Average Annual Percent Changes (AAPC) were calculated by the period before and after 2008. The expected rates of 2009–2016 and the observed-to-expected rate ratios (RR) were calculated. Correlation and multiple linear regression analyses were used to test the impact of socio-economic variables on health outcomes; (3) Results: A reverse in downwards trends of PNM, IMR, and NNMR is observed since 2009. All observed values of 2009–2016 were found significantly higher than the expected ones by 12–34%. All indicators except SBR were found negatively correlated with GDP and DHI. A positive correlation was found between IMR, NNMR, and LBW and long-term unemployment, and no association with public health expenditure; (4) Conclusions: Economic crisis was associated with remarkable adverse effects on perinatal outcomes and infant mortality, mainly determined by long-term unemployment and income reduction. The findings stress a need for interventions to protect maternity and child health during crises. Greece was severely affected by the economic crisis of 2008 and the subsequent austerity measures applied since 2011. Between 2009 and 2014, the GDP per capita reduced by 23.6% [The dramatic deterioration of socio-economic conditions affected several aspects of the population’s health ,6,7. AdvStudies exploring the mechanisms through which economic conditions affect children’s health suggest that malnutrition, infections, insufficient immunization, an increase of risky behaviors of parents, as well as changes in cohort composition may explain the effects on health outcomes ,19,20. OFocusing on Greece, several studies found increased levels of anxiety and stress in the Greek population after the economic crisis ,30,31, aThe socio-economic determinants of the observed effects have little been studied. In times of economic growth, socio-economic factors seem to be in developed countries of less importance for perinatal and infant health ,34,35, bThis study aims to explore the effects of the 2008 economic crisis on perinatal outcomes, maternal and infant mortality in Greece and the possible correlation of these effects with critical socio-economic variables affected by the crisis.Study design. This is an ecological study, using longitudinal data and applying a quasi-experimental design. We calculated and compared the health outcomes of the “exposed” to the 2008 financial crisis period with the ones of the previous “non-exposed” to the crisis period. The method uses as a control group in the same population before the impact of the financial crisis.Source of data. The study is based on data obtained from the national vital statistics of Greece, including all live births, stillbirths, birth weight of live births, perinatal deaths, infant deaths by age, and maternal deaths, from 2000 to 2016. For international comparisons, we used data of the years 1996–2016, obtained from the World Health Organization (WHO) European Health for All Database [Database .Indicators. Considering that economic crisis may affected at a different degree the various parameters of perinatal and infant health, we calculated the annual rates of seven indicators: (i) Stillbirth rate (SBR) defined as the number of stillbirths per 1000 births; (ii) perinatal mortality rate (PMR), defined as the number of stillbirths and infant deaths within 7 days from birth per 1000 births; (iii) infant mortality rate (IMR), defined as the number of deaths within 365 days from births per 1000 live births; (iv) neonatal mortality rate (NNMR), expressing as the number of deaths within 28 days from birth per 1000 live births; (v) post-neonatal mortality rate (PNMR), defined as the number of deaths within 28 to 385 days from birth per 1000 live births; (vi) low birth weight rate (LBW), defined as the number of births with a birth weight less than 2500 gr, regardless of gestational age, per 100 live births; (vii) maternal mortality rate (MMR), representing the number of maternal deaths within 42 days of pregnancy termination due to complications of pregnancy, childbirth, and the puerperium per 100,000 live births.Period identification. We applied Jointpoint regression analyses to identify the point of manifestation of the crisis effects on each of the study indicators. The Jointpoint regression identified 2008 as the turn-point of the slope in PMR, NNMR, and IMR. No turn-point was identified in the curve of SBR, PNMR, and MMR. Based on these regression results, we set the cut-point at the end of 2008 and we analyzed the data in two periods, 2000–2008 and 2009–2016Trend analysis. We calculated the annual values of all indicators for the years 2000–2016 and we computed the Average Annual Percent Change (AAPC) by period, with Jointpoint Regression Program. In addition, we tested the significance of crisis impact on each indicator with Interrupted Time Series analyses (ITS), using an Autoregressive Integrated Moving Average model  with the crisis effect as a dummy variable.Estimation of excess mortality. Based on the pre-crisis trends of perinatal and infant mortality indicators, we calculated the expected rates of each indicator for the post-crisis period (2009-16), using a logarithmic regression model, and we compared them with the observed ones. The model achieved an R2 value of 0.75 in SBR, 0.87 in PNR, 0.85 in IMR, 0.90 in NNMR, and 0.59 in PNMR. The R2 values in LBW and MMR were as low as 0.13 in LBW and 0.02 in MMR. Comparisons between observed and expected rates were performed by calculating the observed-to-expected rate ratios (RR) and their 95% confidence intervals (95% CI).International comparisons. Using data obtained from the WHO European Health for All Database of the years 1996–2016, we explore the trends of perinatal and infant mortality in six other European countries also affected by the economic crisis; Ireland, Portugal, Spain, Italy, Hungary, and Poland. For each country, the AAPC of PMR and IMR during 2000–2008 and 2009–2016 were calculated.Social determinants. We explored the correlation between the study indicators and five socio-economic variables affected by the crisis; (i) Gross Domestic Product (GDP) per capita, (ii) Disposable Household Income (DHI) per capita, (iii) unemployment rate, as a percentage of the economically active 15–64 years old, (iv) long-term unemployment rate, over twelve months of unemployment and (v) public hospital expenditure per capita.Statistical analysis. Time trends and estimation of excess mortality were performed as described above. Correlation and regression analyses were based on the annual values of all dependent and independent variables, which were calculated by region, reaching 221 observations per variable. After testing for normality of variable distribution with Kolmogorov–Smirnov tests, Spearman’s correlation coefficient was used. In addition, the impact of the independent variables was tested with a multiple linear regression model. The model that better fitted was the one that included the following independent variables (i) change (%) of GDP, (ii) DHI per capita, and (iii) long-term unemployment rate. Statistical analyses were performed with the Jointpoint Regression Program and SPSS.During 2000–2016, 1,779,541 live births, 7504 stillbirths, 6895 infant deaths, 29 maternal deaths, and 157,183 low birth weight births occurred in Greece. The average observed rates and trends are exhibited in The AAPC during the post-crisis period reversed from −5.7% to 0.9% in PMR, from −7.3% to 3.7% in IMR, and from −8.2% to 4.7% in NNMR. No significant change of the AAPC was detected in PNMR and MMR. In LBW, a step-change in 2009 was observed without further increasing trends, resulting in an average rate of 2009–2012 by 16.8% higher than 2005–2008 (95% CI 16.3–17.3%). ITS analyses found a significant change after 2008 in the slopes of PNM, IMR, NNMR, and PNMR.Based on the trends from 2000 to 2008, we calculated the expected rates of all indicators for the years 2009-16 . All obsExploring the trends of perinatal mortality in other European countries affected by the financial crisis, significant changes were observed in most of them. Exploring the association of the study indicators with the aforementioned socio-economic variables in Greece, a significant negative correlation of all indicators with per capita GDP and per capita DHI was found, excluding SBR . In addiMultiple linear regression analyses found significant results in all dependent variables excluding SBR . The B cThe financial crisis of 2008 and the consequent austerity policies applied in health have been associated with a rise in mortality of several conditions ,41. A reThe findings regarding infant mortality are more controversial. According to an international report of 2014, “there is no evidence of an overall increase in infant mortality rates after the crisis in countries such as Greece, Italy, Portugal, and Spain, although the share of low birth weight babies has increased in Greece” . HoweverFocusing on Greece, the study findings indicate an association of financial crisis with significant adverse effects on PNM, IMR, and NNMR. The correlation coefficients found do not support a very strong correlation and the results of the regression analysis show that the model can explain only 11.8% to 34.9% of the observed variability. However, although statistical analysis results impose certain reservations in supporting causality, it is remarkable that throughout the entire study period, no one indicator has returned to the last pre-crisis levels. The effects seem to be prolonged until 2016, probably because their determinants are also prolonged until that time, as discussed below. The estimation of the possible impact until 2016 shows that the observed rates in stillbirths, perinatal mortality, infant and neonatal mortality were higher than the expected ones by 25–34% over an 8-year period, and 12% in PNMR and LBW. Infant and neonatal mortality seem to be more susceptible to socioeconomic changes, although the impact on them was manifested with a delay compared with perinatal outcomes. The extension of the effects for so many years reveals a different magnitude of what a first reading of rate changes provides. In fact, the country returned at an infant health level several years back. The findings cannot be generalized; they are directly associated with the aforementioned dramatic socio-economic effects in Greece. Considering the findings in all seven countries, we should conclude that the economic crisis affected perinatal outcomes and infant health in the European countries at a different degree, according to the magnitude and duration of the socio-economic effects of the recession in each country.Exploring the literature, two models of crisis impact on perinatal and infant health have been proposed : A physiSocial determinants. Considering the above exploration of other possible factors that could explain the trends, the findings support an association of perinatal and infant health outcomes with the main socio-economic parameters affected by the crisis. GDP and income reduction, as well as long-term unemployment, were found to be the major socio-economic determinants of the adverse perinatal outcomes and elevated infant mortality. Although similar correlations have been found in certain studies [ studies ,51,52, i studies . Probabl studies  inevitab studies . Consequ studies . The dec studies ,56.On the other hand, the specific conditions in Greece set questions about the appropriateness of the model of maternal and child health protection of Greece. If health policy wants not to ignore the fact that 61.6% of births take place in private settings, it should include measures supporting pregnancy and birth independently of the ownership of health services. Limiting the support only in providing access to public hospitals, under the current conditions, seems inadequate to address the problem when 61.6% of births take place in private hospitals.Limitations. The ecological nature of the study sets several limitations. Firstly, there are no data about the underlying causes of each death to directly link deaths with economic crisis effects. The findings are exclusively based on time trends of aggregated data. Secondly, the association with long-term unemployment and income reduction is also based on aggregated data and statistical correlations. We do not have individual data to attribute outcomes directly to these parameters. Thirdly, the study design does not allow identifying the mechanisms, which produce adverse effects. Fourthly, the use of projections to forecast expected values is a method that also has certain limitations. Although we selected a projection model that does not result in unacceptable values and provides sensible and conservative results, there is no way to ensure that the forecasts would happen. Besides, as in any projection, we do not know the combined impact of other not-explored determinants on the projected rates. Finally, it should be noted that the study findings are not directly comparable to those from other studies, because of different designs or methods used.Considering all the above limitations, the study findings indicate a remarkable impact of the economic crisis on adverse perinatal outcomes and infant mortality, extended until 2016, and mainly determined by long-term unemployment and income reduction. The findings have obvious health policy implications, stressing a need for interventions aiming to protect maternity and child health especially in unemployed and people under critical income constrains.


Ferritin status during prenatal brain development may influence the risk of attention deficit and hyperactivity disorder (ADHD) symptoms in childhood. We investigated the association of maternal ferritin in pregnancy and ADHD-like symptoms in offspring. A total of 1095 mother-child pairs from three birth cohorts of the INMA Project (Spain) were studied. Maternal plasma ferritin in pregnancy was measured at 11.57 weeks of gestation. Children′s ADHD-like symptoms at ages 4–5 years were assessed using the ADHD Rating Scale-IV. The count model of the zero-inflated Poisson regression model showed a significant inverse association between ferritin (continuous variable) and inattention, β = −0.19 , for boys. Comparing ferritin level by tertiles, significant differences were observed between the first tertile  and the second  and third tertiles  (mg/L).The number of symptoms was lower for those in the third tertile, β = −0.3 , and for those in the second one, β = −0.37 . The model stratification by sex also showed this inverse association for boys only, β = −0.21 . No associations were found between ferritin level and hyperactivity or total ADHD symptoms. High ferritin levels during pregnancy show a protective association with child inattentive-type ADHD symptoms. Attention deficit/hyperactivity disorder (ADHD) is the most frequent childhood-onset neuropsychiatric condition, with an estimated worldwide prevalence of approximately 5% in school-aged children . ADHD syDespite ADHD being the most studied neuropsychiatric condition in child psychiatry worldwide , the etiThe human brain is highly sensitive to environmental exposure occurring during particular periods of vulnerability ,9. In eaIn recent years, it has been suggested that iron deficiency (ID) may contribute to behavioral and cognitive dysfunctions . Iron isFurther evidence supports the hypothesis that a lack of brain iron might contribute to the pathophysiology of ADHD ,17. FirsThe role of serum ferritin levels as a reliable measure of iron stores in body tissues, including the brain, in children with ADHD has been studied in recent years. A meta-analysis  and a syTherefore, the objective of the present study was to evaluate the relationship between prenatal ferritin levels with infant ADHD symptoms. For that, the association between ID during pregnancy measured by ferritin levels in maternal serum and ADHD symptoms in children aged 4–5 years was assessed. Findings might have important implications for clinical practice, regarding prenatal iron supplementation.The INMA  Project , a multiMaternal whole blood samples were collected during pregnancy (mean [SD] 13.3 [1.5] weeks of gestation) by venipuncture under fasting conditions and stored between −70 and −80 °C until analysis. Maternal plasma ferritin concentrations were quantified in samples from Gipuzkoa and Sabadell cohorts by time-resolved fluorescence immunoassay (DELFIA Ferritin kit A069–101), at the Gipuzkoa Public Health Laboratory, and in samples from the Valencia cohort by immunoturbidimetry  at La Fe hospital.2) and breastfeeding (weeks of any breastfeeding). Anthropometric measures at birth and the sex of the infant were obtained from the child’s medical records. Deliveries before 37 weeks of gestation were defined as preterm births. Gestational age was calculated from the date of the last menstrual period reported at recruitment and confirmed using ultrasound examination at week 12 of gestation. Whole blood samples were collected by venipuncture of cord vessels before the placenta was delivered for the measurement of mercury in the newborn. At 14 months of age, various types of data related to the children were collected including daycare attendance, birth order among siblings (first/not first), whether they were living with their parents (both/only one) and the number of people in the household. The exact age of the child was also recorded at the time of the assessment of ADHD-like symptoms.Data on maternal and child characteristics were collected through two questionnaires administered during face-to-face interviews at different points in the first and third trimester of pregnancy, at birth, at 14 months after birth and when children reached 4–5 years of age. We used data on maternal country of origin (Spain/other), maternal social class , maternal education , maternal age, maternal mental health , maternal intelligence quotient, parity, smoking during pregnancy (yes/no), alcohol intake during pregnancy (yes/no), pre-pregnancy body mass index (BMI) . The difference in the mean number of symptoms was analyzed using the Student’s t-test (for two samples) and one-way analysis of variance (more than two samples). p-value ≤ 0.20 in the bivariate analysis were added to the base models (ferritin level and ADHD symptoms). These variables were maintained in the models if they changed the magnitude of the main effects by more than 10% or were significant. The final model was adjusted for: cohort , maternal smoking during pregnancy (yes/no), alcohol intake during pregnancy (g/day), pre-pregnancy BMI and social class , the child’s sex, age at the time of the test and whether they were living with parents (both/only one) and the week of sample collection for ferritin analysis. For the count model of the association of inattention symptoms with ferritin levels, the interaction between ferritin and sex was significant, and hence results are shown separately for boys and girls. The final model was also stratified by cohort and sex of the child. Statistical analyses were conducted using R version 3.6.1. Due to the excess of zeros in symptom ratings, the association between ferritin level and symptoms was analyzed using zero-inflated Poisson regression models. This type of model has two parts, a Poisson count model and a logit model for predicting excess zeros. The level of ferritin was entered in the models in two ways: as a continuous variable and categorized in tertiles ) to study the trend across the tertiles. Initially, variables with a Overall, 1095 eligible mother-child pairs were included in this study . The socThe mean maternal ferritin level was 35.9 mg/L (standard deviation: 26.81 mg/L). In the univariate analyses, the total ADHD symptom score was higher in boys than girls. Further, total ADHD symptom scores were higher in children of mothers with higher BMI, lower alcohol intake, worse mental health and lower education and social class, who smoked and did not breastfeed . p = 0.002). In contrast, no significant association was found between ferritin level and hyperactivity/impulsivity or total ADHD symptom scores , in boys. In addition, comparing ferritin levels by tertiles for boys, there were significant differences between the first and second tertile, β = −0.3 , and the first and third tertile, β = −0.37 , with a significant trend , and also when comparing the individuals by tertiles: the expected change in the number of symptoms was lower for those in the second tertile, β = −0.32 , and for those in the third one, β = −0.4  (p for trend 0.001). In contrast, the count model for inattention showed a positive association for the girls in the third tertile of ferritin levels, β = 0.58 , compared with those in the first one (p for trend 0.012). Similarly, when considering the total number of ADHD symptoms, a negative association was observed for the boys in the third tertile, β = −0.22 . The zero-inflation model for ADHD symptoms showed a positive association, β = 0.6 , for girls in the second tertile and a positive association was also observed when taking ferritin level as a continuous variable, β = 0.39  .The present study assessed the association between maternal ferritin levels during pregnancy and ADHD symptoms in their offspring when the children reached 4–5 years of age. Significant inverse associations were observed between maternal ferritin level during pregnancy and symptoms of inattention in boys. The stratification by sex of the count model also showed this negative association between inattention symptoms in boys and ferritin levels, both analyzed continuously and by tertiles. In contrast, in girls, a positive association was observed with ferritin levels in the third tertile compared with the first tertile. This positive association was also found for the zero-inflated model of total ADHD symptoms in girls.There is a large body of evidence about iron deficiency during pregnancy and maternal and fetal outcomes . Two recThe involvement of iron in several biological processes has been described previously . NeverthSerum ferritin reflects the status of iron stores in the body: bone marrow stores are only depleted when the level falls below 10 ng/mL and then anemia develops. The role of iron deficiency with and without anemia and developmental/cognitive deficits has been demonstrated in various neurologic and developmental disorders in both laboratory and clinical studies . As ironHuman studies have shown that iron deficiency and iron-deficiency anemia in infants are associated with behavioral impairment ,46, but ADHD is a complex multifactorial condition in which multiple genes and environmental factors act together to affect individual risk and contribute to an ADHD phenotype and clinical presentation. The heritability of ADHD was estimated at 72% based on 1316 child and adolescent twin studies . On the Various models have indicated that dopamine is a key element of ADHD pathophysiology. First, dopamine is associated with the modulation of psychomotor activity and executive functions, which are core features in ADHD. Second, molecular genetic studies of ADHD have focused on the genes involved in dopaminergic function, especially the dopamine D4 receptor gene and the dopamine transporter gene (DAT1) . Third, In our study, total ADHD and inattention symptom scores were also predicted by maternal years of study, social class, maternal smoking during pregnancy, maternal BMI and breastfeeding. ADHD has traditionally been associated with a range of indicators of social and economic disadvantage including poverty, housing tenure, maternal education, income, lone parenthood and younger motherhood; the association of ADHD with socioeconomic disadvantage has found several potential explanatory pathways often operating through differential exposure . Such exFinally, in our study, breastfeeding was not a predictor of total ADHD symptoms or inattention in 4 to 5-year-old children according to the multivariate model, though it was significantly correlated with ADHD in the bivariate analysis. A robust body of research literature has reported on the short-term medical, developmental and emotional benefits of breastfeeding for infants and toddlers ,60. A reIn accordance with previous studies, we observed sex differences in our results regarding inattention, hyperactivity/impulsivity and ADHD symptoms. Differences have been reported previously ,62,63, wOverall, some of these differences may be partly explained by diagnostic and ascertainment biases. Nonetheless, it is likely that most are due to sex biological differences . There iA hypothesis that could explain the sex-specific association of ferritin and ADHD symptoms is related to acetylcholinesterase (AChE) activity. AChE activity has been associated with deficits in neurodevelopment, particularly attention, inhibition and memory, in boys but not in girls . In laboAnother explanation could be related to mitochondrial function in brain cells, since mitochondrial proteins have been related to neurodevelopmental abnormalities and to the pathophysiology of ADHD . Iron ovFinally, in our study, ferritin levels in maternal serum at week 12 of pregnancy predicted symptoms of inattention; interestingly, maternal ferritin level was not a predictor of hyperactive and impulsivity symptoms. Previous studies have already suggested how different ADHD presentations or subtypes may correlate with different etiopathological models . Our resThis study has a number of limitations which should be recognized. First, the study explored ADHD symptoms assessed using a rating scale based on DSM-IV criteria; however, a confirmed clinical diagnosis was not available. In addition, we only have a single measurement of ferritin during pregnancy, and it might not be a representative measure of ferritin levels throughout pregnancy. Moreover, ferritin levels in children were not measured, and therefore the study relies solely on maternal ferritin levels in the first trimester of pregnancy. On the other hand, this study has considerable strengths such as the large sample size covering different geographical regions, which increases the external validity, the prospective design and the inclusion of several confounding variables in the statistical models.In summary, this study makes a new contribution to understanding the association between ferritin levels in mothers during pregnancy and ADHD symptoms in their children. There is a need for more research to clarify the mechanisms of action of iron and neurotransmitters in relation to cognitive function. Maternal ferritin levels during pregnancy are independently associated with ADHD symptoms in 4 to 5-year-old offspring. More specifically, maternal ferritin levels seem to influence inattention symptoms and specifically in boys, whereas girls seem to be more protected. Other maternal variables including BMI and education level are also associated with ADHD and inattention symptoms.


Healthcare facilities in China are facing increasing demands as the country has the fastest aging populations in the world. Day surgery can be utilized to address some of these demands. Benefits of day surgery include shortened hospital stay, decreased risk of hospital-associated infections, and increased cost efficiency. We present a retrospective study of eight years of day surgery data from West China Hospital, one of the largest hospitals in China, with an emphasis on an examination of the growth in day surgeries. We examined patterns of utilization of day surgery versus inpatient surgery (including types of surgeries performed in the Day Surgery Center and the ratio of day surgery versus elective surgery), as well as unplanned readmission and return to inpatient department rates, and a comparison of average costs and length of stay for day surgery versus hospital surgery.Day surgery has a safe and cost-effective way to alleviate the soaring healthcare demands in West China. There is potential opportunity to further address the ever-increasing demands on the healthcare system in this area by performing more complex surgeries as day surgeries. This article presents an effective organizational protocol and proposes a reliable medical quality assurance system, which prioritizes safety of the growing day surgery program; furthermore, it describes the factors and lessons learned from the successful implementation of a day surgery system. China offers many lessons regarding healthcare in a developing country. Healthcare facilities in China are facing increasing demands as the country has one of the fastest aging populations in the world . Due to Day surgery is also known as same-day surgery, ambulatory surgery, and outpatient surgery, with terms varying from country to country. The concept of day surgery dates back to 1899, as proposed by James H. Nicoll, who is known as the “father of day surgery” . Day surInstitutional Review Board approvalIRB approval was given by the Biomedical Research Ethics Committee of WCH, Sichuan University.Data sourceWCH, also as known as Hua’xi Hospital, is a medical center in southwest China, which has been ranked second in mainland China from 2009-2018 based on academic achievements and public reputation. It has 4,300 licensed beds. More than 5 million outpatient visits and 175,000 surgeries were recorded in 2018. It serves patients from all over the country . WCH is Data collectionThe data were retrieved from the Hospital Information System from January 1, 2010, to December 31, 2018. A total of 140,738 cases were recorded. Relevant data points included admitting department, admission date, surgery date, surgery type, diagnoses, discharge date, and ICD-10  code. Diagnoses, procedures, or surgeries presented have been coded using the ICD-10, Clinical Modification (ICD-10-CM).MethodsEstablishment of Day Surgery CenterThe successful implementation and operation of a day surgery service depend on coordination among clinical, administrative, and medical quality control staff and systems. Ever since the opening of the Day Surgery Center at WCH on October 28, 2009, administrative and clinical management practices have been consistently reviewed and revised as appropriate. Part of this protocol was the founding of a Day Surgery Management Committee of WCH, which includes an administrative supervisor and a department director, as well as multiple physicians and nurse representatives. Physician member selection is based on specialty and experience, as well as their enthusiasm and passion to promote and advance day surgery. WCH also established a Day Surgery Center patient service system, which provides a pre-operative assessment, surgery scheduling, healthcare education, coordination with pre-operative visit, assessment, and surgery scheduling. The department director and head nurse are in charge of the daily administration duties. Five physicians and 26 registered nurses were recruited for the Day Surgery Center for postoperative medical management.Two Organizational ModesThere exist two possible modes of managing admission and discharge flow for day surgery, as shown in Figure Medical Quality Assurance System for Day SurgeryWCH established a new medical quality assurance system for day surgery, including patient selection, operation selection, surgeon qualification, nurse qualification, and team construction and management. How each dimension operates under this system is detailed as follows:Patient selection: The patient must have adequate family and social support, especially for the first 24 hours after surgery. The patient must have access to transportation for 24 hours postoperatively either by a private vehicle with a driver other than the patient or by access to a 24-hour taxi service. They must reside at a less than two-hour driving distance from the hospital. Patient selection for day surgery is also based on their general health, age, and so on. The following basic requirements for patients have been proposed after the conclusion of practice:1. The American Society of Anesthesiologists (ASA) scale: in general, only patients in class ASA I and II will be eligible for day surgery. Notably, there exists literature regarding ASA III patients undergoing day surgery, with low incidences of complications . In WCH,2. Age: the literature demonstrates that day surgery has been successfully completed on patients of a wide range of ages ,16. The 3. Body mass index (BMI): being overweight or obese can increase the difficulty and incidence of postoperative complications. Hypertension, congestive heart failure, and snoring are the main postoperative complications associated with obese patients . The Bri4. Co-morbidities: patients with chronic diseases may still be considered for day surgery as long as their diseases are stable, known to the anesthesiologists and surgeons, and appropriately maximized for surgery by their medical team. Examples include hypertension, diabetes, and coronary artery atherosclerotic heart disease. However, end-stage diseases such as liver failure and kidney failure are excluded -22.Surgery selection: A list of approved surgeries was developed by the Day Surgery Management Committee of WCH. Criteria are as follows: an estimated operation time less than two hours (so as to permit early ambulation and enhance rapid recovery), management of postoperative pain by prescription of oral analgesics only, and no special postoperative care back home.Surgeon qualification: Surgeons must be senior attending physicians with experience over 10 years with the ability to operate independently and have completed a minimum number of cases, the amount of which is variable depending on the procedure. Example requirements include a minimum of 150 cases of hernia repair, LC, and vein stripping and ligation. Last but not least, these doctors must be enthusiastic and committed to the promotion and development of day surgery.Nurse qualification: Nurses must have a minimum of 10 years of pre- and postsurgical care experience, strong communication skills, comprehensive knowledge of different specialties, and knowledge of hospital regulations, national policies, and medical insurance reimbursement procedures.WCH follows clinical pathway protocol to optimize both clinical and non-clinical activities, including the financial and resource utilization components of care. By standardization of medical tests, orders, and treatment, clinical care safety and efficiency are maximized. Day Surgery Center has 5 physicians and 26 registered nurses assigned to either the pre-operative care team, peri-operative care team, or postoperative care team. The pre-operative care team consists of three senior nurses in the outpatient department. Their duties include double-checking the pre-operative tests and the management of surgery scheduling, health education, and inquiries. Five physicians are part of the peri-operative and postoperative care teams. They are responsible for reassessing surgical patients before surgery, medical record quality control, and taking care of patients postoperation. There are also four senior registered nurses in the postoperative care team. Their duties include follow-up and health education. Their primary focus is on postoperative complications that patients may experience at home. Discharged patients may reach the postoperative care team through telephone, a mobile application, or social media 24 hours a day, seven days a week for support managing any postoperative complications they may have, such as pain, nausea, and vomiting, or to make an appointment.Growth of Day SurgeriesThe number of day surgeries at WCH Day Surgery Center has increased steadily since its establishment. WCH began performing day surgeries on January 1, 2019. From that date through November 30, 2019, 36 cerebral angiography cases were performed, with no postoperative complications. The cancellation rate of booked procedures, unplanned return, and readmission rate remained zero. Additional procedures will be introduced as appropriate, such as performance of percutaneous micro-balloon decompression for the treatment of trigeminal neuralgia.From January 1, 2010, to December 31, 2018, WCH performed 140,738 day surgery cases, of which 48,854 (34.71%) cases were performed in the Day Surgery Center and 91,884 (65.29%) cases were performed in Inpatient Departments  defines day surgery as a planned surgery that is performed, and the patient is discharged within 24 hours, excluding outpatient surgery. The maximum duration of hospitalization is less than 48 hours , but hosCurrently, day surgery has dominant the surgery in some European countries and the United States, with around 65% of elective surgery being performed as day procedures in the United Kingdom and around 70% in the United States , due to Due to the different domestic situations, only some of the clinical indicators recommended by the International Association for Ambulatory Surgery (IAAS) can be applied to day surgery in China . We alloDay surgery reduces the strain on the healthcare system in China resulting from increased medical demand. Day surgery in WCH is a safe and cost-effective way to meet the soaring medical demands in southwest China. Day surgery has its own advantages compared with traditional inpatient surgery. Furthermore, it cuts costs, shortens the length of stay, and allows the hospital to accommodate more patients.


Structural equation modeling largely confirmed our expectations. These results suggest that narcissism can be understood in terms of a deficit in community feeling. It turned out that community feeling and narcissism are related constructs but they are not reducible to each other.The objective of the current study was to examine the relations between narcissism and Adler’s community feeling. Based on theoretical considerations, we claim that community feeling can be treated as an opposite pole of narcissism and we expected that: (1) both grandiose and vulnerable narcissism would be negatively related to community feeling and that (2) grandiose and vulnerable narcissism would be positively related to anti-community domination and isolation. A sample of 520 university students (M In the first half of the 20th century, two great analysts, the creator of psychoanalysis – Sigmund Freud and the creator of individual psychology – Alfred Adler, independently described two seemingly related constructs. On the one hand, Gemeinschaftsgefühl) was described by Alfred Adler in the 1930s based on data collected by him in psychotherapeutic practice . Below we present the understanding of community feeling proposed by Adler in his classical texts , but it is also dynamic and active (anti-community motivation: striving to defeat others). In contrast, there is no negative pole in the concept of communion – only a higher or lower level of communion.Studies show that while a high level of agency is associated with high self-esteem, a high level of communion is not. In a series of 12 studies, on different groups, different nationalities, and using different self-esteem measures, agency proved to be an important predictor of self-esteem in all studies, and communion in none of the studies . Accordir = 0.62), unmitigated communion (r = 0.36) and agency (r = 0.30) and negatively with unmitigated agency (r = −0.36). Anti-community domination is positively related to unmitigated agency (r = 0.50) and negatively to communion (r = −0.45) and unmitigated communion (r = −0.28). Anti-community isolation is negatively correlated with agency (r = −0.53) and communion (r = −0.36) (Preliminary studies of the correlation between community feeling (measured by the first version of the CFQ) and agency – communion  .To sum up, Adler’s  considerations and some preliminary research  have shoNarcissistic Personality Disorder) is diagnosed by the presence of at least five of the following criteria: (1) exaggerated self-esteem; (2) fantasizing about unlimited successes; (3) the conviction of own uncommonness and uniqueness, the possibility of being fully understood only by exceptional people and the conviction that it is worth associating only with people or institutions of a special status; (4) requiring excessive admiration; (5) the expectation of being treated in a special way and submitting others to those expectations; (6) exploitation of others; (7) lack of empathy; (8) jealousy toward others or the belief that others envy them; (9) arrogance and haughty behaviors or attitudes.In various contexts, the term narcissism refers to the developmental phase, personality traits, and the personality disorder. In the DSM-5 , a narciSince the concept of narcissism derives from psychoanalytic theories, it is worth looking at how narcissism is formulated using this approach. In addition to primary narcissism, which is a normal phase of child development, Freud discussed pathological secondary narcissism, in which libido due to injury is focused mainly on oneself instead of referring to external objects. Secondary narcissism is the nucleus of the psychotic structure and it can also lead to depression. According to Traditionally, the concept of narcissism referred to the psychopathology of personality. In newer psychological literature, however, the more popular approach is to treat narcissism as a subclinical phenomenon that can appear in two forms: grandiose and vulnerable . VulneraIn initial studies, the two forms of narcissism were found to be unrelated . This haVulnerable narcissism and the admiration seeking strategy of grandiose narcissism are more removed from each other while the rivalry strategy of grandiose narcissism is located between them and is the closest to self-importance. This was confirmed by The distinction between grandiose and vulnerable narcissism is also considered by the recently developed Narcissism Spectrum Model . In thisA somewhat similar distinction is found in the trifurcated model . In thisThe integration of various approaches to narcissism was made using the Circumplex of Personality Metatraits  – a modeThe theoretical considerations and preliminary research on community feeling led to a distinction between two forms of anti-community orientation: anti-community domination and anti-community isolation. As we presented above, analysis of their theoretical content suggests that they correspond to two facets of narcissism: grandiose and vulnerable. It is worth noting that both community feeling and narcissism are constructs of psychoanalytical origin, proposed by the founder of the psychoanalytical paradigm (Freud and Adler). On the other hand, both community feeling and narcissism are conceptualized and operationalized in current psychology, which enables the relations between these constructs to be tested in the individual differences framework. The aim of our study was to use this opportunity and empirically verify the theoretically predicted relations between two psychoanalytical classic concepts: community feeling and narcissism.Specifically, based on the considerations presented above we hypothesized that:(1)Both types of anti-community orientation are negatively related to the pro-community orientation.(2)Narcissistic rivalry as a facet of grandiose narcissism is positively related to narcissistic admiration (another facet of grandiose narcissism) and vulnerable narcissism.(3)All aspects of narcissism are negatively related to community feeling (pro-community orientation).(4)Grandiose narcissism is positively related to anti-community domination  while vulnerable narcissism is positively related to anti-community isolation.All hypotheses will be tested together in a model presented in The sample consisted of 520 participants, including 386 women and 134 men with ages ranging from 18 to 62 . The questionnaires were distributed to 562 people, but 42 people did not fill in the questionnaires completely and therefore were dropped from the analyses. Participants were Polish university students of the following disciplines: special education, social work, English, German, and French philology, psychology, history, speech therapy, cultural management, national security, management, administration, IT, mechanics and machine construction, and power engineering.The study was conducted in 2018 in Polish universities. After consultation with the lecturers, at the beginning of the classes, students were given questionnaires (in paper form) with a request to complete them. Participation in the study was voluntary and involved no incentives for the participants. The questionnaires were filled in anonymously. Students filled them out immediately, during the classes, and after filling them in, the sheets were collected.https://osf.io/6euyq/.We used a revised version of the CFQ . The CFQcompletely disagree to 6 = completely agree). These items make up two subscales representing the two strategies of maintaining a grandiose self-image: admiration and rivalry. The Cronbach’s alphas of the NARQ subscales were: admiration: α = 0.85; rivalry: α = 0.86.The NARQ measures grandiose narcissism, understood as a personality trait, and consists of 18 items measured on a 6-point Likert scale (1 = completely disagree to 6 = completely agree).The HSNS is a brief, unidimensional measure of vulnerable narcissism , which cThe positive pole of community feeling (pro-community orientation) was negatively correlated both with grandiose narcissism – rivalry, and with vulnerable narcissism. We did not find a significant relationship between community feeling and the admiration strategy of grandiose narcissism. Anti-community domination correlated positively with all forms of narcissism, but, consistent with our expectations, it correlated most strongly with the rivalry strategy of grandiose narcissism. Anti-community isolation, as predicted, correlated most strongly and positively with vulnerable narcissism, as well as negatively with grandiose admiration.Regarding gender differences: men have a higher level of anti-community domination and of grandiose narcissism  than women. There are no other significant gender differences. The results are presented in 2 = 75.67, RMSEA = 0.064 (0.048–0.081); CFI = 0.985, SRMR = 0.036; (2) The model for NARQ: df = 8, χ2 = 11.85, RMSEA = 0.030 (0.000–0.064); CFI = 0.998, SRMR = 0.020. In the second step the full SEM model was run.The theoretical model presented in 2 = 333.44 (df = 120), CFI = 0.967; RMSEA = 0.058 (0.051–0.066); SRMR = 0.043. As shown, most of the expected relations were confirmed. The only exceptions were the lack of a negative relation between narcissistic admiration and pro-community orientation and (2) a negative relation between narcissistic admiration and anti-community isolation.The model presented in In the current article, we argue that community feeling derived from the tradition of Adler is systematically related to narcissism originated in the tradition of Freud. Narcissism has been heavily studied in social, personality, and clinical psychology for decades. Taking into account Adler’s conceptualization of community feeling, one can claim that narcissism can be treated as a deficit in community feeling. Thus, community feeling and narcissism can be treated as two opposing phenomena.The results of the current study confirmed the hypothesis that anti-community orientations are strongly related to narcissism. Especially anti-community domination is positively related to grandiose narcissism (as measured by NARQ) and anti-community isolation is positively related to vulnerable narcissism (as measured by HSNS).The relations between community feeling and both aspects of narcissism on the basis of the Spectrum Narcissism Model  are presTreating community feeling (pro-community orientation) and narcissism as two opposite psychological phenomena does not mean they are identical or reducible to each other. Describing some constructs as opposing is not rare in psychology. It is especially useful in circular models. An example of that is Schwartz’s  model ofThe above conclusions, however, mainly concern maladaptive forms of narcissism. Our research has not confirmed the hypothesis of a negative relationship between pro-community orientation and one form of grandiose narcissism: narcissistic admiration. It can be explained by the fact that a narcissistic admiration strategy can have an adaptive function . ResearcThe strength of the article lies in it taking a step toward the integration of two psychological concepts originally derived from two different classical psychoanalytical traditions. At the same time, this has been done by conducting research with tools enabling their integration into contemporary personality concepts. It is worth noting that the concept of narcissism is derived from the works of The results after some replications can also have a practical application. In particular, showing the connection between maladaptive forms of narcissism and community feeling can be used in the psychotherapy of people with narcissistic personality disorder. According to Adler’s assumption, community feeling, although it is a relatively stable disposition, is formed in the first years of life and can also be potentially developed in later life periods. Therefore, one can expect that supporting the development of community feeling will help in narcissistic personality disorder psychotherapy.Our study is not free of limitations. First, there are some measurement limitations. The validity of the HSNS (as a measurement of vulnerable narcissism) has been discussed and is considered controversial . AdditioSecond, there are some construct limitations that need to be taken into account in future research. Community feeling measured with the CFQ has to be distinguished in empirical results from related constructs like communion  and collected the data. AK-W and WS developed the revised version of the Community Feeling Questionnaire. AK-W, WS, and JC designed the study. WS and JC ran the statistical analyses. AK-W in collaboration with WS wrote the manuscript. JC commented on the draft of the manuscript and helped to improve it to the published version. All authors 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.


The short wavelength, i.e., blue light, is crucial for non-image forming effects such as entrainment of the circadian system in humans. Moreover, many studies showed that blue light enhances alertness and performance in cognitive tasks. However, most scientific reports in this topic are based on experiments using short exposure to blue or blue-enriched light, and only a few focused on the effects of its reduced transmittance, especially in longer periods. The latter could potentially give insight into understanding if age-related sleep problems and cognitive decline are related to less amount of blue light reaching the retina, as the eyes’ lenses yellow with age. In this study, we investigated the effects of prolonged blocking of blue light on cognitive functioning, in particular—sustained attention and visuospatial working memory, as well as on sleep, and melatonin and cortisol levels. A group of young, healthy participants was randomly allocated to either blue light blocking or control group. Depending on the group, participants wore amber contact lenses, reducing the transmittance of blue light by ∼90% or regular contact lenses for a period of 4 weeks. No changes were observed for measurements related to sleep and sleep–wake rhythm. Dim light melatonin onset, evening levels of melatonin, and morning cortisol answer did not show any significant alterations during blue light (BL) blockade. The significant effects were revealed both for sustained attention and visuospatial memory, i.e., the longer blocking the blue light lasted, the greater decrease in performance observed. Additionally, the follow-up session conducted ∼1 week after taking off the blue-blocking lenses revealed that in case of sustained attention, this detrimental effect of blocking BL is fully reversible. Our findings provide evidence that prolonged reduction of BL exposure directly affects human cognitive functioning regardless of circadian rhythmicity. Humans adapted their life to 24 h light–dark cycle. As a diurnal species, we are exposed to light that is necessary not only for vision but also constitutes a powerful modulator of non-visual functions. The non-visual  effects of light such as circadian rhythms regulation and pupil constriction are mediated by a retinal photoreceptor system built of the intrinsically photosensitive retinal ganglion cells ipRGC;  probablyIn these unique ipRGC cells, the triggering signal transduction is accomplished by the photopigment melanopsin, which shows maximum sensitivity to the blue, i.e., short wavelength, part of the spectrum ∼480 nm; . BehavioHere, we focus on alerting and cognitive functions, and how these are affected by changed light condition. Studies demonstrated that exposure to monochromatic blue light improves performance, i.e., participants respond faster and with better accuracy, and at the same time reduces sleepiness in terms of subjective ratings  or stimuMost studies focusing on the effects of short-wavelength light present the experiments with exposure to blue or blue-enriched light. In addition, in most cases, they report the effect of short-lasting exposure to light (from short pulses to minutes and to hours). However, taking into account the aging process of the eye lens, it is also important to consider the condition of filtering the blue light for a prolonged time (days or weeks). During aging, the natural lens becomes more yellow because of the accumulation of chromophores that decrease transmission especially in the short-wavelength range of the visible spectrum . InteresTherefore, studying the effects of reduced exposure to blue light is an important aspect of understanding the changes related to aging process. Only a few studies reported the consequences of short-term BL filtering using the short-wavelength attenuated polychromatic white- or blue-light blocking glasses. It was shown that this reduction leads to decrement of performance, subjective vigilance and efficiency, and affects physiological parameters linked to sleepiness and vigilance  as well The goal of the current study was to observe the long-term effects of blue light filtering. In contrast to the aforementioned study by The study was registered in the International Standard Randomized Controlled Trial Number (ISRCTN) clinical trial registry ; 32 female] started the experiment and were divided into two groups differing in the type of contact lenses used: blue light blocked (BLB) group and control (CTRL) group . Participants were not aware of which group they would be assigned to; allocation was performed by a member of the research team by lot separately for each 6-week round of experiment . All of them had nearsightedness (myopia) and good experience with contact lenses wearing. Each participant underwent a thorough ophthalmologic examination to exclude other sight problems and passed the Ishihara test for color blindness. Participants assigned to BLB group wore the amber contact lenses reducing the transmittance of BL by ∼90% on the 24 h basis , whereas CTRLs wore the regular contact lenses . Two subjects were excluded because of an elevated level of daytime sleepiness throughout the whole experiment and particularly high ESS score in baseline session; they were from the CTRL group. Due to dropouts, exclusion of participants, or technical problems, data from different number of participants were analyzed in used measures .P.M. and those from the BLB group approximately at 9:30 P.M. The timing of the test differed between groups, however, it was the same in every session for each group. The goal was to examine two people from both groups on the same day in order to make sure they were exposed to the same photoperiod. To check whether this discrepancy did not introduce bias regarding circadian and/or homeostatic factors, we have compared the results from the baseline session between groups. No significant differences were observed; thus, the time difference between acquisition did not affect our results.The experiment lasted 6 weeks . For eacP.M.).For the first 2 weeks, all participants wore regular, daily disposable contact lenses. After the first week, participants familiarized themselves with a complete experimental protocol including experimental tasks (training session). The session after the second week was treated as a baseline. For the next 4 weeks, participants wore monthly disposable contact lenses with proper filter properties according to the group. They visited the laboratory after each week to complete experimental sessions. Additionally, participants from the BLB group had one more session (follow-up) ∼1 week after the main experiment; testing was performed in the evening hours  directly before the session. They were also asked to abstain from alcohol and caffeine during 24 h preceding the measurements. Chocolate, bananas, and citrus fruits or juices were not allowed on the day of examination. The experiment was conducted during spring to fall months ensuring greater availability of sunlight.At each session, participants performed two experimental tasks in front of the computer screen and filled in the ESS questionnaire. They were also asked about visual sensations and discomfort in the preceding week; one of the goals of this interview was to monitor compliance of lens wear. During baseline and on the last experimental session, participants additionally fulfilled the PSQI questionnaire. Through the whole experiment (6 weeks), they wore actigraphs (AMI – Ambulatory Monitoring Inc. or MotionWatch8 – CamNtech Ltd.) on their non-dominant wrist. From the recordings, the following parameters were calculated: sleep onset and offset, sleep onset latency , and actual sleep time. Additionally, for 19 participants that wore MotionWatch8 actigraphs (11 from BLP and 8 from CTRL group), the non-parametric circadian analysis was performed . Three pPM. Participants were asked to keep morning samples refrigerated and to bring them to the lab in the evening. For melatonin assay, five samples were collected – every hour from 7 to 11 P.M. For this time, participants were asked to sit quietly, under dim lighting conditions (<5 lx). They rinsed their mouth with water 10 min before each sample and were not allowed to eat or drink 30 min before sampling. The samples were frozen and stored below −18°C. Salivary melatonin and cortisol were measured with competitive ELISA . Before analysis, all samples were vortexed and centrifuged at 1,500 × g for 15 min to get rid of mucins, which may affect antigen binding to the antibody and lead to incorrect results. The analysis was carried out according to the manufacturer’s protocol. Into appropriate wells of a microtiter plate, coated with antimelatonin or anticortisol monoclonal antibodies, standards, controls, and saliva samples were pipetted. Then, into each well, enzyme conjugate, containing melatonin or cortisol conjugated to horseradish peroxidase enzyme, was added, and plates were incubated for 3 h at 6°C in case of melatonin assay or for 1 h at room temperature in case of cortisol assay. After washing, into each well, tetramethylbenzidine substrate solution was pipetted, and plates were incubated in the dark at room temperature for 30 min (melatonin assay) or 25 min (cortisol assay). Within 10 min of adding Stop Solution, the optical density was read in Infinite 200 PRO (Tecan) at 450 nm. To obtain the best results, a secondary filter correction at 625 nm (melatonin assay) or 491 (cortisol assay) was performed. The concentration of melatonin and cortisol in the saliva samples was determined using a four-parameter non-linear regression curve fit. Melatonin levels were analyzed as baseline as well as second and fourth experimental sessions. Examples of melatonin profiles are presented in At each session, participants from the BLB group provided saliva samples using a passive drool method , a widely used test of sustained attention . The tasIn the analysis, errors of commission were defined as responses without a stimulus or those with RT < 100 ms, whereas errors of omission as lack of response on stimulus or responses with RT ≥ 500 ms. The number of errors was calculated as a percentage of all stimuli in the task. For correct responses, mean RT, mean RT for 10% of the fastest responses, and mean RT for 10% of the slowest responses were calculated as the most frequently reported PVT outcome metrics . AdditioTo study visuospatial working memory, we used a sequential picture location task SPLT; . In the Both tasks were performed on a computer with 19-in LCD screen. For training and baseline session for the BLB group as well as for all experiment for the CTRL group, the blue-blocking filter was used on the screen to ensure similar visual conditions  for all participants (see filter properties in session (five levels accounting for one baseline and four sessions of wearing BLB/regular contact lenses – a repeated measure within-subject factor) and group (two levels: BLP and CTRL group – between-subject factor) was checked in the two-factor mixed design (ANOVA) test. The Tukey honestly significant difference (HSD) test was used for post hoc comparisons. Tests were performed using Statistica software . This way, the PVT outcomes, as well as actigraphy and questionnaire data and time spent outside during the day, were analyzed .The outcomes of the measures used in the experiment were tested if they show a changing pattern through consecutive sessions and if this pattern differs between groups. Thus, the interaction of minutes) was introduced to ANOVA test. For the SPLT task, an additional between-subject factor was added to the ANOVA analysis in order to take into account the two versions of the task (note: none of the effects including task version factor was significant).The comparison of the PVT outcomes and ESS questionnaire in the follow-up session with baseline and the last week of wearing the BLB contact lenses was performed on data from the BLB group with repeated-measures ANOVA test. The goal of this analysis was to check whether any changes in behavior diminished ∼1 week after taking off the blue light blocking contact lenses. To test the time-on-task effect in the PVT task, additional factor .F = 1.96, p = 0.10; see F = 0.20, p = 0.66].The comparison between groups was made in terms of age, gender, body mass index (BMI), sleep quality, level of daytime sleepiness, and chronotype for the group of 38 participants that completed the study . Data are summarized in t(36) = 0.17, p = 0.86; mean RT for 10% of the fastest responses: t(36) = 0.36, p = 0.72; mean RT for 10% of the slowest responses: t(36) = 0.25, p = 0.80; number of omission errors: t(36) = 1.13, p = 0.27] nor for SPLT task .Since the timing of the PVT and SPLT task differed between groups, we have checked the results from the baseline session. No significant differences were observed between groups neither for PVT  and mean RT for 10% of the fastest responses . The Tukey HSD post hoc comparisons yielded a significant increase in these measures in consecutive sessions only for the BLB group; detailed test results are presented on the graphs  = 1.54, p = 0.19], number of omission errors , and number of commission errors .The analysis of PVT data was performed on data obtained from 38 participants (19 from the BLB and 19 from the CTRL group). The outcome metrics are presented on graphs in e graphs . Other mF = 9.94, p < 0.001, partial η2 = 0.22]; however, interaction with group and session was not significant . The comparison of slopes did not reveal significant interaction between sessions and groups , neither the standard deviation of RT .The time-on-task effect, i.e., increasing RT in the course of the task, was present , mean RT for 10% of the fastest responses , mean RT for 10% of the slowest responses  and number of omission errors . The post hoc tests for all the above-mentioned analyses revealed significant difference between the baseline session and fourth week of wearing BLB contact lenses and between this session and the follow-up. There was no difference between the baseline and follow-up sessions. The number of commission errors did not show significant differences between sessions .For the PVT task, we compared the follow-up session with the baseline and last week of wearing the BLB contact lenses for the BLB group . The repgroup and session for the accuracy in the SPLT task .Sleep parameters assessed with actigraphy are presented in F = 1.99, p = 0.15; DLMO, F = 1.68, p = 0.21]. In addition, cortisol data in terms of CAR did not change between sessions . However, one may observe a slight increase in mean evening melatonin levels after 2 weeks of BL blockade as well as weaker morning cortisol response after this time; those trends do not continue in the second half of the experiment. The results are presented in Melatonin data did not show significant effect of session . When considering the follow-up session, the ESS score did not show significant effect . The questionnaire results are reported for 38 subjects (19 from the BLB and 19 from the CTRL group).The subjective daytime sleepiness (ESS) and sleep quality (PSQI) results are presented in In this study, we investigated the effects of prolonged blocking of blue light on sustained attention and visuospatial working memory as well as on circadian rhythmicity. We used the PVT, a simple reaction time task that indicates the ability to achieve and maintain a certain level of cognitive performance , as wellAs hypothesized, our study showed that blocking blue light slows down reactions in sustained attention task and causes deterioration of performance in the visuospatial memory task. This effect gradually strengthens in consecutive weeks. Interestingly, our results revealed that in case of sustained attention, this effect is reversible, as the reaction times decrease to the baseline level after returning to “normal” light conditions .The effect of blue light on cognitive processes may be considered in terms of complex interactions between circadian, sleep, and arousal factors. Particularly, blue light, through the NIF system, can either act directly on the neuronal system and thus on alertness and behavior, or indirect effects may occur due to disrupted entrainment of the circadian system and/or sleep . Therefoper se and in consequence on performance through this indirect pathway. The unchanged DLMO as well as evening melatonin and morning cortisol levels corroborates this assumption.Based on previous studies on sleep–wake regulation, it can be stated that blocking blue light causes similar outcomes to those of sleep deprivation . Thus, pTherefore, the results of our study could be interpreted in terms of the direct effect of light on alertness. The series of neuroimaging experiments by Vandewalle and colleagues demonstrated that blue light induces modulations of brain activity while participants are engaged in non-visual cognitive tasks , b, 2009Prolonged filtering of the blue light is a part of the aging process of the eye. As known, aging is often associated with sleep and circadian disturbances  as well A methodological limitation of our study is the fact that the participants from each group performed tasks at different times . This time difference could potentially introduce a bias in the results. However, as stated in sections “Materials and Methods” and “Results,” we have compared the results from the baseline session between groups and found no significant differences. It is important to note that the time of task performance was the same in every session for each group; thus, bias regarding circadian and/or homeostatic factors was eliminated in the comparison between subsequent experimental sessions. Nevertheless, the timing of testing could alter the effect of prior light history on performance in both tasks.Our experiment was conducted in the so-called “natural settings.” The participants did not stay in the lab, and we did not impose on them a specific sleep–wake schedule. Therefore, we had no control over all potentially disruptive factors that could affect the sleep–wake cycle and, consequently, the psychophysical state. However, the activity was controlled with the use of actigraphs and sleep parameters calculated from these recordings differed neither between sessions nor between groups.P.M.), risking that, in some cases, it might not cover the time of melatonin rise and those data would be unusable. Indeed, we noticed a wide range of sleep times in our participants and the problem with determining DLMO happened with one subject.Because of organizational constraints, we were not able to set individual timetables for every participant, taking into account their habitual wake- and bedtimes. We decided to collect the saliva samples at most common hours (from 7 to 11 In summary, we found that prolonged and substantial reduction of blue light causes a worsening of performance in sustained attention and visuospatial memory tasks. At the same time, no effects on sleep parameters were observed. The lack of significant changes in sleep pattern and melatonin indicators during a 4-week experiment may be an indirect proof of the stability of sleep–wake rhythm. Thus, the observed deterioration of cognitive functioning was not related to indirect effects through disruption of the circadian system, but rather, it may be directly attributed to a lack of boosting effect of blue light.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Bioethics Commission at the Polish Military Institute of Aviation Medicine. The patients/participants provided their written informed consent to participate in this study.AD, HO, EB, MF, PC, MR, and TM: conception and design of the work. AD, HO, and MP: acquisition and analysis. AD, HO, EB, MF, and TM: interpretation of the results. AD: drafting the work. AD, HO, EB, MF, MP, PC, MR, and TM: revising the manuscript critically and final approval of the version to be published. 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.


N = 690 Chilean and Latin-American immigrant secondary students. Results showed that cultural self-efficacy reduced the effect of prejudice in satisfaction with school, in the cases of both immigrant and Chilean students. The dimensions of cultural self-efficacy in processing information from other cultures and mixing with different others make the difference. Findings’ contributions for the understanding of adolescents’ intergroup relations and psychosocial interventions at school are discussed.Latin-American immigration has transformed Chilean schools into new multicultural scenarios. Studies about intergroup dynamics among students from different cultural backgrounds and their psychological consequences are still limited in south–south migration contexts. Literature has suggested that intergroup relations influence students’ satisfaction with school, and they could be improved by the development of competences to cope with cultural differences. This study aims to verify if cultural self-efficacy and its dimensions mediated the influence of prejudice on satisfaction with school, in a sample composed by  School is the main scenario for intergroup contact between adolescents from different ethnic backgrounds. Quotidian experiences of mixing with different others at school could have important consequences on intergroup attitudes, even affecting their relations with outgroup members on their adulthood . MoreoveCultural diversity at schools is a new and challenging reality to the Chilean educational system. During the last years, Chile has shown a progressive increase of the immigrant population, which represents 7.7% of the total inhabitants and mostly came from other Latin-American countries (90.96%) . As a coStudies about immigrant and Chilean students’ intergroup attitudes and school well-being are still limited and have shown diverse results. On the one hand, some researches have suggested the existence of negative intergroup dynamics , while oSubjective well-being can be understood as a global evaluation of one’s life and its different circumstances and contexts . The stuIn addition to age differences, literature also shows contrasts according to gender and group status, among others. For instance, a research in Spain showed that girls report higher levels of satisfaction with several domains of their lives  . This str = 0.201, CI ]. Other studies reported that positive peer and friend relationships are positively associated with most domains of adolescents’ life satisfaction  study possible differences between immigrant and Chilean students on cultural self-efficacy and school satisfaction; (2) establish the influence of sex, age, and length of residence in Chile (immigrant students) on the aforementioned variables; (3) verify the relationships between prejudice, cultural self-efficacy, and school satisfaction perceived by Latin-American immigrants and Chilean students; and (4) establish the possible incidence of cultural self-efficacy on the relationship between prejudice and school satisfaction. As a hypothesis, we expect that (1) Chileans students will present lower levels of school satisfaction than immigrants; (2) girls will present higher levels of school satisfaction and lower levels of prejudice than boys; (3) there will be a negative relationship between prejudice and school satisfaction; and (4) cultural self-efficacy will reduce the negative effect of prejudice on school satisfaction.In Chile, the mean of immigrant students’ concentration at schools is 2.2% , and immM = 16.02; SD = 1.41). In the case of immigrant students, 54% of them were women, while in the Chilean group, women represented 52%.The sample was composed of 691 secondary students (44% immigrants and 56% Chilean), with ages between 13 and 19 years old .Immigrant students were 304, and all of them were born in foreign Latin-American countries, particularly in Peru (53.3%), Venezuela (24.3%), Colombia (10.9%), Bolivia (5.3%), Ecuador (4.3%), and Dominican Republic (2%). The length of residence in Chile varied from 1 to 180 months  = 12.441, p < 0.05; CFI = 0.989; TLI = 0.967; SRMR = 0.028; RMSEA = 0.070 [90% CI ]. In the case of Chilean students, the confirmatory factor analysis results were also adequate: χ2(5) = 14.153, p < 0.05; CFI = 0.990; TLI = 0.971; SRMR = 0.032; RMSEA = 0.069 [90% CI ].The School Satisfaction Scale  was appl2(35) = 81,628, p < 0.001; CFI = 0.968; TLI = 0.950; SRMR = 0.041; RMSEA = 0.066 [90% CI ]. The confirmatory analysis results for the Chilean group were also adequate: χ2(34) = 64.516, p < 0.001; CFI = 0.984; TLI = 0.975; SRMR = 0.040; RMSEA = 0.048 [90% CI ].The emotional prejudice scale  was appl2(181) = 420.192, p < 0.001; CFI = 0.940; TLI = 0.930; SRMR = 0.024; RMSEA = 0.066 [90% CI ], as well on the Chilean student group, χ2(181) = 262.780, p < 0.001; CFI = 0.973; TLI = 0.967; SRMR = 0.036; RMSEA = 0.053 [90% CI ].The Cultural Self-efficacy Scale for Adolescents (CSES-A)  was applSantiago is a city with a higher concentration of immigrant population in the country (65.2%) . Thus, tParticipants’ selection was conducted using a convenience sampling, according to schools’ availability to participate. Second-generation immigrant students and the ones with low levels of proficiency in Spanish were excluded. Parents’ and students’ consent were requested by means of personalized letters, aiming to safeguard voluntary participation. Participants completed the questionnaire protocol voluntarily in their educational centers and during regular class time. Questionnaire administration was done collectively and lasted 40 min. The procedures followed in the study were certified by the Research Ethics Committee of Universidad Alberto Hurtado, considering all the standards of the Helsinki Declaration.r (n = 107). The second group was composed by Peruvians (n = 162), who belong to the largest and former immigrant group in Chile. The third group was mixed, and it included students from different minority nationalities, such as Ecuadorians, Dominicans, and Bolivians (n = 35). ANOVA test reported no significant differences among groups in the studied variables. Thus, immigrant participants were considered as a single group for the following analysis. Mediation analyses were carried out based on the Process macro (model 4) system of SPSS, which on the bases of the Sobel test establishes whether the indirect effect of the mediator is significantly different from zero. When the confidence interval does not include 0, the effect is significant, and mediation is confirmed  was controlled for, prejudice had a significant negative effect on school satisfaction . Prejudice had also a negative influence on cultural self-efficacy . Conversely, cultural self-efficacy had a positive impact on school satisfaction . The indirect effect of prejudice on school satisfaction through cultural self-efficacy was significant . The direct effect of prejudice in school satisfaction was still significant when all the variables were in the model . This indicates that cultural self-efficacy partially mediates the relation between prejudice and school satisfaction. The model explained 22% of school satisfaction’s variability  were controlled for, prejudice had a negative effect on school satisfaction . Likewise, prejudice had a negative impact in self-efficacy in processing information about other cultures , in self-efficacy in mixing satisfactorily with other cultures , and in self-efficacy in understanding other ways of life . Besides, self-efficacy in mixing satisfactorily with other cultures  had a positive effect on school satisfaction, while the dimensions of processing information  and understanding other lifestyles  were not significant mediators.Aiming to further comprehend the mediator role of cultural self-efficacy, a second model which included its three dimensions was performed. When the effects of sex . Thus, the effect of self-efficacy in mixing satisfactorily with other cultures partially mediated the association between prejudice and school satisfaction. This model explained 23% of immigrant students’ satisfaction with school ]. The direct effect of prejudice was still significant when all the variables were in the model  and age  were controlled for, prejudice’s negative impact on school satisfaction was significant . Besides, it had a significant negative influence on cultural self-efficacy . Cultural self-efficacy had a positive effect on school satisfaction . The indirect effect of prejudice on school satisfaction through self-efficacy was also significant , but its direct effect was not significant when all the variables were in the model . These results indicate that cultural self-efficacy totally mediates the relationship between prejudice and school satisfaction. The model explained 15% of the variability of satisfaction with school on Chilean students  and age  were controlled for, prejudice exerted a significant negative influence on school satisfaction . It also had a negative effect on self-efficacy in processing information about other cultures , on self-efficacy in mixing satisfactorily with other cultures , and on self-efficacy in understanding other ways of life . Both cultural self-efficacy in processing information from other cultural groups  and in mixing satisfactorily with other cultures  had a positive impact on school satisfaction, but the dimension of understanding other lifestyles was not a significant mediator .The fourth model showed that when the possible effects of sex . This result shows that these two dimensions of cultural self-efficacy totally mediated the effects of prejudice in school satisfaction. The total amount of explained variability was 17% ] and self-efficacy in mixing satisfactorily with other cultures  were significant. The direct effect of prejudice was not significant when all the variables were in the model (β = −0.12,  17% see .Intergroup relations have been identified as important antecedents of students’ school adjustment and well-being . LiteratBesides, students reported high levels of management in cultural diversity scenarios at school, feeling capable to process information from other cultures, mixing satisfactorily with other cultures, and understanding other ways of life. These results coincide with those informed by In this context, immigrant students tended to show higher self-efficacy than did Chilean in processing information from other cultures, which is also consistent with former reports . LiteratParticipants from both groups also informed levels of school satisfaction over the midpoint of the scale. Different to previous research findings , immigraIn the case of immigrant students, we found that age and length of residence in Chile were not related to any of the studied variables. An interpretation could be that social and cultural conditions might be more decisive than time in their adjustment to the new context . ResultsOutcomes from the Chilean students’ group showed that the increment of age was related to an increase in prejudice. Reports from former studies about this relation during adolescence are diverse. For example, a meta-analytical research  concludeAlso, in the Chilean group, girls presented fewer levels of prejudice than boys. Literature has plenty of evidence about this relationship. A meta-analytical study conducted by Correlation analyses between prejudice, cultural self-efficacy, and school satisfaction showed a common pattern across both groups of students. Prejudice was negatively related to school satisfaction, as was expected. This result emphasizes the importance of peer intergroup relationships in students’ well-being, which are especially sensible in cultural diversity scenarios . PrejudiSimple mediation analyses suggest that the role of cultural self-efficacy in the relation between prejudice and school satisfaction works slightly different for each group of students. Cultural self-efficacy partially reduced the impact of prejudice on immigrants’ school satisfaction, while its effect in the case of Chilean students was total. A plausible explanation for these outcomes could be found in studies which have evaluated results of intervention programs to improve intergroup relations between majority and minority groups’ students. These studies have suggested that their impacts tend to be stronger on the first ones, because those who are members of low-status groups still have to cope with social and cultural barriers .Multiple mediation analyses results including cultural self-efficacy’s dimensions offer a deeper comprehension about these phenomena. In the case of immigrant students, cultural self-efficacy in mixing satisfactorily with other cultures was the only significant mediator, stressing the importance of social relatedness to school experiences and especially to well-being . The senOn the other hand, results from the Chilean group revealed that cultural self-efficacy both in processing information from other cultures and in mixing with other cultures totally mediated the effect of prejudice on school satisfaction. Literature on cultural intelligence  has propIt is also interesting that for immigrant and native students, cultural self-efficacy in understanding different ways of life was not a significant mediator in the relationship between prejudice and school satisfaction. We think that this may be due to the aspects that this dimension assessed. Cross-cultural similarities between Latin-American countries in family configurations, religion, and artistic expressions  could exThis study presents limitations to be considered. The use of an intentional sample in the framework of a cross-sectional design does not allow appreciation of the development of the relationship between prejudice, cultural self-efficacy, and school satisfaction across time. This could be important on this population due to the changes that occur during adolescence. Second, in this research, we did not include immigrant students who could perceive higher levels of cultural differences and also have to deal with language barriers at school, like in the case of Haitian students. They were excluded because they represented a small percentage of the sample. The results of this study could vary by including this type of students due to stronger difficulties to cope with school relationships and tasks . BesidesHowever, our results stress the importance of intergroup relations and cultural self-efficacy in school satisfaction. Furthermore, our findings suggest a favorable context, which could be less conflictive than was expected. This could be due to the nuances of south–south migration processes , differeFinally, we think that multicultural education programs in our region should include the development of students’ cultural self-efficacy. These are self-beliefs and skills that can be learned, which will improve adolescents’ well-being in diversity contexts and help the construction of cultural integration and social cohesion. Multicultural education to promote the creation of a culture of peace is one of the main objectives of UNESCO for Latin America and the Caribbean. The development of interventions through which students could learn capabilities to understand cultural differences and mix with different others might facilitate respect and friendship between people with different national, ethnic, and religious identities . The attThe datasets generated for this study are available on request to the corresponding author.The studies involving human participants were reviewed and approved by the Comité de ética Universidad Alberto Hurtado. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.MM-L, MB, and NB designed the study. MM-L collected the data. All authors contributed in the analysis and interpretation of data, drafted the manuscript, discussed the results, and commented on the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The association between dietary diversity and frailty remains unknown in older people. We evaluated whether a limited dietary variety is associated with frailty in older adults with diabetes mellitus (DM). This cross-sectional investigation included 1357 adults . DM was determined by self-reporting, the Dietary Variety Score (DVS) was used to evaluate dietary variety, and the revised Japanese version of the Cardiovascular Health Study criteria evaluated frailty. Participants were divided into 4 groups: no DM/high DVS (non-DMHV), no DM/low DVS (non-DMLV), DM/high DVS (DMHV), and DM/low DVS (DMLV). The prevalence of frailty in each group was 3.6%, 6.7%, 6.7%, and 12.2%. After adjusting for covariates, logistic regression analysis revealed the highest odds ratio (OR) of frailty in the DMLV : 1.25–3.83); DMHV, OR = 1.87 (95% CI: 0.63–5.52); DML, OR = 5.03 (95% CI: 2.05–12.35)). Another logistic regression analysis revealed that a low DVS and DM were independently associated with frailty. Both a low dietary variety and DM were independently related to frailty in older people and the combination increased the prevalence of frailty. These findings suggest that high dietary variety could be important for the prevention of frailty in people with DM. As the population aging rate continues to increase, it is of the utmost importance to prevent disability and extend healthy life expectancy. Frailty is defined as being vulnerable to falls, disability, hospitalization, and mortality after a stressor event due to the age-related loss of functional reserve. Appropriate interventions, such as diet and exercise, can improve the condition of people with frailty, as it is reversible . NationaAccording to diabetes surveys and national health/nutrition surveys in Japan, the incidence of people with strongly suspected diabetes mellitus (DM) has constantly increased over the past years: 6.9 million in 1997, 8.9 million in 2007, and 10 million in 2016 ,4,5. TheA decrease in the intake of total energy and specific nutrients, such as protein and vitamins A and B, is reported to be associated with frailty ,16,17,18This study used pooled data from the Takashimadaira Study and the Otassha Study, which are cohort studies concerning older community members of the Tokyo metropolitan area of Japan. The designs and protocols of the two studies have been described in detail elsewhere ,23,24. TThis study was approved by the research ethics committee of the Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology . Written informed consent was obtained from all participants.A well-experienced nurse interviewed participants to determine if they had a medical history of DM. A medical history of comorbidities  and knee pain was also taken.At healthcare facility, interviews about Dietary Variety Score (DVS) were conducted by trained investigators using the paper-based questionnaires. The DVS developed by Kumagai et al.  was usedThis study used the revised Japanese version of the Cardiovascular Health Study (revised J-CHS) for the evaluation of frailty ,28. The The following items were evaluated: sex, age, body mass index (BMI), the number of household members, alcohol consumption , and smoking . Serum levels of creatinine, albumin, and HbA1c were measured using conventional laboratory methods.p-values were set at 5%.Participants were divided into the following 4 groups based on the results of the DM and dietary evaluations: the no DM/high DVS (non-DMHV) group, no DM/low DVS (non-DMLV) group, the DM/high DVS (DMHV) group, and the DM/low DVS (DMLV) group. The Kruskal–Wallis test for continuous values and chi-square test for categorical variables were used to assess the differences between these 4 groups. A chi-square test was also performed for the presence of DM and DVS scores. Results are expressed as median (interquartile range (IQR)) and numbers of participants (%). Binomial logistic regression analysis was performed to examine the independent relationship between the above-defined 4 groups and frailty in the crude model. In the adjusted model 1, demographic variables  were adjusted. In the adjusted model 2, variables about lifestyles, comorbidity, and laboratory findings, which significantly associated with DM/DVS groups in univariate analysis, were further adjusted: alcohol consumption, hypertension, hyperlipidemia, heart disease, osteoporosis, the presence of knee pain, and serum creatinine. Another logistic regression analysis using the DVS and DM as independent variables was conducted to examine whether dietary variety and DM are independently associated with frailty. SPSS Statistics ver. 25  was used for all statistical analyses. n = 832) were women. n = 644, 47.5%), non-DMLV , DMHV , and DMLV . The median BMI, DVS, serum creatinine, and HbA1c, and the prevalence of sex, alcohol consumption, a past history of hypertension, heart disease, hyperlipidemia, and osteoporosis were significantly different among the 4 groups. There were significant differences in the frequency of all foods consumed daily between the high DVS and low DVS groups in participants with and without DM (The median (IQR) of the age of participants was 77 (72–81) years. Approximately 61.3% (thout DM .p = 0.002).To examine the independent association between frailty and a low DVS or DM, another logistic regression analysis was conducted . Both a This study indicated a significant relationship between a low DVS or DM and frailty in the older population. The prevalence of participants with DM consuming a poor dietary variety was 12.2%, which was approximately 3.4 times higher than those participants without DM consuming a high dietary variety. After adjusting for covariates, including comorbidities, the odds ratio of frailty in the group of participants with DM and a low DVS was the highest at 5.0. To the best of our knowledge, this study is the first large-scale study that examined the relationship between frailty and the combination of DM and dietary variety.In our study, the prevalence of frailty was about twice as high in participants with DM as in those without DM. The result is consistent with that of similar cross-sectional and longitudinal studies ,9. This In our study, a low DVS was also associated with a high prevalence of frailty. This result is consistent with another study of 665 older community residents with a mean age of 73.6 years, showing that a high DVS is associated with a low degree of frailty . The assIn addition, a varied diet shares similarities with the Mediterranean diet and other healthy dietary patterns in that they are high in fish, vegetables, and fruits, and low in refined grains. In a meta-analysis, a high adherence to the Mediterranean or other healthy diet was associated with a reduced risk of frailty in the older population ,20 and pIn our study, we found that the combination of DM and a low DVS further exacerbates the risk of frailty. It has been reported that older adults with DM are more likely to have malnutrition compared to their counterparts without DM . ExcessiThis study has several limitations. First, it was a cross-sectional study, and therefore causal relationships cannot be inferred. It is necessary to conduct longitudinal and intervention studies. Second, information on DM that was collected from participants in this study was not sufficient. While a nurse interviewed participants for their past history of DM, information on the type of DM, age of onset, and medications was not collected. Information about dietary management, such as the experience of receiving nutrition counseling regarding the management of DM and the current situation of dietary control, was also unknown. Future studies would need to allocate participants to different groups according to the type of DM—that is, type 1 or type 2. Third, participants may have been healthy. The participant frailty rate was 5.5%, which was lower than that reported in earlier studies ,27. ThisBoth a limited dietary variety and DM are independently associated with frailty in older people and the combination increased the prevalence of frailty. These findings suggest that high dietary variety could be important for the prevention of frailty in people with DM. Further studies are needed to examine whether nutritional intervention using the Dietary Variety Score is as effective as aggressive nutritional guidance targeting specific nutrients and total energy intake in improving frailty in older adults with DM.