JS still holds a positive relationship. Our findings based on a meta-analytical study reveals counterintuitive findings that the relationship between WE and JS turns negative for healthcare workers in the context of the COVID-19 pandemic. We interpret this finding to suggest that the specific macro context shapes workplaces' beliefs, feelings, and behaviors. In a dramatic context, such as COVID-19 pandemic, where WE is not encouraged but enforced for healthcare workers, JS is adversely affected. Ardebili et al.  stated tDuring the pandemic, healthcare workers who worked on the front line, regardless of their temporal engagement, were the ones most at risk (Zhang et al., Most policy interventions focus on improving and strengthening WE. However, as in our study, policy interventions in a context where WE is regulated with coercive measures, JS declines. As highlighted in previous studies, insufficient job resources “precludes actual goal accomplishment, which causes failure and frustration” (Bakker et al., Moreover, providing organizational trust to employees at all stages of the work together with organizational support can increase the positive psychological capital of employees and alleviate the negative effects on JS Yildiz, . In emerProtective measures should be offered to meet personal demands and needs, such as flexible hours, dynamic workload management, employee allowances, motivational speeches from dedication leaders, effective leadership, a strong collaborative atmosphere, fast and easy transport to home, and alternative accommodation for employees who do not want to go home to prevent contagion after the shift (Chen et al., There are systematic reviews on JS and WE i.e., Harter et al. , HalbeslAlong with its strengths, this study has some limitations that can be addressed by future researchers. The pandemic process has reversed the positive relationship between WE and JS. Although we used national culture and presence of COVID-19 to determine the heterogeneity of the research results, the management of the pandemic varied by country, and these samples were also collected from workplaces operating under these conditions (Lulli et al., The scope of this study is limited to healthcare workers and their WE and JS relationship. Future research could explore the innovative policies that could mitigate the negative consequences of the pandemic on WE and JS. Researchers in different regulatory environments could also examine whether organizational support in healthcare setting moderates the link between WE and JS. Because of the analytic nature of this study, qualitative studies were not synthesized. To reach a deeper understanding of the topic, further research could examine the topic with systematic reviews or content analysis. Because searched databases were limited to the specific ones mentioned in the study's earlier sections, further research could also search other databases such as national thesis databases and online university libraries. This study investigated the moderator roles of presence of COVID-19 and national culture on the effect size heterogeneity. In explaining effect size heterogeneity, moderators play an essential role in the meta-analyses; therefore, to explore the source of heterogeneity, further research could test other moderators' effects such as age, gender, tenure, salary, and profession, and type of publication. Finally, despite the statistical power of this study being high, we investigated 36 studies conducted on healthcare workers due to the limited amount of research. It is recommended that future researchers conduct new research at periodic times, especially after the pandemic and when more research piles are formed.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.BY, TY, HY, and MO contributed to conception and design of the study. BY and TY organized the database and wrote the first draft of the manuscript. BY performed the statistical analysis. HY, MO, and BY wrote sections of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Graduates of doctoral (Ph.D.) programs are expected to be competent at designing and conducting research independently. Given the level of research competence needed to successfully conduct research, it is important that assessors of doctoral programs  have a reliable and validated tool for measuring and tracking perceived research competence among their students and graduates. A high level of research competence is expected for all Ph.D. graduates worldwide, in addition to in all disciplines/fields. Moreover, graduates of Ph.D. programs may complete their studies in one country but then obtain a research position in another country, emphasizing the need to ensure that all doctoral programs are fostering similar levels of research competence. Thus, the purpose of this study was to gather additional evidence for validity and reliability of the Research Competence (R-Comp) scale. Specifically, we sought to extend the findings of by adapting the scale, translating it to other languages, and applying the tool with a sample of early stage researchers. Our findings provide initial evidence that the adapted PR-Comp is appropriate for use in three languages and across a variety of disciplines/programs of study. The degree doctor of philosophy (Ph.D.) is considered a research intensive degree, designed to foster the development of independent researchers. Upon completion of a Ph.D. program, individuals are expected to be not only experts in their chosen field but competent in designing and conducting research independently following the rules of science ; this exAccording to self-determination theory SDT; , motivatResearch specifically focused on perceived research competence is limited both in quantity and in scope. Regarding graduate student and early career researchers’ perceived competence, research often focuses on broader perceived professional competency , clinicaReviewing the state of research, Methodological skills, skills in Reflecting on research findings, Communication skills, and content Knowledge  were primarily female (62.7%) and ranged in age from 19 to 64 with the average age being 33.1 (SD = 8.09) years of age. Our sample represented 28 nationalities (see n = 405) were still enrolled in a Ph.D. program; these students’ current year of study ranged from first (21.5%) to five or more (7.9%). Approximately 12% of the sample were recent graduates/early career researchers. Most students (n = 365) were enrolled in or completed their doctoral program full-time though 20% were enrolled part-time. Participants reported an average of 5.10 (SD = 3.14) years of research experience, including their Ph.D. experience; research experience ranged from not having any experience at all (n = 9) to as much as 22 years of research experience (n = 1). Lastly, slightly more than half (54.40%) of the sample had not attended any additional education or training on research methods outside of what their Ph.D. program offered.Current enrollees in or recent graduates of Ph.D. programs were recruited to participate in this study. Participants  native speakers of these languages and (2) worked and recruited in countries where these languages are predominantly spoken. The original R-Comp items were translated from German to English solely for publication purposes see . Our provia email or by seeing the study advertisement on social media then completed the questionnaire online, on their own time, in one sitting. Participants were informed their participation was completely voluntary and anonymous. After consenting, participants could choose to complete the questionnaire in either Catalan (n = 141), English (n = 111), or Spanish (n = 204). Data collection took place from late fall of 2019 to summer of 2020.Using an electronic recruitment campaign, a non-probabilistic sample of students and recent graduates from doctoral programs in Mexico, Spain, and the United States were recruited to participate in the study. Students were recruited from programs in these countries since the authors themselves worked in or had connections to programs in these countries. Additionally, students currently and recent graduates of doctoral programs were recruited to participate using social media advertisements. Consenting participants who received the link to the questionnaire either forward approach . To evaluate the model fit, we used 2X  for the language-models. All data were analyzed using SPSS and AMOS version 23.Data were screened for response patterns prior to analyses. Descriptive analyses were conducted and both Cronbach’s alpha and McDonald’s omega were calculated to examine the internal consistency of the five subscales in each language. Once internal consistency and normality within each language were established, we then conducted confirmatory factor analysis (CFA) using all data to confirm the five-factor structure of the PR-Comp and provide added evidence for validity based on internal structure. Model fit was assessed using the following indices: comparative fit index (CFI) > 0.95 ; Tucker-Prior to analyses, we examined descriptive statistics and assessed our data for missingness; our data were complete and as such, there were no missing data patterns identified. However, those completing the PR-Comp in English did tend to have higher scores than those completing the PR-Comp in Catalan and Spanish; all descriptive statistics are provided in 2X (5) = 12.58, p = 0.03. To assess model-data fit, we examined the RMSEA and its 90% confidence interval, the CFI, the TLI, and AICs of a five-factor model including all 36 PR-Comp items and a reduced five-factor with items having low or moderate scale-item correlations removed. Deleting items with low moderate scale-item correlations did not result in improved model fit. The full model resulted in a more favorable RMSEA value and a marginally more favorable CFI and TLI values as well as a lower AIC. However, the confidence intervals for the RMSEA provided weaker evidence of good model fit. Taking all of these indices together, the five-factor model including all 36 items was championed . The patients/participants provided their written informed consent to participate in this study.CQ-P and SM were the leaders of this project and contributed most to the project by designing the study and taking the lead on manuscript preparation. KN and ES-I contributed to data collection efforts and drafted the initial introduction of the study. JM-F supported data collection and reviewed drafts of the manuscript. All authors contributed to data collection efforts and manuscript preparation.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.


This study aimed to identify the subgroups of individuals sharing similar blood pressure (BP) trajectories from childhood to youth and explore the associations of these trajectories with arterial stiffness in adulthood.A group-based trajectory model was used to identify BP trajectories among 2,082 individuals in the Hanzhong adolescent hypertension cohort by using BP values repeatedly measured at four visits from childhood (6–15 years) to youth (14–23 years). The brachial–ankle pulse wave velocity (baPWV) was examined 30 years after the baseline survey. Mixed linear regression models were used to examine the associations of these trajectories with adult baPWV.n = 889), medium-level group , and high-level group (n = 172). The baPWV in adulthood was higher in medium-level and high-level groups compared with the low-level group . After adjustment for potential confounding factors, the association between baPWV and systolic BP trajectories was statistically significant . Similar results were obtained for the association of baPWV with the trajectories of diastolic BP and mean arterial pressure (MAP), except for pulse pressure.Among the 2,082 individuals, three trajectory groups of systolic BP were identified as follows: the low-level group (Our investigation demonstrates different BP trajectories from childhood to youth and shows the trajectories of systolic BP, diastolic BP, and MAP are significant predictors of arterial stiffness in adulthood. Increased arterial stiffness is increasingly recognized as a surrogate endpoint for cardiovascular disease (CVD) . As an iBlood pressure (BP) level is closely related to baPWV in the same period, whereas whether long-term baPWV can be independently predicted by BP in childhood remains controversial –5. It isIn the present study, we aimed to identify the subgroups of individuals sharing similar BP trajectories from childhood to youth and explore the associations of the trajectories with baPWV in adulthood on the basis of longitudinal data from the Hanzhong adolescent hypertension cohort recruited in 1987.The Hanzhong adolescent hypertension cohort is a prospective cohort study that recruited 4,623 school students aged 6–15 years old from 26 rural areas in three towns in Hanzhong City, Shaanxi, China, in 1987. Thereafter, this cohort was large-scale followed up in 1989, 1992, 1995, 2013, and 2017. A more thorough description of the study design and conduct has been previously published . WrittenIn the latest follow up (in 2017), a total of 2,780 individuals were examined, and 1,832 individuals were absent . During this period, baPWV measurement was performed in 2,461 individuals. After excluding 379 individuals with less than three BP measurements from childhood to youth (1987–1995), the remaining 2,082 participants were included in the analysis .2). Cigarette smokers are defined by the World Health Organization (WHO) as individuals who smoke at least one cigarette daily for a continuous period of at least 6 months. Family history (FH) of hypertension at the baseline was defined as a minimum of one first- or second-degree relative suffering from hypertension.Demographic characteristics, personal/family medical history , parents’ educational levels (at baseline), current medication use, family medical history, cigarette smoking, and drinking history were obtained through a self-administered questionnaire. Anthropometric indicators, including height, body weight and waist circumference were measured repeatedly during each visit, and the mean of each parameter was used for analysis. Height and weight were measured on individuals without shoes and wearing underwear. Height was measured to the nearest 0.2 cm and weight to the nearest 0.5 kg. BMI was calculated as kilograms per square meter , total cholesterol (TC), and high- and low-density lipoprotein cholesterols  were measured using a Hitachi 7060 automatic biochemical analyzer.Sitting blood pressure (BP) were measured at the baseline and during each follow-up period by using mercury (1987–2013) or electronic sphygmomanometer  by trained and certified staff members in accordance with the procedures recommended by the WHO or operating instructions in a quiet and comfortable environment . The appThe baPWV was assessed using an automatic arteriosclerosis diagnostic device BP-203RPE III  in a quiet and comfortable environment. The operator encoded the following information of subjects in the user interface: name, gender, height, body mass, and date of birth. Measurements were performed on the subject in a supine position after a rest period of 5 min, with cuffs wrapped around both sides of the upper arm and ankle, electrocardiogram electrodes sandwiched both wrists, and a heart sound sensor placed on the fourth intercostal space left sterna border. PWV, BP, electrocardiogram, and heart sounds were simultaneously recorded by the instrument. The time interval between the upper arm and ankle (ΔT) was defined as the time interval between the wave front of the brachial waveform and that of the ankle waveform. The path length from the suprasternal notch to the brachium (Lb) or to the ankle at the same side (La) was automatically calculated according to the subject’s height using the following formulae : Lb (cm)All analyses were conducted using Stata software version 12.1  and SPSS16.0 . BP trajectories were identified using group-based trajectory models within a Stata plugin program (Traj) . The modN = 86). A p-value < 0.05 was considered statistically significant in this study.The associations of BP trajectories with baPWV in adulthood were analyzed by mixed linear regression model with unstructured covariance. In the full adjusted model, BP trajectories were used as dummy variables, and the trajectory group with the lowest BP level was treated as reference. The number of visits was included as a random variable. Associations were adjusted for time-dependent variables , biochemical indicators , and categorical variables . For observing whether interactions occur between gender and BP trajectory groups, gender × SBP trajectories and gender × DBP trajectories were incorporated into the corresponding overall association analysis. We also performed hierarchical analysis based on sex. In addition, to exclude the impact of medication use at the last follow up on the results, we performed sensitivity analysis after excluding individuals who were taking antihypertensives, hypoglycemics, or statins at the time (n = 889) of participants began with a low SBP, which increased from 1987 to 1995, but only up to around 110 mmHg (referred to as low-level group). Meanwhile, 46.8% (n = 1021) of the participants were measured with an SBP of 100–110 mmHg and manifested rapid BP increase over the 8-year period that remained < 125 mmHg (referred to as the medium-level group). Lastly, 10.0% (n = 172) commenced at high levels and experienced the highest increase in SBP throughout the observation period (referred to as the high-level group). Meanwhile, the three DBP trajectories were low-level (35.2%), medium-level (54.9%), and high-level (9.8%). The trajectories differed at the baseline and increased over time . Similar trends were found in the DBP and MAP trajectories, except for the PP trajectories (The characteristics of participants at baseline and the last follow-up based on different SBP trajectory groups are presented in ectories .ptrend < 0.001). After adjustment for potential confounding factors in early life, the association between baPWV and the SBP trajectories remained statistically significant . For DBP trajectories, the trajectory level was a significant predictor of arterial stiffness in adulthood . Furthermore, no interaction effect was found between sex and SBP or DBP trajectories in the overall association analysis .p < 0.001). Additionally, a significant positive association was observed between baPWV with PP trajectory levels when adjusted for gender and age. However, this association completely disappeared after further adjusting for the time-variant variable SBP . No significant change in the values and characteristics of BP trajectories were noted . In addition, the MAP trajectory groups, but not the PP trajectory groups, were also independently associated with long-term arterial stiffness.Arterial stiffness can be improved by several medications, including antihypertensive and hypoglycemic drugs or statins . We perfre noted . MeanwhiIn a perspective cohort of 2,082 Chinese children and adolescents, we identified three trajectories for SBP and DBP from childhood to youth using BP measurements at four time points over 8-year period. In addition, we conducted a 30-year follow-up study and found that high BP trajectories from childhood to youth were associated with high baPWV in adulthood. Identifying BP trajectories from childhood to youth may provide an effective approach to distinguish populations with increased risk for developing CVD.Recently, increasing attention has been focused on the BP trajectory because of its potential role in cardio- and cerebrovascular diseases and end points , 17. At To date, the relationship between BP trajectory in early life and long-term arterial stiffness remains unclear. To our knowledge, this study is the first to illustrate the issue. Our results showed that baPWV in adulthood was higher in medium-level and high-level groups compared with the low-level group. More importantly, after adjustment for age, sex, SBP, DBP, and current medication use, high SBP trajectories from childhood to youth were identified as significant predictors of increased adult baPWV. The results obtained seem to be best explained by the relationship of arterial stiffness with BP load and cumulative burden over time. Aatola et al.  demonstrIn view of the significant impact of higher BP trajectories on long-term arteriosclerosis and the developmental heterogeneity in BP trajectories over time, it is particularly important to explore the various risk factors that differentiate between normal and pathological BP trajectories early in life. Height is known to be a main determinant of BP in children and adolescents, and is commonly used in the assessment of childhood BP status and the standardization of PWV , 28. To Several limitations exist in the current study. First, since this study were followed up for 30 years, combined with the study population were in young-adult stage, with great daily liquidity, resulting in high dropout rate during the last two visits. Second, considering the study conditions, biochemical indicators  from childhood to youth were unavailable for discounting the potential confounding effects of metabolic factors. Finally, the study population comprised a Chinese Han population from rural areas of China. The baseline age was 6–15 years. BP trajectories are affected by factors, such as race, region, and age; therefore, the extrapolation of the results to other homogenous populations should be performed with caution.In summary, different BP trajectories exist from childhood to youth, and the trajectories of SBP, DBP, and MAP are significant predictors of arterial stiffness in adulthood. Monitoring BP trajectories from childhood to youth may provide an effective approach for distinguishing populations with increased risk for developing CVD. Further study needs to optimize the time taken to identify common BP trajectories and determine high-risk individuals for carrying out targeted prevention as early as possible.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by the Academic Committee of the First Affiliated Hospital of Xi’an Jiaotong University. Written informed consents were obtained from all participants at each visit, and for those under 18 years of age at baseline, consent from a parent/guardian was obtained.CC and J-JM were responsible for designing the study and writing of the manuscript. CC, Y-YL, M-JH, QM, W-LZ, YY, J-WH, X-JX, and Y-NF performed the follow-up of this cohort and collected the data. Y-YL and M-JH analyzed the data and revised the manuscript. R-HY and J-JM were responsible for research organization and coordination. All authors read and accepted the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.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.


As an important rare earth element (REE) extensively applied to industry, agriculture, and medicine, lanthanum (La) has attracted a host of health concerns. This study aimed to explore the relationship between La exposure and the risk of developing oral cancer through a case-control study with a large sample size. Serum La levels of 430 oral cancer patients and 1,118 healthy controls were detected by inductively coupled plasma mass spectrometry (ICP-MS). The association of La level with the risk of oral cancer was assessed in two ways: (1) as a continuous scale based on restricted cubic splines (RCS); (2) as a priori defined centile categories using multivariate logistic regression model, based on propensity score matching (PSM) and inverse probability of treatment weighting (IPTW). The RCS revealed a non-linear U-shaped relationship between serum La and oral cancer risk. Serum La deficiency or excess was associated with an increased risk of oral cancer. When the La level was analyzed as a categorical variable, a similar U-shaped association was observed. Of note, compared to those with La concentrations of 0.243–0.341 μg/L , the risk was increased in those with the lower or higher quantiles . The results were generally consistent with the PSM and IPTW analyses. This preliminary study provides strong evidence that there was a U-shaped relationship between serum La levels and oral cancer risk. Much additional work is warranted to confirm our findings. Oral cancer, the most common kind of head and neck tumor, is a collective term for malignant tumors that arise in the lip, tongue, gums, floor of the mouth, jaw, buccal mucosa, oral vestibule, and other sides . Accordivia numerous routes, including skin absorption, respiratory and dietary intake via the oral cavity. A recent study investigated the residual levels of REEs in 14 representative food categories collected from 33 major cities in China and found La being the second most abundant REEs in all food samples (Lanthanum (La) is one of the most common elements of REEs (rare earth elements), and it has been widely utilized in diverse fields for decades, including agriculture, catalysis, pharmacology, and electronics , 6. Year samples . Moreove samples , 10. Lon samples –14. ThusSeveral experimental studies have indicated that La has an anti-cancer effect on several cervical cancer cells, hepatocellular carcinoma cells, and ovarian cancer cells –19. OtheThe case-control study was carried out from January 2010 to August 2019 in Fujian Province, China. A total of 430 newly diagnosed cases of oral cancer were enrolled from the First Affiliated Hospital of Fujian Medical University. During the same period, a total of 1,118 healthy controls were recruited from the health examination center of the same hospital.The following are the inclusion and exclusion criteria of the study: Participants in both case and control groups were (1) aged 20–85 years old; (2) lived in Fujian Province for more than 10 years; and (3) answered questions clearly. All cases were (1) primary oral cancer with post-operative histologically confirmed; (2) had never previously received chemotherapy or radiation therapy. All controls had no history of oncological diseases. If any of the following conditions were met, participants were excluded from the study: (1) with severe systemic infections, severe heart disease, hepatic disease, renal system and hematopoietic system disease, malnutrition of the whole body, or systemic immune diseases; and (2) had taken long-term medications or dietary supplements that would interfere with study outcomes.This study was conducted in compliance with the Declaration of Helsinki's ethical principles and was authorized by the Fujian Medical University's Institutional Review Board in Fuzhou, China .Relevant information on each subject was gathered through a face-to-face-based structured questionnaire by trained professional investigators. All the participants signed informed consent. The information we collected mainly included: demographic characteristics , lifestyle habits , and dietary factors . Smokers were classified as those who smoked more than 100 cigarettes throughout their lives . AlcoholFasting venous blood samples (about 3–5 mL) were donated from the patients on the second day of hospitalization before any drug treatment or examination. Also, the blood samples of the healthy controls were obtained on the day of their physical examination at the same hospital. All samples were centrifuged at 3,000 rpm for 10 min at 4°C and then were preserved at −80°C until measurement.3) and 4 mL of ultrapure water for microwave digestion . The surplus acid was then evaporated at 140°C until the solution was almost dry. The digested samples were diluted with 5% nitric acid to a volume of 10 ml. The concentrations of La were then determined by inductively coupled plasma mass spectrometry .The detailed methodology for elemental detection can be found in our previous study , 30. BriFor quality control, human hair powder  the closest human composition standard for serum La, was utilized as internal standard reference material for continuous monitoring of the efficiency and accuracy of ICP-MS analysis. Briefly, each batch included at least two experimental blanks and two quality control samples. Simultaneously, 12.5% of each batch's samples are chosen at random for parallel sample testing, and the relative standard deviation of the parallel sample testing findings does not exceed 10%.Chi-square or Fisher's exact tests were performed to compare baseline characteristics between oral cancer patients and controls. The serum La level was represented as a median (quartile25–quartile75), and the Wilcoxon rank-sum test was used to examine the difference between cases and controls. The association between La levels and oral cancer was assessed using a continuous scale or restricted cubic spline curves (RCS) based on multivariable logistic regression analysis with adjustment for covariates. To balance the best fit and overfitting in the major splines, five knots were chosen at the fifth, 27.5th, 50th, 72.5th, and 95th percentiles of the La distribution based on the lowest Akaike information criterion value. To avoid possible selection bias and balance demographic differences and other confounding variables, propensity score analyses, including propensity score matching (PSM) and inverse probability of treatment weight (IPTW) analyses, were applied. In PSM, the matching ratio was 1:1 ratio, and the caliper was 0.02 with 288 cases successfully matched with 288 healthy controls. Given that PSM can cause sample loss, we also performed the estimated propensity scores to calculate IPTW. After PSM and IPTW, group differences were assessed using standardized mean differences (SMD), with an SMD value of 0.1 deemed balanced.P-value < 0.05 was considered statistically significant. All analyses were performed using R software version 4.0.5.Furthermore, associations between seven established La classes and oral cancer in unmatched and matched populations were investigated. The categories of La were defined by the 5th, 20th, 40th, 60th, 80th, and 95th centiles with the reference category (41st−60th centiles) determined by the La level linked with the lowest risk of oral cancer in RCS analysis. Finally, multivariate-non-conditional logistic regression  and conditional logistic regressions (for PSM and IPTW populations) were utilized to calculate the odds ratios (ORs) and the 95% confidence intervals (CIs) of the relationship between La classes and the risk of oral cancer. A 2-tailed The study comprised a total of 1,548 participants, with 430 oral cancer patients and 1,118 healthy controls. The baseline characteristics of the study participants are summarized in P < 0.001, data not shown]. Then, the multivariable-adjusted restricted cubic splines revealed a non-linear U-shaped association between serum La and the risk of oral cancer, which indicated that low or high levels of La both increased the risk of oral cancer (Pfornon−linear < 0.001). The lowest risk was observed at 0.28 μg/L level of La  promoting cell proliferation and high concentrations (180 μM) inhibiting cell growth. The same pattern of effect was also observed in the HT-29 cells . These fu et al. , found tu et al. , 17. Sevu et al. –33. Neveu et al. –36. The u et al. , formatiu et al.  as well u et al.  or variou et al. , 36. Solu et al. –23. Thes3 on cisplatin-induced inhibition of ovarian cancer cell proliferation and tumor growth has been found  and identifying specific forms of La are therefore needed. Third, although our study provides a reference range of serum La concentrations for the lowest risk of oral cancer, identifying the pharmacological effects is challenging at this stage, and much more extensive research will need to be performed.The strength of this study is to utilize two powerful approaches  to significantly reduce potential selection bias and confounding effects and to provide the first epidemiological evidence of a non-linear association between serum La and the risk of oral cancer in the Asian population. However, certain limitations should be mentioned. Firstly, due to the case-control design of this study, the causal direction of the associations cannot be settled, due to the lack of a temporal relationship. Thus, our findings need to be further validated in multi-center, longitudinal population cohorts, whilst In summary, the present study suggests, for the first time, a non-linear U-shaped association between serum La levels and oral cancer risk, with both excess and deficient serum La exhibiting unfavorable effects. These observations shed new light on the role of serum La in oral cancer and have important public health implications as environmental La exposure is a growing concern. In parallel, further research is needed to uncover potential mechanisms of La, which will facilitate the use of La in the diagnosis and treatment of oral cancer and provide new techniques to enhance tumor prevention.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.This study was conducted in compliance with the Declaration of Helsinki's Ethical Principles and was authorized by the Fujian Medical University's Institutional Review Board in Fuzhou, China . The patients/participants provided their written informed consent to participate in this study.JW, BH, and FL participated in the design of the study. YuyW, YuxW, YC, LL, and YQ were responsible for recruitment and interviewing participants. LP, XZ, and LW contributed to sample collection. JW, JC, and FC performed laboratory experiments. QD and YuxW analyzed the data. FC, JW, and QD wrote the manuscript and which was revised by all authors. All authors contributed to the article and approved the submitted version.This study was funded by the High-Level Talents Research Start-Up Project of Fujian Medical University (No. XRCZX2018001) and Central Government-Led Local Science and Technology Development Special Project (No. 2020L3009).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 aim of this study is to compare the muscle strength, balance ability, thickness, and stiffness of the tibialis anterior and gastrocnemius muscle in the elderly, with  and without  fall experience, and confirmed the correlation between the variables mentioned above and muscle stiffness in the faller. We selected 122 elderly participants, comprising 40 fallers and 82 non-fallers, and measured the muscle strength of the tibialis anterior (TA) and the gastrocnemius (GA). Balance ability was measured by the functional reach test (FRT), timed up and go test (TUG), short physical performance battery (SPPB), and gait speed (GS). We used shear wave elastography (SWE) to determine the thickness of the TA and the medial (GAmed) and lateral head (GAlat) of the gastrocnemius and the stiffness during relaxation and contraction. Balance ability, except muscle strength, was significantly lower in fallers compared with non-fallers. The GAmed and GAlat thickness were significantly lower in fallers than that in non-fallers. In fallers, the thickness, rest, and contractive stiffness of GAmed were correlated with the FRT, GS, SPPB. Low rest and GAmed contractive stiffness were related to lower balance ability in fallers. The muscle stiffness measurement using SWE was a novel method to assess potential fall risk. In older adults, the risk of falling affects their physical ability to maintain independence . These fAccording to a recent study, the stiffness or elasticity of the lower extremity muscles during contraction is correlated with physical functions such as fast walking speed. ,14. UsinEvaluating changes in muscle properties, such as muscle stiffness of the lower extremities rather than muscle strength or physical function, may be more effective in the early recognition of deterioration in balance function in the elderly, such as the risk of fall. Therefore, we aimed to compare the balance ability, muscle strength, thickness and stiffness of the TA, GAmed, and GAlat in community-dwelling and independently living older adults, with  and without fall experience . In addition, we intended to determine the correlation between the above-mentioned parameters and muscle stiffness in fallers. We hypothesized that the stiffness of the TA, GAmed, and GAlat was lower in fallers than that in non-fallers, considering their decreased physical function and that these differences were associated with a decline in balance ability.We performed a cross-sectional trial. All participants were provided detailed information on the study procedure and safety, and they provided their written informed consent. All study procedures were approved by the Institutional Review Board (1044396-202105-HR-097-01), and the study was conducted in accordance with the tenets of the Declaration of Helsinki. Data were collected from July 2021 to August 2021.We enrolled 122 older adults  through various means of community center advertisement, such as posters. The participants were selected by telephonic interviews according to the eligibility criteria. The inclusion criteria were: (1) the ability to independently perform activities of daily living; (2) no history of cardiovascular disease (except hypertension); (3) no history of surgery for musculoskeletal disorders of the lower extremities; and (4) no history of neurological disorders, such as cerebral infarction. (1) Individuals who had a mini-mental state examination score of less than 24; (2) were unable to walk without assistive devices; (3) had premorbid or current orthopedic problems involving the lower extremities; and (4) did not undergo the measurement procedures were excluded.The participants were contacted one day prior to the study date. On the study day, they completed questionnaires on demographic characteristics and fall experience, including the number of falls in the past year. Then, other than assessing their balance and muscle strength, we performed the mini-mental state examination to screen for cognitive dysfunction. Finally, we measured the muscle thickness and stiffness. All data collection was performed at the university laboratory.This study used the G*Power 3.1.7 software  to calculate the sample size, which was determined based on the one-tailed test, power = 0.8, α = 0.05, and effect size = 0.5. The calculated sample size was 102, and a dropout rate of about 20% was considered. A total of 137 elderly participants were recruited; of these, 9 were excluded and 8 did not complete the procedure. The remaining 122 participants were then divided into the experienced  group and the non-experienced  group.The cognitive function of participants was evaluated using the Korean version of the Mini Mental State Examination (K-MMSE) . MMSE isBalance ability was measured by the functional reach test (FRT), TUG time, short physical performance battery (SPPB) score, and gait speed was use for assessing the fall risk. The FRT represents the maximal distance a person can reach forward beyond the arm’s length while maintaining a fixed base of support in the standing position , and it Muscle strength was measured by maximal isometric spontaneous contractions in the dominant leg using a MicroFET2 handheld dynamometer . This battery-operated load cell system has a digital readout of the peak force expressed in Newtons (N). The device can select a high or low threshold for the minimum force required to initiate the test. The device was calibrated by the manufacturer prior to the initiation of the study . The maxWe measured the thickness, rest, and contraction stiffness of the TA, GAmed, and GAlat of the dominant leg. We measured the thickness of each target muscle in a relaxed state, followed by the rest stiffness. Then, the participants were requested to contract the leg for 10 s to measure the contractive stiffness. Thickness and stiffness were measured using an RS85 ultrasound machine  equipped with a 5–10 MHz linear probe. Muscle thickness was measured in cross-section using B-mode . Subsequently, we rotated the probe in the direction of the muscle fiber and acquired the rest and contractive muscle stiffness in the longitudinal plane using the SWE mode. Muscle thickness was measured as the distance between the superficial and deep aponeurosis .For muscle stiffness measurement, the participants were allowed to lie comfortably. With the participant in the supine position, the TA muscle stiffness was measured at a point 1/3rd of the distance between the lower margin of the patella and the first metatarsal base  left 3737. The Gn = 40) and non-fallers (n = 82). We compared differences in all the variables between the groups using the independent t-test. In fallers, we used Pearson’s correlation test to determine the correlation between physical function and muscle thickness and elasticAll statistical analyses were conducted using SPSS version 26 . We analyzed the frequency and used descriptive statistics to assess the participants’ general characteristics. The participants were divided into two groups: fallers  and 82 (mean age: 73.53 years) participants, respectively. p = 0.001), TUG (p = 0.015), SPPB (p = 0.011), and gait speed (p = 0.027) were significantly worse in fallers than in non-fallers. There was no difference in the muscle strength between the groups. Regarding muscle thickness and stiffness, the TA rest (p = 0.021) and contraction stiffness (p = 0.021), GAmed thickness (p = 0.008) and contraction stiffness (p = 0.002), and GAlat thickness (p = 0.014) and contraction stiffness (p = 0.006) were significantly lower in fallers compared to non-fallers  and gait speed . Whereas Gamed rest elasticity was correlated with the SPPB , Gamed contraction elasticity was correlated with the gait speed  and SPPB . However, TA and Galat showed no significant correlations with any of the above parameters.This study compared differences in the muscle strength, muscle thickness and elasticity of the ankle joint, and balance ability between elderly fallers and non-fallers. Despite no difference in the muscle strength, fallers demonstrated significantly decreased balance ability , rest, and contractive stiffness of the TA, and thickness and contractive stiffness of the Gamed and Galat. Moreover, their Gamed thickness, rest, and contractive stiffness were correlated with balance ability. Thus, contractive stiffness has a greater association with falls in older adults than muscle strength of lower extremities.In the elderly, lower extremity strength decreases faster than upper body strength . DecreasAn FRT ≥ 25.40 cm predicts no risk of fall, compared with a value ranging from 15.24 cm to 25.40 cm that predicts a risk of fall within 6 months . The TUGDecreasing muscular strength of the lower limb is associated with an increased risk of falling . HoweverTherefore, we identified GAmed stiffness and thickness as predictive factors for balancing ability in older adults. Accordingly, an evaluation of muscle elasticity of lower extremities could lead to greater reliability of faller detection among elder population. In addition, in this study, the author predicts that fallers would have a slower walking speed in activity daily of living compared to the non-faller. Therefore, authors proposed that power walking such as walking at a high speed may prevent fall risk while maintaining or improving GAmed activities and contractile velocity in the elderly.The present study had some limitations. First, previous studies mentioned that the elasticity and thickness of the rectus femoris were associated with dynamic balance and gait speed . This waThe low rest and contractive stiffness of GAmed was correlated to lower balance ability in the faller group. The GAmed muscle stiffness can be used to effective methods for predicting potential fall risk in the elderly due to balance deterioration.


Background: The most used questionnaires for PTSD screening in adults were developed in English. Although many of these questionnaires were translated into other languages, the procedures used to translate them and to evaluate their reliability and validity have not been consistently documented. This comprehensive scoping review aimed to compile the currently available translated and evaluated questionnaires used for PTSD screening, and highlight important gaps in the literature.Objective: This review aimed to map the availability of translated and evaluated screening questionnaires for posttraumatic stress disorder (PTSD) for adults.Methods: All peer-reviewed studies in which a PTSD screening questionnaire for adults was translated, and which reported at least one result of a qualitative and /or quantitative evaluation procedure were included. The literature was searched using Embase, MEDLINE, and APA PsycInfo, citation searches and contributions from study team members. There were no restrictions regarding the target languages of the translations. Data on the translation procedure, the qualitative evaluation, the quantitative evaluation , and open access were extracted.Results: A total of 866 studies were screened, of which 126 were included. Collectively, 128 translations of 12 different questionnaires were found. Out of these, 105 (83.3%) studies used a forward and backward translation procedure, 120 (95.2%) assessed the reliability of the translated questionnaire, 60 (47.6%) the dimensionality, 49 (38.9%) the performance, and 42 (33.3%) used qualitative evaluation procedures. Thirty-four questionnaires (27.0%) were either freely available or accessible on request.Conclusions: The analyses conducted and the description of the methods and results varied substantially, making a quality assessment impractical. Translations into languages spoken in middle- or low-income countries were underrepresented. In addition, only a small proportion of all translated questionnaires were available. Given the need for freely accessible translations, an online repository was developed.HIGHLIGHTSWe mapped the availability of translated PTSD screening questionnaires.The quality of the translation and validation processes is very heterogenous.We created a repository for translated, validated PTSD screening questionnaires. Most commonly, screening is undertaken with the help of a questionnaire either completed by or administered to the individual who is being assessed. In clinical settings, these screening measures are often used to identify those likely to meet a PTSD diagnosis, while in research settings, they are used in a variety of study designs for example in epidemiological studies to assess the prevalence of PTSD in populations  prerequire enough available information to ensure that the research question of interest can be addressed with the current literature. Regarding translations of PTSD questionnaires, no overview of the relevant literature exists. In addition, the above outlined reviews identified few studies investigating the performance of a translated PTSD questionnaire . More information about the conducted evaluation procedures will be provided for each study (see below). The aims of this review are twofold: First, to identify published, peer-reviewed PTSD screening questionnaires that were translated to at least two different languages. The decision to only cover peer-reviewed, published studies as well as to exclude questionnaires with less than two translations, was made to limit the scope of this review, to ensure its feasibility and to include a criterion reflecting the use of a given questionnaires across a minimal number of different language groups. The second aim is to map all evaluated translations of the screening questionnaires identified in step one in terms of translation techniques used, results from the qualitative and/or quantitative evaluations, and accessibility of the translated questionnaires.2.2.1.The aim of a scoping review is to map existing evidence on a prespecified topic. In contrast to systematic reviews, scoping reviews are more exploratory and cover a broader spectrum of evidence . Third, the project was designed to be published as a registered report. Registered reports follow a two-phase publishing model , an open-source platform maintained by the Center for Open Science, a non-profit technology organization.The initial protocol including the appendices were revised upon the suggestions made by the reviewers during the first-phase review process. Following journal guidelines on registered reports, after the revised manuscript and the protocol were accepted ‘in-principle,’ the revised protocol was deposited and time-stamped here: 2.4.Population, Concept, Context (PCC) framework as follows:To ensure the feasibility of this review, its scope will be limited to PTSD screening questionnaires that were translated at least two different times. Two translations may include translations into different language , different versions or dialects within a given language , and different translations within the same language and dialect . Therefore, the inclusion of records is conducted in a two-step process which is shown in Populations: This review focuses on translations of screening questionnaires developed for adult populations (≥ 18 years). No additional restrictions are imposed for the inclusion of populations .Concept: The overarching concept of interest for this review is to map the availability of translated and evaluated PTSD screening questionnaires commonly used in traumatic stress research and/or in clinical practice. The following aspects of the concept of interest are discussed in depth: (a) PTSD, (b) screening questionnaire, (c) translation and/or cultural adaptation (d) evaluation.PTSD: For the purpose of this review, questionnaires developed to assess PTSD as defined by either the fourth, the text-revised fourth or the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders . Brewin, . A list Translation: The translation of a questionnaire to a new population is a resource-intensive and complex process . Consequently, to cover the presumably very heterogeneous literature, we will include studies with any kind of information on the questionnaire’s performance, even if this information was gained using non-standard practices.Context: We will consider studies with no restrictions regarding the context in which they were conducted.Types of evidence sources: Only peer-reviewed, published studies reporting quantitative and qualitative results of the evaluation of the adapted questionnaire will be considered. Such studies can include but are not limited to the following designs: epidemiological study, experimental study, and cross-sectional studies. Qualitative studies and any kind of study not reporting quantitative or qualitative results of the evaluation of the adapted questionnaire(s) will not be considered for this review.Languages: Articles published in English, German, Spanish, French, Chinese, Filipino and Hebrew will be included.Date range. The publication date range will not be limited. However, the definitions of PTSD considered for this review are limited to the DSM-IV, DSM-IV-TR, DSM-5, ICD-10, and ICD-11, of which the DSM-IV was introduced in 1994 and the ICD-10 in 1990.2.5.Our search strategy for the identification of articles of interest rests upon four main pillars to ensure coverage of the index, but also of the grey literature. First, we will conduct a systematic search of three electronic bibliographic databases: Embase, MEDLINE, and APA PsycInfo. Second, we will search the reference list of relevant review articles .The search strategy for the bibliographic databases was developed in several steps. Initially, a limited search of MEDLINE was conducted to identify relevant articles. Index terms and relevant words from the identified articles’ titles and abstracts were obtained. Next, the search strategies of existing systematic reviews  will be revised. All articles deemed to meet inclusion criteria by at least one reviewer will be included in the review.Following the search, all citations identified through each pillar of the search strategy will be exported into 2.7.Covidence, adhering to the JBI Manual for Evidence  Study characteristics, (b) Translation and evaluation, and (c) Access.Study characteristics: For each record, the following data will be assessed:Translation and evaluation: As outlined above, multiple recommendations and guidelines for the translation of existing questionnaires exist  or can be requested from the authors with responses including the questionnaire within four weeks .Supplemental data). The data extraction form will be implemented with instructions into Covidence. The data extraction process will be piloted using five randomly selected full-text records which will be assessed by the involved data extraction reviewers. Disagreements will be discussed, and the extraction form will be revised as necessary with any resulting modifications explicitly stated in the resulting scoping review.A draft of the extraction form is provided in Appendix IV  mp.’) for these two databases to increase consistency across all searched databases. However, this deviation only broadened the search criteria and did therefore not jeopardize the preregister aim of this scoping review.3.3.1.substantial .The flow through the study selection process is shown in 3.2.n = 23; 18.0%); the Harvard Trauma Questionnaire ; the Impact of Event Scale-Revised ; the PTSD Checklist for the DSM-5 ; the International Trauma Questionnaire ; the Posttraumatic Diagnostic Scale ; the Davidson Trauma Scale ; the Global Psychotrauma Screen ; the PTSD Symptom Scale-Interview ; the Harvard Trauma Questionnaire for DSM-5 ; the Posttraumatic Diagnostic Scale-5 ; the Primary Care PTSD Screen ; and the Trauma Screening Questionnaire . Most studies evaluated the translations in civilian populations , followed by forcibly displaced , post-conflict/veteran , and mixed  populations. Study settings were clinical , community , emergency departments , and mixed settings . Sample sizes ranged from 18 to 7034 participants. Countries in which studies were conducted can be seen in n = 16), Spanish (n = 14), Chinese (n = 8), German (n = 7), Korean (n = 5), and French (n = 5); with all other languages ranging from 2–4 translations.The details of the included studies are outlined in 3.3.n = 105) of studies described using a forward and back translation procedure. Regarding the evaluation of translated questionnaires, 95.2% of studies (n = 120) used quantitative reliability analyses , 47.6% (n = 60) used quantitative dimensionality evaluations , 38.9% (n = 49) used quantitative performance analyses  and 33.3% (n = 42) used qualitative methods . Regarding the availability of the translated questionnaires, 17 (13.5%) questionnaires are freely available online, 5 (4.0%) were made freely available online by their authors after being contacted by the study team, and in 12 (9.5%) cases the authors stated that they are willing to share the questionnaires upon request. We were unable to obtain 92 (73.0%) of all questionnaires for different reasons (e.g. the authors declined or did not respond to our request). For a more detailed description of the results see Supplementary Materials.Eighty-three per cent  identifying published, peer-reviewed screening questionnaires that were translated in at least two different languages, and (2) mapping these questionnaires across translation techniques, qualitative and quantitative evaluation procedures, and accessibility of translated questionnaires. This scoping review identified 12 PTSD screening questionnaires that had undergone at least two translations and evaluations from English into another language.n = 34, 27.0%) of all identified questionnaires are freely available online or upon request from the developers. These inequities in research funding and resources may exacerbate the disparity in global mental health and mental health research. More global partnerships are needed to provide valid translations of PTSD screening questionnaires to reduce this gap.The breadth of the questionnaires identified in this review covers definitions of PTSD according to the DSM-IV, the DSM-5, and the ICD-11. While the 12 questionnaires identified in this review represent a broad sample of PTSD screening questionnaires, if this list is limited to current definitions (i.e. DSM-5 or ICD-11), many fewer questionnaires were identified . The target languages included in this review highlight the diversity of translations and gaps to be addressed. The most frequent translations comprised targeted languages such as Arabic, Spanish, Chinese, German, Korean, and French. While these are dominant languages spoken in multiple countries, they tend to represent the dominant languages spoken in high income countries, and/or the language of the most dominant migrant groups that reside in those countries. The over-representation of high-income countries in target languages is reflected when viewing the geographic locations in which these studies were conducted. These include the USA, China, Germany, and Korea, while relatively fewer studies were conducted in parts of Africa, South America, Eastern Europe, Southeast Asia, and the Middle East. These findings are not surprising, given that most research funding comes from high income countries. However, for clinicians and researchers residing in low- and middle-income countries, the lack of available non-English screening questionnaires poses major challenges . While most of the world’s population resides in lower- and middle-income countries, mental health resources in these contexts are limited  that provides global access to translated PTSD screening questionnaires. On this website, questionnaires can be downloaded or requested from the developers and the relevant studies are linked so that the developers can be credited appropriately. Moreover, the website also highlights gaps in the literature.While the translation and evaluation process of PTSD screening questionnaires can be costly and burdensome , the only questionnaire for which we found less than two translations. This cut-off was partially arbitrary, as was the list of the included questionnaires, both not covering all existing questionnaires and translations. Future studies should aim to map these uncovered gaps, for example, questionnaires that were developed in a language other than English. Finally, this study only examined English questionaries that were translated into a target language. Therefore, there may have been non-English PTSD questionnaires that have been developed, which were outside the scope of this review.To conclude, while the results identified 12 translated PTSD questionnaires, more transparency is needed around translation processes, and more rigorous evaluation methods are needed to ensure the utility of these measures in clinical and research contexts. Furthermore, more investment is needed in developing high quality translations of PTSD screening questionnaires in countries and language groups that have thus far been neglected. As the majority of existing translations were not accessible, more avenues for freely accessible translations of PTSD questionnaires are urgently needed. Making translations available in an online repository will hopefully help eliminate the need for duplicate translations and create space for more rigorous validation studies to be made widely available.Click here for additional data file.Click here for additional data file.Click here for additional data file.Click here for additional data file.Click here for additional data file.Click here for additional data file.Click here for additional data file.