Past research has examined the beneficial effects of contact focusing mainly on the affective dimension of intergroup relationships. Limited research has examined cognitive dimensions, in particular considering at the same time minority and majority group perspectives. This study tested whether contact in a work context relates differentially to the perception of interethnic conflict in Italian (n = 67) and immigrant  blue-collar coworkers with the potential mediation of reciprocal stereotypical content (competence and warmth dimensions), interethnic attitudes, perceived discrimination, and whether organizational identification amplifies the effect of contact. Multigroup path analysis revealed that the two stereotype dimensions, warmth and competence, mediate the relationship between interethnic contact and perceived discrimination for Italians, and between organizational identification and perceived conflict for immigrants. Results highlighted an asymmetrical effect of contact on perceived conflict, detrimental and direct for immigrant workers, beneficial and mediate via the outgroup cognitive image for the Italian workers. Findings suggest that a superordinate identity, in terms of organizational identification, may be effective in reducing conflict at the workplace for majority members, whilst a personalized strategy seems to be more suitable for minority members. The theoretical and practical implications of these findings are discussed along with the acculturation perspective. Migratory flows from the most underprivileged to the wealthiest countries leads to increased diversity in host societies and constitutes a challenge for our new plural societies. Italy, compared to other European countries, is a country of recent immigration but, from 2006 onwards, the annual quota of workers coming from abroad has regularly increased. Factories of North East Italy have recorded a widespread workforce of regular and irregular immigrants at a low qualified professional level. Currently employed in the industry are 18.1% foreign workers and 20.2% Italian workers . This siBy examining social psychological theories, such strategies mainly rely on intergroup contact and on the creation of a superordinate common membership. However, past research has examined the beneficial effect of intergroup contact mainly in majority group members, with a specific focus on the affective dimension of prejudice. Limited research has at the same time considered the effect of intergroup contact in minority and majority group members whilst highlighting cognitive dimensions. To contribute to filling this gap, this study tested whether intergroup contact and organizational identification in a real-world context differentially relates to the perception of interethnic conflict in Italian and non-European Union (N-EU) immigrant blue-collar coworkers. The two ethnic groups, employees of the same factory, are in daily contact and we conjectured that in a workplace context, the cognitive, more than the affective, dimension of prejudice will be the most relevant . We thusIn psychosocial research, decades of studies have suggested that intergroup contact exerts a beneficial effect on intergroup relationships. However, most studies have focused on the majorities or members of the host societies. Less attention has focused on minority status groups, although recent contributions have suggested that in disadvantaged groups the contact effects are weaker , nonexisAlso when exploring at the same time majority and minority group members , researcThe relationship between an individual and an organization has generally been conceptualized in terms of the individual’s commitment to the organization; however, drawing on the social identity theory , a conceIn a factory environment, it is particularly evident that group relations take place within the context of a relevant superordinate identity . IdentifTheoretical models on diversity management at work identify as key antecedents of intergroup conflict factors such as social identity and categorization, intergroup contact, realistic group conflict and social dominance orientation, with the mediation of stereotype and prejudice . The groAmong the strategies that may be undertaken in an attempt to remove the sources of intergroup conflict, Despite the relevance of social structural variables such as competition and status as predictors of warmth and competence outgroup attribution, and ultimately behavioral reactions in intergroup relationships, few studies have linked the intergroup contact hypothesis to the stereotype content models, mainly finding that contact enhances the stereotype content dimension on which a specific outgroup is derogated . AccordiBased on evidence, we first predicted that both intergroup contact and organizational identifications would increase the knowledge of the outgroup and enhance the perception of competence and warmth of outgroups and improve the attitude towards the outgroup. We further hypothesized that this enhancement would mediate the relationships between contact and organizational identification and perceived discrimination and conflict, albeit differentially in Italian and immigrant worker groups.This study focuses on the perception of interethnic conflict at the workplace both in N-EU immigrant minority and Italian majority members. All participants are blue-collar workers, not often considered in psychosocial studies, despite most ethnic minority members ending up as unskilled factory workers. The amount of voluntary contact, in several situations where the coworkers may meet, and identification with the superordinate identity group, represented here by the firm they all worked for, are expected to be differentially related to perceived conflict in ethnic majority and minority group members, both directly and indirectly, via the cognitive dimension of intergroup relationships .In line with the classical psychosocial models of attitudes , we expeSpecifically, our hypotheses are as follows, differentially for the Italian majority and immigrant minority workers:H1: As empirical evidence supports that contact has stronger positive consequences on intergroup biases for majority than for minority groups, its effect on perceived conflict was hypothesized to be weaker among the immigrant compared to Italian workers.H2: On the basis of previous research regarding the different consequences of superordinate identity on majority and minority groups, Italian workers were expected to have a higher organizational identification, which would be negatively and directly related to perceived discrimination and conflict; whilst immigrant workers were expected to have a lower level of organizational identification, with a weaker and mediated relationship between their organizational identification and perceived discrimination and conflict.H3: Following H4: The stereotype content and the cognitive dimension of the interethnic attitudes drive the indirect effect on the contact/organizational identification and discrimination-conflict relationship.All hypotheses were tested simultaneously with path analysis models.SD = 8.6), with no significant differences between the two groups. On average, the Italians had been working for the firm 3.9 years (SD = 0.9) and the N-EU immigrants 3.3 years .One hundred and seven blue-collar workers were involved in the study: 67 Italians and 40 N-EU immigrants, all males. The immigrants, working in the same factory and carrying out similar duties, were mostly from Central (17) and North Africa (18), the remainder from Eastern European countries. The age of the respondents varied from 19 to 63 , approved by the management. Participants volunteered to complete the survey and signed informed consent.All factory workers present on the day of the test were contacted and all but a couple of them agreed to participate. The workers did shift work, and 70% of the total 153 workers were on the day shift. Night shifts and day shifts are assigned on a rota system and so the sample was expected to be representative of the whole workforce. Two versions of the questionnaire, for the two groups, were devised in Italian (the immigrants were fluent enough to answer in that language). The measures for both groups were identical except that Italian participants answered questions about immigrant coworkers and vice versa. With adult participants and anonymous questionnaires, ethical approval was not required, in line with national guidelines of the Italian Association of Psychology (AIP).Outside-of-Work Contact. To measure the quantity of contact, respondents were asked the following questions adapted from never, sometimes, often). These five items were added up (α = 0.76).Organizational Identification. We adapted two items: “I feel I am part of the factory,” and “I don’t feel particularly respected by the organization” (reversed)  from the Organizational Identification Questionnaire (r = .74).ionnaire  ResponseStereotypical Content. Following competence  and warmth  were considered. Participants were asked to rate on 5-point scales the extent to which they personally associated the traits to outgroup coworkers . Two indices were computed from the average.Attitude towards the outgroup was measured on a 10-point feeling thermometer .Perception of discrimination at the workplace was measured with a single item: “the Italian workers/the N-EU immigrant workers get more than they deserve”  ; “How often does it occur?” (from 1 = never to 5 = very often). Responses were averaged to obtain a global index .Firstly, a MANOVA with Ethnicity as the between factor was conducted on all study variables. Secondly, we explored the antecedent of the perceived conflict in Italians and immigrants with multigroup path analyses (Lisrel 10.2). Typically, multiple items or measures are used to assess latent variables . In the present study such an approach would have produced an unacceptably high ratio of estimated parameters compared to sample size; therefore, the tested models used composite variables of the constructs as observed variables. Hypothesized predictors were: organizational identification and interethnic contact as exogenous variables; reciprocal stereotypical content, attitude towards the outgroup, and perceived discrimination as mediator variables; finally, perception of conflict as outcome variable.F  = 11.9, p < .001, ηp2 = 0.46. Significant multivariate effects were followed up using appropriate univariate tests (t-test). The immigrant workers attributed significantly more competence to the Italian coworkers than their Italian counterparts, t (105) = 5.9, p < .001, while no differences emerged for warmth that the two groups attributed to each other. However, a pairwise comparison of intragroup attribution showed that the immigrant workers judged Italian coworkers more competent than warm, t (39) = 5.44, p < .001, while the difference of the warmth and competence attributed to the immigrants group by their Italian coworkers, albeit congruent with expectations, was not significant, t (66) = 2.03, ns. As predicted, Italian workers identified significantly more with the firm they work for, t (105) = 2.73, p = .007, whereas immigrant co-workers reported significantly more frequent contacts with outgroup members, t (105) = 3.8, p < .05. No significant differences emerged regarding attitude towards the outgroup, perceived discrimination and interethnic conflict at the workplace.The mean, standard deviations, and correlations for Italian and N-EU immigrant workers are presented in We analyzed the input data in two steps. First, we tested the hypothesized mediation separately in the two groups because antecedents were expected to differentially influence perceived conflict in the Italian and N-EU immigrant workers. Second, multigroup path analyses were employed to examine equality/differences of the paths in the two ethnic groups; details are presented in a supplementary file.full mediated model, which included only indirect paths from antecedents to perceived conflict through outgroup image, with a partial mediated model, which also included the direct paths connecting organizational identification and interethnic contact with perceived conflict, each added separately.We first tested a model where organizational identification and contact were allowed to predict the component of the outgroup cognitive image , each image variable was allowed to predict discrimination and conflict, and discrimination was allowed to predict conflict. Subsequently, we compared the described t < 1.96), as suggested by the Wald test. On the basis of the modification indices, the errors of competence and warmth were allowed to correlate .The models were refined by removing non-significant paths  than the fully mediated model . The partial mediation models had the lowest χ2/df ratio (0.89 and 0.73 respectively vs. 1.36 and 0.97), as well as the lowest RMSEA, AIC and CAIC. We also ran a Chi-square difference test, frequently used to test differences between nested models, that is, two identical models one of which could be obtained simply by fixing/eliminating parameters in the other model. If the χ2 diff-value is significant, the “larger” model with more freely estimated parameters fits the data better than the “smaller” model in which the parameters are fixed. Results confirmed that the partial mediated models, with additional direct paths between the predictors and the dependent variables, fit the data better of the full mediated model (Immigrants: Chi-square difference 4.22(1), p < .05; Italians: Chi-square difference 3.28(1), p = .07).The 2 = 19.63, df = 27, p = ns, CFI = 1, RMSEA = 0, AIC = 107.63, CAIC = 269.24).These partial mediated models were used as a starting point for multigroup path analyses. The final best fitting model emerged by imposing cross-group equality constraints on four parameters in which the partial models of the two ethnic groups have significant similar path , while the other path coefficients were allowed to vary freely across the two samples  was 15% for ethnic attitude, 39% for perceived discrimination, 10% for perceived conflict.However, some notable differences emerged between the two samples. In the Italian group, contact was related to an improved outgroup image, particularly in terms of the competence attributed to the ethnic coworkers. In turn, competence had a negative direct association with perception of discrimination at the workplace. Discrimination was positively related to perceived conflict for both samples, albeit somewhat weaker for the Italians, where it did not reach significance. The only significant direct association with perceived conflict is identification with the superordinate ingroup. The amount of variance explained , but rather detrimental as it is directly and positively associated to the perception of conflict. On the contrary, among Italians, it has a beneficial albeit indirect effect, improving the outgroup’s stereotypical image. A possible explanation may be that negative interethnic contact is more prominent in the minority than in the majority workers  were also confirmed. Asymmetries in the stereotype content only partially confirm our hypothesis (H3): the low-status N-EU immigrant workers recognize greater competence to the high-status Italian workers, although the latter do not attribute higher warmth to the low-status immigrant workers. Therefore, the N-EU Immigrant workers hold an envious prejudice but the Italian workers do not adhere totally to a paternalistic prejudice . Cognitive prejudice measures, like those used in the current study, reflect participants’ beliefs about the outgroup and may exert a relevant role in specific circumstances and specific behavioral consequences such as perceived discrimination and conflict at the workplace, due to the establishment of instrumental more than close relationships.The two dimensions of the stereotype, warmth and competence, mediate the relationship between interethnic contact and perceived discrimination for the Italians, and between organizational identification and perceived conflict for the immigrants :Appendix: Antecedents of interethnic conflict – Alternative path models.MonaciM. G. (2022). Supplementary materials to "Interethnic workplace conflict: Reciprocal perception of italian and immigrant blue-collar coworkers"[Appendix]. PsychOpen. 10.23668/psycharchives.6697


Cervical cancer is a female-specific cancer with relatively high morbidity and mortality. As known to all, immune cell infiltrations in the cancer microenvironment are closely related to the cancer diagnosis and prognosis. Here we revealed that the CD8+ T cell infiltration was significantly upregulated in cervical cancer versus normal cervix uteri samples. Through univariate and multivariate cox analyses, we discovered that the CD8+ T cell infiltration was the only independent beneficial factor for the prognosis of cervical cancer. To explore the genes associated with the CD8+ T cell infiltration in cervical cancer, we performed the WGCNA analysis on the differentially expressed genes (DEGs) of cervical cancer versus normal cervix uteri tissues. As a result, 231 DEGs were found to be associated with CD8+ T cell infiltration in cervical cancer. Subsequently, with the Cytoscape analysis, we identified 105 hub genes out of the 231 DEGs. To further explore the genes that might be responsible for the prognosis of cervical cancer, we performed a univariate cox analysis followed by a LASSO assay on the 105 hub genes and located four genes  finally. The four genes could be applied to the prediction of the prognosis of cervical cancer, and relatively higher expression of these four genes predicted a better prognosis. These findings contributed to our understanding of the prognostic values of CD8+ T cell infiltration and its associated genes in cervical cancer and thus might benefit future immune-related therapies. Cervical cancer, which primarily arises from the cervix, is the fourth most common and death-causing cancer in women worldwide . AccordiImmune cell infiltration in cancer is an indispensable microenvironmental factor that has been widely applied to prognosis prediction and immunotherapy –15. The In this study, we evaluated the changes in immune cell infiltration of cervical cancer versus normal tissues. We found that the CD8+ T cell infiltration was the only independent beneficial factor for the prognosis of cervical cancer. Four genes  were found to be CD8+ T cell infiltration-related genes. The four genes could be applied to the prediction of cervical cancer prognosis.The clinical information and RNA sequencing (RNA-seq) data of the Cervical Squamous Cell Carcinoma and Endocervical Adenocarcinoma (CESC) were downloaded from The Cancer Genome Atlas (TCGA), which included 306 cervical cancer tissues and 3 normal control samples (termed TCGA-CESC cohort). The clinical information of the TCGA-CESC cohort was shown in https://david.ncifcrf.gov/). P value < 0.05 was used as the significance threshold. GO results were plotted with the “GOplot” package in R, while KEGG results were plotted using the “ggplot2” package in R.Differentially expressed genes (DEGs) were determined by the “DESeq” software. The adjusted P value <= 0.01 and |log2(FoldChange)| > 2 were used as the cutoff criteria. The gene ontology (GO) analysis was performed using the “clusterProfile” package in R (version 4.1.0) and the Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis was performed at The Database for Annotation, Visualization and Integrated Discovery (DAVID) platform  and plotted with the Cytoscape software. The hub genes in the protein-protein interaction network were determined by 12 algorithms in the cytoHubba of Cytoscape, respectively, which were Betweenness, BottleNeck, Closeness, ClusteringCoefficient, Degree, DMNC, EcCentricity, EPC, MCC, MNC, Radiality, and stress. The shared hub genes by all 12 algorithms were considered to be the candidate hub genes, which were determined and plotted with the “UpSetR” package in R.The protein-protein interaction was analyzed in the STRING database  analysis. The LASSO analysis was performed using the “glmnet” package in R to further filter the genes that significantly affected the prognosis of cervical cancer.The expressions of selected genes along with the overall survival data of the TCGA-CESC cohort were used to evaluate the predictive values of these genes in the prognosis of cervical cancer. The ROC curve and areas under the ROC curve (AUC) were generated by the “timeROC” package in R.291 patients in the TCGA-CESC cohort, whose OS was larger than zero, were included in the OS analysis. The OS was examined by log-rank and Kaplan-Meier plots. When studying the impacts of target genes on the OS, the patients were equally divided into two groups (i.e. “high” versus “low”) based on their median expressions. The OS curves were plotted with the “survival” and “survminer” packages in R. P value < 0.05 was considered to be significant.Tumor and para-carcinoma tissues of cervical cancer were embedded in paraffin and then sectioned. Immunohistochemical staining was performed using an Immunohistochemistry Kit  according to the manufacturer’s instructions. In brief, slides were first dewaxed with xylene and rehydrated with gradient ethanols. Subsequently, the slides were subjected to antigen retrieval with citrate solution in boiling water. The slides were then blocked with bovine serum albumin (BSA) and incubated with primary antibodies overnight. After that, the slides were incubated with HRP-conjugated secondary antibodies and then reacted with the DAB solution in the kit. Finally, the slides were incubated with hematoxylin. The staining results were observed with a Leica DMi8 fluorescence microscope. The antibodies used in this study were as follows: IGSF6 mAb , TLR10 mAb , FCRL3 mAb , IFI30 mAb , and Goat Anti-Mouse HRP secondary antibody . The cervical cancer samples used in this study were obtained with written informed consent from patients. Our study was approved by the Ethics Committee of Anhui Normal University.We downloaded the RNA-seq data of the TCGA-CESC cohort along with normal cervix uteri samples from the GTEx database. To investigate the immune cell infiltrations in normal cervix uteri and cervical cancer, we performed a CIBERSORT analysis on the RNA-seq data. Among the 22 infiltrated immune cell types, activated dendritic cells, resting dendritic cells, M0 and M1 macrophages, resting NK cells, regulatory T cells, follicular helper T cells, activated memory CD4+ T cells, CD8+ T cells, and memory B cells were significantly upregulated, while resting mast cells, M2 macrophages, monocytes, activated NK cells, resting memory CD4+ T cells, and naïve B cells were significantly downregulated.  of cervical cancer patients, while the CD8+ T cells and M2 macrophages were beneficial factors for the OS.  in cervical cancer compared to normal tissues. We performed a DEG analysis using the “DESeq2” package in R on the merged RNA-seq data of the cervix uteri in the GTEx and the TCGA-CESC cohort. |log2(FoldChange)| > 2 and adjusted P value < 0.01 was used as the cutoff. As a result, we identified 2111 upregulated and 2160 downregulated DEGs. . We used 0.9 as the cutoff for the scale-free fit index and chose soft-thresholding power = 2 for the WGCNA.  finally. The four genes could be applied to the prediction of the prognosis of cervical cancer, and the higher expression of the four genes suggested lower risks for cervical cancer patients.Immune cell infiltrations in cancer serve as a crucial tumor microenvironment factor that mediates tumor metabolism, immunotherapy outcome, and cancer prognosis prediction –15. AlthWe also analyzed the DEGs in cervical cancer versus normal cervix uteri tissues. As a result, we identified 2111 upregulated and 2160 downregulated DEGs. We performed GO analyses on the upregulated and downregulated DEGs, respectively. In line with the immune cell infiltration analysis, the processes, such as leukocyte-mediated immunity, lymphocyte-mediated immunity, positive regulation of leukocyte activation, immune response-regulating signaling pathway, and production of molecular mediator of the immune response, were enriched in the upregulated DEGs. Likewise, the cytokine/chemokine-involved pathways were enriched in the KEGG pathway analysis of the upregulated DEGs. These results suggested that the upregulated DEGs in cervical cancer were involved in the regulation of immune cell infiltration, implying a necessity of revealing immune infiltration-related DEGs.WGCNA is a powerful tool to locate candidate gene clusters (modules) that were related to external sample traits, for example, immune cell infiltrations here . We hereIGSF6 was reported to be involved in the immune regulations of atherosclerosis  and inflPublicly available datasets were analyzed in this study. This data can be found here: GEO (GSE151666) and The Cancer Genome Atlas (TCGA).The studies involving human participants were reviewed and approved by the Ethics Committee of Anhui Normal University. The patients/participants provided their written informed consent to participate in this study.Conceptualization, XS, CW, and ML; Methodology, XS, CW, and ML; Software, XS and CW; Investigation, XS, CW, ML, SW, YZ, ZL, and GZ; Writing – original draft, XS; Writing – review and editing, XS; Visualization, XS, CW, and SW; Supervision, XS; Project administration, XS; Funding acquisition, XS. All authors contributed to the article and approved the submitted version.This work was supported by the National Natural Science Foundation of China (No. 31701289), Anhui Provincial Natural Science Foundation , Anhui Provincial Funding Scheme to Outstanding Innovative Programs by Returned Scholars (No. 2019LCX003), Anhui Provincial Key Laboratory of Molecular Enzymology and Mechanism of Major Diseases (No. fzmx202001), Educational Commission of Anhui Province of China , Key Projects for Young and Middle-Aged People from Wannan Medical College (No. WK2021ZF08), and the Foundation for High-level Talents in Higher Education of Anhui Province of China and Funds from the Anhui Normal University .We thank the platforms and resources provided by Anhui Provincial Key Laboratory of Molecular Enzymology and Mechanism of Major Diseases, Anhui Provincial Engineering Research Centre for Molecular Detection and Diagnostics, Anhui Provincial Key Laboratory of the Conservation and Exploitation of Biological Resources, and Key Laboratory of Biomedicine in Gene Diseases and Health of Anhui Higher Education Institutes.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. 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There was no significant difference in the mode of delivery between the study’s parity cohort group. A significant increase in cesarean deliveries was noticed among obese women with a BMI between 35–39.9 (52.14%). This increase was even greater among those with a BMI above 40 (63.83%). Fetal distress, malpresentation and abruptio placenta were the most significant indications for CS among all age groups . Conclusions: The number of cesarean deliveries has no association with parity or age. However, there was a statistically significant association with BMI, a perineal tear after previous vaginal delivery, and a history of diabetes mellitus and gestational diabetes. The most reported reasons for CS were fetal distress, malpresentation, and abruptio placenta among all age groups.In the context of the global increase in the rate of cesarean deliveries, with an associated higher morbidity and mortality, this study aimed to investigate the role of maternal age and parity in the cesarean section rate among women in the Hail Region of Saudi Arabia. This retrospective cohort study used data collected from the labor ward of the Maternity and Child Health Hospital, Hail, over a period of 8 months, forming a cohort of 500 women. Women were categorized into four different parity classes. The results revealed that there was no significant relationship between cesarean deliveries and maternal age ( Worldwide, cesarean section (CS) remains the most common surgical procedure performed on women of childbearing age. One in three American women undergo CS, and it is the leading cause of maternal mortality and morbidity in the US . In receSeveral studies indicated important maternal factors that are likely to be associated with the rising rate of CS, such as educational status, income, preference, parity, and other indications including cephalopelvic disproportion, hypertensive disorders of pregnancy, antepartum hemorrhage, previous cesarean section, and fetal distress ,6,7,8,9.Maternal factors are strong determinants of birth outcomes. These factors may be genetic, environmental, or health factors. Parity is one of the most important factors affecting the health of mothers and fetuses . IncreasHigh parity is considered one of the main public health problems. It is common in developing countries, particularly in Arab countries such as Saudi Arabia, where large families are the trend . While eIn the last three decades, there has been an increase in CS rates in both developed and developing countries . This riBased on this issue, the researchers of this study found it necessary to investigate the role of parity and age in deciding the mode of delivery among women in Hail, Saudi Arabia. Additionally, the researchers explored other factors affecting the mode of delivery such as maternal BMI, level of education, income, and maternal medical and obstetrical history.Investigate the role of maternal factors on the rate of cesarean section among women in the Hail Region.The research was carried out through a retrospective cohort study.Data were collected from the labor ward of the Maternity and Child Health Hospital, Hail Region, Kingdom of Saudi Arabia.The sampling technique used was convenience sampling.The sample size was 500, which was calculated by applying the following formula for a single proportion:Zα/2 is the critical value of the normal distribution at α/2 , MOE is the margin of error, p is the sample proportion, and n denotes the sample size. Charts of study participants were reviewed for all pregnant women who were booked or unbooked and underwent delivery in the Maternity and Child Health Hospital, Hail, Kingdom of Saudi Arabia. Inclusion criteria included all pregnant Saudi women who delivered a single neonate at a gestation age of ≥28 weeks. Exclusion criteria included pregnant women with multiple gestations, pre-existing illnesses that could cause adverse outcomes during pregnancy such as renal and cardiac diseases, known diabetics, smokers, and those with hypertension before their first pregnancySociodemographic data and information on pregnancy-related complications such as gestational diabetes, hypertension , etc., as well as patient medical records and past obstetrical records, were retrieved from participants’ files. Participants were followed in the postnatal ward till their discharge.Women were classified into 4 groups according to parity: primigravida (1 birth), multipara (2–4 births), grand multipara (5 or more births), and great-grand multipara (10 or more births).A sample size of 457 ensures a maximum error of estimates of 5 percentage points at the 95 confidence level.® . Differences between groups were assessed using the chi-square (χ2) test (Fisher’s exact test and likelihood ratio (LR)). p ≤ 0.05 was the significance threshold. In addition, logistic regression of the cesarean section rate was performed. Enter method was used for variable selection.Data were analyzed using SPSS software v.25.0 for WindowsInformed verbal consent at the time of admission was given by all participants prior to their participation in the study to use their medical records from their previous and current pregnancies.The study was approved by the Research Ethics Standing Committee (REC) of the university of Ha’il (H-2022-010).The sample size was achieved in 8 months (from the 1 October 2021 to 31 May 2022).p-value of 0.07. There was no significant difference in the mode of delivery between the study parity cohort groups, as shown in p-value, 0.000, 0.021 and 0.048, respectively). p-value, 0.000, 0.000, 0.035, 0.049, respectively). There were six women (not shown in the table) who underwent an elective cesarean section procedure based on their preference and request without having any medical indications.p-values of 0.005, 0.001, 0.01, 0.002, and 0.021, respectively.p-values of 0.012, 0.015, 0.030, and 0.035, respectively The overall CS rate of 48.6% for the study period compares favorably with rates reported in developed countries. Lower rates of cesarian sections have been reported in the United States 24.4%) and Denmark (20.4%) ,23. The .4% and DThe higher rate of cesarean section in Saudi Arabia may be accounted for based on advanced maternal age (women 35 years of age or older), which is associated with an increase in CS rates . AdvanceThis study did not show any association between the rate of CS and the age of the mother. Our results differ from the results shown by a study performed by Martinelli et al. (2021) that studied the association between parity and the mode of delivery in women of advanced maternal age. They observed that women of an advanced maternal age were more likely to undergo cesarean section . InconsiOur study’s results align with previous studies concerning the relationship between CS rate and BMI. A study conducted by Barau et al. found a linear association between maternal BMI and the risk for cesarean section, and the trends were similar; an increased BMI increased the risk of cesarean section . Obese wIn the analysis of the Consortium on Safe Labor data, Boyle et al. reported that the most common indications for cesarean delivery overall were failure to progress, non-reassuring fetal heart tracing, and fetal malpresentation . AnotherThe significant association between the percentage of CS and GDM and preexisting DM found in this study was also detected in a retrospective study conducted in the US in 2015. This association may represent an independent association between GDM and CS rate that could be explained by the higher incidence of fetal macrosomia and other indications for cesarean delivery, such as obesity and previous cesarean delivery, in patients with GDM .The rise in the CD rate is alarming. Given the associated morbidity and mortality, it is imperative that a national strategy be considered to reduce at least some of the unnecessary CDs in Saudi Arabia. It is important to develop programs or guidelines to reduce C-section rates while maintaining maternal and neonatal safety.As the study represents pregnant women who were admitted to the labor ward of the Maternity and Child Health Hospital, Ha’il Region, Saudi Arabia, the findings may not be generalizable. The significant findings represent association, not causation, and should be interpreted with caution due to the nature of our study design . Other limitations include the retrospective nature of our analysis.This study concluded that no association was found between parity or age and the mode of delivery. However, the association between the rate of cesarean section and BMI was statistically significant, as was the association with a perineal tear after previous vaginal delivery, and a past medical history of DM and GDM. The most reported reason for CS was the failure of induction.


Green total factor productivity (GTFP) is an excellent index for green development. The objective of this study was to check whether environmental regulation (ER) can affect GTFP through the mediating role of foreign direct investment (FDI) quantity and quality. Using the super-efficiency Epsilon-based measure (EBM) model and a Malmquist–Luenberger (ML) index, China’s GTFP growth was measured during 1998–2018. On this basis, we adopted a Systematic Generalized Method of Moments (SYS-GMM) to analyze the effect of ER on GTFP. The findings show that China’s GTFP declined first and rose again during the sample period. GTFP in the coastland was greater than that in the inland region. ER positively affected China’s GTFP growth. FDI quantity and quality mediated the nexus between ER and GTFP growth in the whole nation. Specifically, this mediation role of FDI quantity and quality was only significant in coastal China. Additionally, financial development can also boost GTFP growth in China. Given the importance of developing a green economy, the government should improve the FDI quality and attract green FDI. With thmissions . The Unimissions . Considemissions .2 emissions is still on the increase. IEA stated that China is the only major economy that increased fossil fuel demand and reached the highest ever level [2 emissions in 2021 increased by 6% above 2019 levels. This suggests that China’s green development still has substantial room for improvement [However, statistics show that the amount of China’s coal consumption and COer level . As a corovement . On thisWith the increasing attention paid to global environmental issues, ER is regarded as one of the essential tools for accelerating green economic growth. The nexus among ER and green economic growth has attracted numerous scholars, but the conclusions have failed to reach a consensus. On the one hand, ER exerts an inhibitory effect in promoting green development due to its increased production costs . On the Additionally, China is diligently practicing the opening strategy; therefore, inflow of foreign direct investment increased dramatically by 20% in 2021 over 2020, reaching a record of 179 billion dollars . HoweverTo seek answers to the above questions, it is of great practical significance to check whether ER can affect GTFP through the mediating role of FDI quantity and quality, which provides empirical evidence for other developing countries to formulate ER and opening policies. This study contributes to erstwhile literature in the following manner. Firstly, this study employed the metafrontier super-efficiency EBM model with undesirable output (Undesirable-M-Super-EBM) and ML index to construct a more accurate assessment of China’s GTFP. Compared with the traditional radial and non-radial DEA models, the Undesirable-M-Super-EBM model contains slack variables and allows the input variables to change proportionally, which improves the accuracy of productivity measurement. Secondly, this paper probed into the influencing channels through which ER affects GTFP. The existing research mainly focuses on the mediation role of FDI quantity when analyzing the indirect effect of environmental regulation. However, few scholars have also looked at the mediating role of FDI quality. Thus, this paper measured the quality of FDI from the following four perspectives: FDI’s performance, FDI’s unit scale, FDI’s export capacity and FDI’s technological spillover, and checked the mediating role of FDI quality through environmental regulation on GTFP. Last, taking into consideration the huge regional heterogeneities, this paper performed heterogeneity analysis and investigated the influences of ER on GTFP in coastal and inland areas.The paper is structured as follows. The related literature is reviewed in There have been three mainstream theories on the ER–GTFP nexus in the extant literature. The first theory is the “Compliance cost hypothesis”, postulating that the strengthening of ER intensity will constrain improvement in GTFP . IncreasOn the other hand, the “Porter hypothesis” proposed by Porter held the opposite view . Porter The debate on the “Compliance cost hypothesis” and “Porter hypothesis” also yields the third school of thought, which claims that a nonlinear relation is exists between ER and GTFP . The degHypothesis 1.ER exerts a direct promotion effect on GTFP growth.The literature on the nexus between FDI and GTFP growth can trace back to two famous hypotheses, namely the “Pollution halo” and “Pollution haven” hypothesis ,24. The The Pollution Haven hypothesis postulates that high polluting industries are inclined to transfer to regions with lax environmental standards, which might worsen the host countries’ environmental quality and inhibit GTFP growth . In the On this premises, the second hypothesis was developed as follows.Hypothesis 2.FDI can promote GTFP growth.The theoretical frame of ER on GTFP is displayed in Contrary to this, the local government might also compete to intensify ER to pull high-quality FDI, which will expand GTFP growth . It is kBased on the, the third hypothesis is proposed.Hypothesis 3a.FDI quantity is a mediating path of ER and GTFP growth.Hypothesis 3b.FDI quality is a mediating path of ER and GTFP growth.In this section, we firstly introduce the undesirable super-EBM model under metafrontier and ML index, which is widely used to measure GTFP growth . Then, t2) always coexist with the good output due to the consumption of energy [P(x) was constructed as follows:On a production line, companies or organizations place factors, such as labor, capital and energy into production for increasing desirable output, e.g., GDP. However, according to null jointness theory, the undesirable outputs, e.g., carbon dioxide emissions , o et al. , EquatioH technology groups. The production set under metafrontier metaP is described in Equation (3).The production possibility set defined in Equation (1) assumed that all DMUs (decision making units) have the same production technology. However, in the reality, due to the heterogeneity of the factor endowments and economic growth among different provinces, the production technology might be different. Hence, we follow the study of Luo et al. , and defGTFP is extensively measured by the DEA model. The traditional radial models, e.g., CCR, might neglect the non-radial slacks, which will overvalue the efficiency score. Meanwhile, the non-radial models, e.g., SBM model, may fail to change proportionality and lead to a biased estimation . To solvmkox, rkoy, and vkob are respectively inputs, desirable, and undesirable outputs. mkox, rkoy, and vkob; x,y,bε is the weight of non-radial part in the EBM model. Although the EBM model has made significant progress compared to the CCR and SBM models, there are some problems that need to be solved in the measurement of GTFP. The original EBM model failed to take the undesirable output into consideration. It cannot discriminate the efficiency scores that are equivalent to 1. Hence, following the study of Luo et al. , UndesirtD denotes the distance function of period t. ttML+1 is the GTFP change from period t to t + 1. When ttML+1 > 1, GTFP increases, and vice versa. Additionally, ttML+1 can be disintegrated to ttTC+1 and ttEC+1. According to Liu and Xin [In line with Luo et al. , the ML  and Xin , the TC 2 emissions is used as the bad output.The green economic development can be regarded as an input–output production process. The selection of the input and output variables is presented in (1)Dependent variable. The ML index measured by the super efficiency EBM-ML model under metafrontier is used to proxy the GTFP growth.(2)Key variable. Considering a single indicator is hard to describe the real environmental regulation intensity , followi(3)FDIMit) is calculated by the ratio of FDI to GDP. Evaluating FDI quality is more complex. Researchers are unanimous on the proxied variable of FDI quality. In the view of Wang and Luo [it/FDItFDI)/(it/GDPtGDP); FDI unit scale = actual use of FDI/the number of foreign-funded enterprises; FDI export capacity: FDI industry exports/total regional exports; FDI technological spillover: jtDS denotes the R&D stock of j country at period t; itFDI represents the FDI stock of i province at period t in China; jtFDI is the FDI stock from j country to China. This paper chooses 22 countries in OECD, including America, England, Japan, German, France, Sweden, Canada, Austria, Turkey, Czech Republic, Belgium, Denmark, Greece, Finland, Ireland, Norway, Portugal, Netherlands, Spain, Hungary, South Korea, and Poland as the main sources of FDI technology spillover. The reason is that the technological innovation capacity of these countries is in the forefront of the world. Their R&D capital accounts for nearly 70% of the world’s total R&D capital.Mediation variables. In line with Wang and Luo , FDI qua and Luo , FDI qua and Luo . Yu and  and Luo . Hu and  and Luo . Based o(4)itFine is calculated by the ratio of loans to deposits [itFine might stimulate the usage of high energy consumption products, e.g., air conditioners, and increase environmental pollution [itGov is proxied by the ratio of general financial expenditure to GDP [itInfra is estimated by the proportion of post and telecommunications business to GDP [Control variables. deposits . The impollution . On the ollution . Govit ie to GDP . The GDPe to GDP . Infraits to GDP . Infrasts to GDP .This study adopts the dataset of 30 Chinese provinces during 1998–2018. Due to the data availability, Tibet, Hongkong, Macaw and Taiwan are excluded. The data are arranged from “China Statistical Yearbook”, “China Environment Yearbook”, “OECD Statistics” and “China Energy Statistical Yearbooks”. The descriptive statistics of the selected variables are exhibited in The purpose of this study is to study the influence of ER on China’s GTFP growth. The baseline econometric model was constructed as shown below.itGTFP denotes the green TFP of i province at period t. itER denotes environmental regulation of i province at period t. itX is the control variable matrix, which contains financial development efficiency (itFine), governmental intervention (itGov) and infrastructure level (itInfra). iμ, and itε represent the individual effect and random error, respectively.Considering the current GTFP growth might be impacted by the previous TFP growth , we lengFDIMit and FDIQit denote FDI quantity and FDI quality.To investigate the mediating role of FDI quantity and quality through the influencing channel of ER on GTFP growth, this paper follows the study of Baron and Kenny , and conitGTFP) might lead to endogenous problems, we adopt the SYS-GMM technique to overcome this problem. The GMM method was firstly proposed by Arellano and Bond [Considering the lagged term of dependent variable . Moreover, itFine positively boosted China’s GTFP growth at the 10% level, indicating that the development of finance can expand innovation and productivity.ER exerts a significant and positive influence on GTFP growth in terms of whole nation. The stricter ER might force firms to strengthen technological innovation, which can offset the compliance costs and promote GTFP growth ,32. In citER on GTFP is positive at the 5% level, confirming the results based on SYS-GMM. Moreover, we also used the first and the second lagged term of ER to replace itER, and re-estimate the impact of ER on GTFP growth. The results in For the validity of the estimation results above, robust analysis was carried out by changing the estimation method. Considering the data distribution of the GTFP growth is truncated, the estimation results based on SYS-GMM might lead to bias. Hence, we employed the Tobit regression model and Truncated regression model to investigate the nexus among ER and GTFP growth in China. It is observed that the influence of itER on itFDIM is significantly positive, while the influence of itFDIM on itGTFP is positive at the 10% significance level, indicating that FDI quantity can explain the relationship between ER and FDIM in coastal area. In the inland area, the influence of ER on FDI quantity is positive but fails to pass the statistical confidence test, implying that the mediating role of FDI quantity is not significant. In the coastal model, the coefficient of iFinet exerts a positive role on FDI quantity with the coefficient of 0.232, which agrees with the study of Chen et al. [iGovt on GTFP is 0.383 and statistically significant. It suggests that the governmental performance evaluation system is environment-driven in coastal provinces [Regarding the control variables, n et al. . The impFor the robustness of the conclusions drawn above, Sobel test, Aroian test and Goodman test were employed to examine the mediation effect of FDI quantity in the impacting channel of ER on green TFP growth. The results of the Sobel test, Aroian test and Goodman test are 1.817, 1.759 and 1.880, confirming the validity that FDI quantity has a significant mediation effect.Similarly, we also tested the mediation role of FDI quality based on the model proposed by Baron and Kenny . The resFindings from the control variable indicated that when governmental intervention increases, it impedes improvement of FDI quality at the national level, more specifically, in the coastal areas. Infrastructure level plays a positive role on promoting FDI quality as well as GTFP growth at 10% significance level. Massive infrastructural development has the tendency to attract large-scale and highly competitive foreign-funded enterprises to China. Additionally, the results of Sobel, Aroian and Goodman tests on the mediation effect of FDI quality are 1.473, 1.396 and 1.5647, respectively. It suggests that the mediation role of FDI quality is significant in China.Based on the provincial dataset during 1998–2018, this study employed the Undesirable-Super-EBM-ML model to measure China’s GTFP growth. The system GMM model was adopted to explore the effects of ER on China’s GTFP from the angle of FDI quantity and FDI quality. The empirical results showed that China’s GTFP fluctuated during 1998–2013, then increased dramatically during 2013–2018. GTFP in coastland is larger than that in inland. In addition, ER plays a significant promotion role on GTFP growth in China and coastal areas. The mediation effect of FDIM and FDIQ is verified in the intermediary paths of ER to promote China’s GTFP growth in China and coastal areas.This paper proposed some policies based on the findings. First, it is imperative to strengthen the environmental regulation intensity. The Chinese government should stress environmental governance and pay attention to the synergy between different types of ER to improve the FDI quality and promote GTFP growth. Furthermore, the technology spillover of FDI quality significantly promotes China’s GTFP growth. It is important for China to stick to the “Opening up” strategy and attract FDI inflow from modern high-tech and service industries. Policymakers should also increase the foreign capital entry threshold and promote FDI quality. Last, the increase in financial development efficiency can promote GTFP growth and FDI quantity. The Chinese government should transcend to promote financial development, especially green finance.This study contributes to the existing literature by analyzing the mediating role of FDI quantity and FDI quality in the influencing channel of environmental regulation on GTFP growth. Due to data unavailability, the data period was restricted from 1998 to 2018, and the provincial data were used. It might be insightful to check the effect of ER on GTFP at a city level or Micro-enterprise level. Furthermore, future research could explore more intermediary paths of ER on green development, e.g., industrial structure upgrading and technological innovation. Future research could also analyze the mechanisms of different environmental regulation tools on GTFP.


Changes in hydrologic and climatic trends will influence the ecology of Florida, and climate scenarios agree that many areas of Florida are susceptible to sea-level rise impacts. The U.S. Fish and Wildlife Service’s Climate Change Action Program focuses on a framework to examine climate change effects on fish, wildlife, plants, and habitats of all three. To follow the program, this study examines how to incorporate current scientific knowledge about regional climate projections in U.S. Fish and Wildlife Service analyses. It provides climate change and sea-level rise projections based on 2017 projections, information on changes in tropical cyclones, temperatures, and precipitation. This study also examines future effects of sea-level rise on existing habitat from saltwater intrusion of the freshwater lens below Big Pine Key. Projections of future sea-water elevations will periodically be reached or exceeded well before 2040 from short-term, stochastic, and extreme events , and will increasingly inundate the root zone before complete saltwater intrusion. Future trends were connected to 2017 stakeholder-driven conversations about adaptation strategies to develop a suite of actions for creating temporary or permanent freshwater resources. However, beyond 3 ft (0.9 m) of sea-level rise, there are few adaptation options available for the Florida Key deer beyond relocations outside of the Florida Keys. Overall, the approach of connecting future environmental trends to assessments of fish and wildlife resources of concern can be transferred to other situations. Additionally, this approach can be used to update these analyses, such as with the recent 2022 sea-level rise updates by the National Oceanic and Atmospheric Administration, released after this work was conducted. These include cataloging existing environmental and ecological condition data, the use of climate scenario models, and the consideration of additional, co-occurring stressors. Translating these information sources to understanding resultant ecological effects of climate change impacts is a precursor to develop conservation, mitigation, adaptation, and/or resilience-focused ecosystem based management plans. Most importantly, translating climate and ecological effects to decision makers in an understandable fashion takes creativity and sometimes simpler approaches.et seq.) and a number of other regulations that protect fish, wildlife, plants, and habitats of all three. The USFWS Climate Change Action Program (CCAP) focuses on a broad framework to examine how climate change is affecting fish, wildlife, plants, and habitats of all three [In the United States, the U.S. Fish and Wildlife Service (USFWS) is responsible for overseeing the Endangered Species Act  into decisions and planning activities along with ideas for presenting this science to decision makers in a more understandable way. As much as 30% of the habitat in coastal National Wildlife Refuges in the U.S. Southeast is expected to be flooded as a result of rising seas. In the Florida Keys, which experienced a rise in sea level of 23 cm between 1913 and 2006, 90% of land is 1.5 m or less above sea level [Odocoileus virginianus clavium), habitat for hundreds of endemic and migratory species, 21 Federally listed species, and a variety of plants endemic to the Florida Keys. The 2009 15-year Comprehensive Conservation Plan (CCP) for the Lower Florida Keys National Wildlife Refuge Complex [The National Key Deer National Wildlife Refuge (Refuge), comprised of nearly 9000 acres (approximately 3600 ha) of land, was established in 1957 ) to protect and conserve Florida Key deer  inventory of existing conditions; (2) examination of SLR scenarios leading to evaluation of habitat impacts; (3) characterization of additional stressors; and (4) use of stakeholder workshops to translate information for adaptation action planning.2.1.Information on existing conditions in the middle Florida Keys were compiled, including information on: the topography of Big Pine Key; the freshwater lens below the islands, and resulting ground surface inundation and root zone salinization; SLR to date and resulting historical impacts; and information about threatened and endangered species.2.2.The U.S. Geological Survey (USGS) in the National Oceanic and Atmospheric Administration (NOAA) 2020 updated report recommends the inclusion of impacts from tidal flooding and increasing high tides  in the Florida Keys. These are considered a high-risk factor for habitat and freshwater pools on the Florida Keys. To address this need, regional SLR projections were updated ,12 and eIn addition, the U.S. Army Corps of Engineers (USACE) developed a sea-level calculator  that proThe SLAMM simulates the dominant processes involved in wetland conversions and shoreline modifications during long-term sea-level rise . The mod2.3.In addition to information on sea-level rise and habitat change, we examined secondary information about additional stressors, including projected temperature changes, changes in precipitation patterns, changes in tropical system intensity trends, and future urban water supply demands. Using the Coupled Model Intercomparison Project Phase 5 (CMIP5) model, NOAA 2017  revised 2.4.We also examined the utility of considering additional secondary information as part of an integrated effort to connect current knowledge about fish, wildlife, plants, and the habitats of all three to regional climate change projections. A pair of stakeholder-driven workshops , the rate of SLR in the Florida Keys had been an average rate of 0.23 cm/yr  prior to−1 in 2016 [−1. The rate of SLR began to increase at a faster rate in the early 2000s, about 75–100 years after GHG emissions began to rapidly increase due to a “lag effect.”In the early 2000s, SLR began to accelerate exponentially  and was  in 2016 , an incr3.1.4.As a string of small islands, SLR continues to change the shape and size of the Florida Keys along with changes in vegetation types and coverage. For example, SLR has led to the decline in pine trees and pine ecosystems in the Florida Keys coastal forest habitat .The decline of pine forests on the Florida Keys were documented by Alexander and Dickson III . Followi3.1.5.Sylvilagus palustris hefneri), the Key tree-cactus (Pilosocereus robinii), and the Miami blue butterfly (Cyclargus thomasi bethunebakeri), they also examined barriers to implementing climate adaptation actions and how to “manage for change”  for thoThe Florida Key deer, a subspecies of the white-tailed deer, was also a discussion focus of the 2017 workshop. The Key deer population range has been reduced to the middle Florida Keys. Florida Key deer have genetic, physical, and behavioral differences from mainland deer –33. GeogAlthough generalists in mainly upland habitat utilization, this habitat is declining due to human development, saltwater intrusion in upland root zones, and the encroachment of salt tolerant mangroves. The availability of freshwater resources is becoming an even more important environmental stressor, including risks associated with major salinization events, such as tropical cyclone storm surge and rising high tide events due to SLR. For example, Benedict et al.  estimate3.2.3.2.1.The NOAA  report p−1 or greater. This scenario describes GHG emissions that do not decrease over time. This line incorporates some melting of the Antarctic ice shelf ; the polar ice sheet melt was unknown during the IPCC 2013 [The top line in PCC 2013  report. A common misconception is that this set of scenarios is based on a single data set capturing varying degrees of uncertainty. In reality, each line in the scenario graph in 3.2.2.The original 2013 sea-level calculator for the Florida Keys was updated with NOAA and USGS 2017  revisionAs decision makers grapple with understanding scenario graphs, it is apparent that highlighting important environmental conditions, or tipping points, is necessary. Thus, green horizontal lines are added to the scenarios in The effects of SLR on the Florida Keys are exacerbated due to a combination of topography and reliance of plants and animals on the freshwater lens . BecauseDuring the period from now out to 2040–2050, SLR will likely move between various scenario lines. There is higher uncertainty from 2020–2050 due to global model uncertainty of SLR acceleration rates  based onThe most noticeable impact from SLR is the increasing frequency of high tide flooding (HTF), thus examining future projections  provides vital information for addressing coastal flooding impacts . The NOA3.2.3.Projected changes in land cover conditions with 0.3 m, 0.6 m, 0.9 m, and 1.2 m of SLR are shown in 3.3.3.3.1.Average temperatures in the Florida Keys have risen 1.0–1.6 °C since the 1900–1960 period . Project3.3.2.Annual precipitation has increased by 5% since 1900 in the Florida Keys . Since t3.3.3.Current models are in agreement regarding changes in tropical storm and hurricane wind and rainfall events with 20% increases in both rainfall rates and wind speeds expected near the center of storms . These i3.3.4.−1, or a 6.9% increase over 2010 [The Water 2070 Technical Report  developever 2010 .3.4.There is currently sufficient existing species knowledge to make robust decisions.Non-climate stressors  can be equally or more important in the short-term when coupled with climate-based stressors, such as storm surge, spring tides, and hurricanes.Experienced scientists and managers are needed to interpret models and to use them to help develop adaptation options.Priorities should be established based on social and economic values. In some cases, resources can be prioritized for greater species at risk or more socially or economically valuable species.Risks have multiple dimensions associated with action and inaction. Each of these should be assessed on a species-by-species basis or based on species with shared vulnerabilities.Adaptation is by design an ongoing process. For example, Climate-Smart Conservation  emphasizIf natural resource representatives can combine with representatives from other sectors  to develop multi-dimensional adaptation strategies, there will be a greater opportunity to ensure that priorities of natural resource managers are achieved.Implementation is difficult, and ways need to be found to move forward with implementing adaptation strategies.In 2017, a group of stakeholders (Florida Keys Case Study 97) met to discuss incorporating climate change considerations into conservation planning and actions for 98 threatened and endangered species in the Florida Keys . WorkshThis suite of recommendations represents a holistic characterization of conservation planning and future recommended actions in response to climate change and SLR.4.4.1.An important finding that is transferable to other locations/species is the value of combining and integrating current state-of-the-science information with rigorously developed local/regional climate projections. Another important finding is the necessity to bring in information on additional (or co-occurring) stressors and social-ecological sustainable information developed through meaningful stakeholder engagement. This approach is also robust for re-applying to the same location/species when new science becomes available. For example, at the time of this study, the NOAA 2017 SLR projections were considered the state-of-the-science. Since this manuscript was drafted, the SLR by NOAA have been updated , includiFrom a fish and wildlife and habitat perspective, impact assessments of climate change parameters need to be completed, using approaches as those presented here, for State and Federally listed, at risk, and indicator species to allow current information to be comprehensively incorporated into a suite of Federal and State wildlife conservation and action planning efforts. Additionally, continuous efforts to improve on stakeholder engagement, especially working with conservation partners, fish and wildlife scientists, local and regional planners, and climate experts, requires incorporation of “reflective practices” for the sustainability of these efforts. Reflections should focus on intentional examination of whether the goals, expectations, and sustainability of prior conservation and action planning efforts were met, what was learned (including insights gained and identifying changes to make in the future) and focus on identifying elements that are transferable to other conservation contexts. The world of climate change science is changing and advancing. As such, environmental managers should apply sustainable approaches such as the ones presented here to increase the soundness and better understanding of the science introduced into their decision-making processes.4.2.Although a given SLR projection identifies a certain elevation for SLR at some time in the future, that elevation will be periodically reached before then because of short-term pulse events, such as king tides and storm surge . Future 4.3.Climatologic and resulting hydrologic changes will have huge effects on the ecology of the Florida Keys. The Florida Keys are going underwater with SLR, and surge events will exacerbate changes and challenges to ecosystem sustainability management. Even with near-term, interim adaptation strategies , beyond For this study, the 2017 NOAA Intermediate (0.3 m SLR), Intermediate-High (1.4 m SLR), and High (0.2 m SLR) SLR scenarios with projections out to 2100 were the most relevant scenarios for consideration. The Intermediate scenario is based on an analysis done by . The IntFor temperature consideration in habitat and species analyses and management actions, temperature increases in the State of Florida of 0.8 to 2.5 °C by 2050 and 1.7 to 3.9 °C by 2100 are expected. For precipitation consideration, higher fall and winter rainfall (dry season) by approximately 20%, and lower spring and summer rainfall (wet season) by approximately 30% is expected by 2100. According to Mgandu et al. , resultsThe incorporation of urbanization changes into reviews or assessments, including both expected changes in population and land use/land cover, as well as characterization of sustainable changes in water demand is important for analyses. The role of water in human development is important, observed trends and climate forecasting provides evidence that water resources are vulnerable and will be strongly affected by climate change and industrialization which place key challenges to human existence . For thiConsideration of scenario and human behavior uncertainties are important for evaluating the efficacy of climate projections. A common misconception is that the set of scenarios are based on one data set with varying degrees of uncertainty or probabilities. In fact, each graph line in a given scenario represents a different data set, highly dependent on the amount of greenhouse gas emissions that are currently being released, along with a projection of continued, reduced, or increased releases over time. As such, scenarios are intended to describe plausible conditions that support decision-making under human behavior uncertainty .There is higher certainty in projections from 2050–2100 for SLR due to model consensus after the initial acceleration has been completely defined. The scenario “spread” at the timeline end of the scenarios  is not an indication of uncertainty or probabilities but rather a forecast of SLR due to varying greenhouse gas emission rates. There is a lower certainty from 2020–2050 due to global model uncertainty of acceleration rates, which began in the early 2000s. Specifically for this study, most scenarios for the time period of 2050–2100 predict a 0.9 to 1.8 m SLR, which would lead to the disappearance of most of the Florida Keys .4.4.Future needs fall into four main categories: science needs related to regional climate projections; improving impact assessments for fish and wildlife and habitat resources; increased learning on continual improvement in stakeholder engagement; and advancing intentional conversations about adaptation management among scientists, resource managers, and other stakeholders. Examples of climate science needs include increase understanding of the newer science on melting of polar ice caps and its concomitant effects on SLR. The 2017-basedunderstanding is that even less than 2% ice melt will cause an additional 0.9 m of SLR . At regi


Previous studies demonstrated equivalence in terms of efficacy and safety of biosimilars (bsDMARDs) compared to original treatments (boDMARDs) and in switching situations. Less is known about what happens when initiating a bsDMARD in a molecule naïve patient. The objectives of our study were to compare the retention of treatment of subcutaneous boDMARDs and bsDMARDs globally, depending on the disease , molecule [etanercept (ETN) or adalimumab (ADA)], line of treatment, or presence of citrate in the context of first use of each molecule (namely initiation) and to analyze treatment retention’s predictive factors.This multicenter retrospective study used data from shared medical records of the RIC-FRANCE network, encompassing the prescription of hospital rheumatologists and attached practitioners, of patients with RA, SpA, or PsA, with the starting ETN between 03/10/2016 and 31/07/2020, or ADA between 23/10/2018 and 31/07/2020. Clinical data were collected from medical records. Retention analysis was performed using Kaplan–Meier curves and the log-rank test. Retention’s predictive factors were analyzed using Cox proportional-hazard ratio.p = 0.045). When molecules are compared, the difference was significant only for ETN . When comparing diseases, the difference in favor of bsDMARDs was significant in patients with RA only (p = 0.041). Citrated treatments displayed better retention compared to citrate-free treatments (p = 0.0137). Multivariable analysis of predictive factors for the cessation of treatment found shorter disease duration, boDMARD prescription, hospital practitioner prescription, late line of treatment, and female sex as significant. More side effects were observed with boDMARDs, especially more infections (17.8% vs. 7.8%).Eight hundred forty-five prescriptions were analyzed: 340 boDMARDs and 505 bsDMARDs. About 57% of prescriptions concerned women. The mean age was 51.8 years. About 38% were prescriptions for RA, 16% for PsA, and 46% for SpA. An increase in the initiation over time was observed for both ETN and ADA. The retention rate of bsDMARDs was superior to boDMARDs’ one (39 vs. 23 months; Even if bsDMARDs’ prescription increases over time, its penetration rate is still below expectations. bsDMARDs displayed better retention compared to boDMARDs, especially for ETN, and in patients with RA. Citrated treatments had better retention. Prescription by a full-time hospital-based rheumatologist is associated with poorer retention. The treatment of rheumatic diseases has been improved in the last 20 years with the advent of biological disease-modifying anti-rheumatic drugs (bDMARDs) –3. ThoseOriginal bDMARDs (boDMARDs) are sold with a period of exclusivity to allow pharmaceutical companies to recoup the money spent on research and development. Even if efficient, those treatments are costly. In 2012, among the top 15 drugs, there were seven biological agents, four of which  were originators used in rheumatic disease treatment with total sales amounted to $32.6 billion , 8.In order to reduce healthcare costs of bDMARDs, biosimilar drugs of boDMARDs (bsDMARDs) have been marketed at a reduced price compared to boDMARDs. After this period of boDMARDs’ exclusivity, bsDMARDs can be drawn to the market. According to the European Medicine Agency, biosimilar medicine is a medicine highly similar to another biological medicine already marketed . bsDMARDThe regulation of biosimilar products is different between the European Union (EU) and the United States (US), which led to an earlier approval and marketing of bsDMARDs in the EU .Biosimilars’ particular development is based on comprehensive comparability studies with the original biologic. Those studies have to demonstrate that the candidate medicine is highly similar, notwithstanding the natural variability inherent to its nature, and that there are no clinically meaningful differences between the biosimilar and the reference medicine in terms of safety, quality, and efficacy , 11.In France, etanercept (ETN) and adalimumab (ADA) have multiple bsDMARDs available: HULIO, AMGEVITA, IMRALDI, IDACIO, and HYRIMOZ for ADA, ERELZI, and BENEPALI for ETN.The prescription of bsDMARDs instead of boDMARDs had a dramatic impact on healthcare costs. Indeed, it has been demonstrated that biosimilars could reduce direct spending on biological drugs by $54 billion from 2017 to 2026 or by a range of $24 to $150 billion over the same period in the United States . To emphEven if they are described as equivalent to boDMARDs in terms of efficacy, the retention of treatment of bsDMARDs compared to boDMARDs is variable across studies with an absence of differences in some studies –20 or beThe objectives of our study were to compare the retention of treatment of boDMARDs and bsDMARDs, compare the retention of treatment depending on disease , molecule , line of treatment, or presence of citrate in the context of first use of each molecule (namely initiation). Predictive factors of treatment retention, as well as the side effects of bsDMARDs and boDMARDs, have also been analyzed.A retrospective, observational, multicenter study was conducted using medical records from the multicenter RIC-France registry that encompasses patients followed by rheumatologists working full-time in French hospitals  and rheumatologists with a predominantly office-based activity . This registry had already been used for clinical studies on rheumatic diseases . PatientThe inclusion criteria were patients with rheumatoid arthritis (RA) fulfilling the 2010 ACR/EULAR classification criteria , axial sPatients previously treated with ETN or ADA and switched to a biosimilar were excluded.Patients characteristics collected at initiation were as follows: age, sex, type of rheumatic disease, diagnosis date, duration between diagnosis and initiation of treatment, total number of previously received bDMARDs, concomitant treatment with methotrexate (MTX) and corticosteroids, DAS28-ESR and DAS28-CRP at initiation for RA and PsA, and ASDAS-CRP and BASDAI at initiation for SpA.Disease activity was dichotomized into low, moderate, or high disease activity based on the usual threshold for each activity score , 31. LowReasons for the cessation of treatment were collected and classified as a side effect, primary inefficiency, secondary inefficiency, and a switch without a medical reason. Primary inefficiency was defined as an absence of response in the first 6 months following initiation of treatment. Cessation of treatment was defined as secondary inefficiency if the loss of response occurs after 6 months of initial therapeutic response.Citrate-free treatments were those without sodium citrate and/or citric acid .t-test  for quantitative data and Chi2 (or Fisher exact test) for qualitative data. For three groups’ comparison of quantitative data, an ANOVA analysis using the Kruskal–Wallis test was performed in association with Dunn’s multiple comparisons test. The correlation between time and treatment prescription was analyzed using Spearman’s coefficient of correlation analysis. To compare treatment retention, a log-rank test using Kaplan–Meier curves was used. For univariable and multivariable analyses of predictive factors of retention, a Cox proportional-hazards regression was performed. All variables were included in the multivariable analysis using an enter method. A p-value of 0.05 was considered significant. Statistical analysis was performed using GraphPad Prism  and MedCalc .Qualitative data were expressed as percentages and quantitative data as means ± standard deviations. Analysis was conducted using Student’s The study was approved by the local institutional ethics committee and conducted in accordance with the Declaration of Helsinki. Written consent was not required according to the MR-004 French legislation.Eight hundred and forty-five prescriptions fulfilled the inclusion criteria of the study and were analyzed. Detailed characteristics are shown in About 57% of prescriptions concerned women. The mean age at initiation was 51.8 years. Of the 845 patients, 38% of them were patients with RA, 16% of them were patients with PsA, and 46% of them were patients with SpA. Among RA and PsA prescriptions, 47.1% of patients had methotrexate associated with bDMARDs and 25.2% of patients were under corticosteroid therapy.® = 278 prescriptions; ERELZI® = 58 prescriptions) and 169 of ADA .Three hundred forty prescriptions were of boDMARD treatment, including 121 prescriptions of ADA and 219 of ETN, and 505 prescriptions were of bsDMARD treatment, including 336 prescriptions of ETN (BENEPALIp = 0.016). The majority of the hospital centre (5/8) prescribed significantly more bsDMARD than boDMARDs, while two of them equally prescribed both categories of treatment. Attached practitioners prescribed more boDMARDs.The comparison of the bsDMARD and boDMARD groups showed higher disease duration in patients with SpA in the bsDMARD group  but not for ADA .A significant increase of biosimilar ETN prescription over time was observed .First, the comparison of boDMARDs vs. bsDMARDs’ retention was analyzed . The medp = 0.982) with a median retention length of 30 months for ADA and 32 months for ETN   .p = 0.520). The median retention length was 30 months for HUMIRA, but it was not calculable for biosimilars , with a median retention length of 30 months and 45 months, respectively , with a median retention length of 33 months and 11 months, respectively.When prescribed as second-line bDMARDs, bsDMARDs’ retention was higher than boDMARDs’ (p = 0.9238), with a median retention length of 23 months and 19 months, respectively.When prescribed as third-line bDMARDs and more, there were no differences between boDMARDs’ and bsDMARDs’ retention (p = 0.041). The median retention length of boDMARDs was 23 months, while it was not calculable for bsDMARDs because it never falls under 50% .No differences of retention were observed in patients with PsA and SpA (p = 0.047) with a median retention length of 33 months for non-citrated treatments. The retention length was not calculable for citrated bsDMARDs  , older aWhile looking at bsDMARDs’ retention , older aConcerning boDMARDs’ retention , long dip = 0.0320).The reasons for the cessation of treatment are shown in p = 0.0440). Other side effects were not significantly different between groups (The analysis of side effects showed significantly more infection in the boDMARDs group (OR = 3.406 [1.083–10.07]; n groups .In this retrospective multicenter study, better retention of bsDMARDs over boDMARDs had been observed. Apart from bsDMARD prescription, identified predictive factors of retention of treatment were longer disease duration, prescription by a predominantly office-based practitioner, early line of treatment, and male sex.One surprising result was the not-so-obvious initiation of bsDMARDs by French rheumatologists. The prescription rate of bsDMARDs was mediocre for ADA biosimilars, which culminated at 60% in 2019 while it was up to 80% for ETN in 2019. The rate is less than that indicated in recently reported results from the ART-SFR French registry focusing on the initiation of TNF-alpha inhibitors in RA, whatever the molecule. Indeed, in this study, 100% of ADA prescriptions were bsDMARDs in the second trimester of 2019, while it was superior to 90% for ETN . An impoAn inflexion of bsDMARD prescriptions was observed in the first half of 2020. We could speculate an impact of the COVID-19 pandemic outbreak, which is known to have impacted prescribing habits with hydroxychloroquine being the most cartoonish example . It is kThe univariable analysis identified bsDMARD prescription, higher age at initiation, early line of treatment, citrate presence, longer disease duration, prescription by an attached practitioner, and male sex, as associated with treatment retention. Among these results, superior retention of bsDMARDs compared to boDMARDs was the main finding of this study. An analysis of each molecule separately found that superior retention of bsDMARDs was only observed with ETN. This is concordant with a recent Swedish study focused on the initiation of either biosimilar of ADA and ETN, which demonstrated a hazard ratio of treatment retention at 1 year in favor of SB4 biosimilar of ETN, while no differences had been found between HUMIRA and its biosimilars . For ADA® to IMRALDI®, differences in retention between these two biosimilars were significant only in RA when analyzing retention according to the disease (In patients with RA, bsDMARDs had significantly better retention compared to boDMARDs, while it was not the case in PsA and SpA. In a study comparing HYRIMOZ disease . No studWhen used as the first biologic, bsDMARDs and boDMARDs exhibited no significant differences in terms of retention, even if the median of retention was higher for bsDMARDs. This is concordant with the results of Di Gisueppe et al., with no difference in the retention of treatment for ADA, while there was a slightly better retention of biosimilar ETN . When usPrescription by an attached practitioner was associated with better retention of treatment in general and for boDMARDs. To our knowledge, this point is nearly never addressed in clinical studies, most of them using only hospital-based databases. Literature about the physician–patient relationship in the context of rheumatic disease is also scarce. However, it has been shown that patients are in demand of the availability of physicians. Appointment delays, lack of continuity of care, or feeling of a lack of interest from the physician are described as negative factors in the relationship with a possible impact on disease and effect of treatment , 54. A hBetter retention of treatment in men is a well-known feature in the literature. A recent study about the retention of bDMARDs in the same three rheumatic diseases as here found that female gender was associated with more cessation of treatment, but this was not significant in the multivariable analysis . This phCitrated treatments display superior retention compared to citrate-free treatments, either if considering all prescriptions or only bsDMARD prescriptions. This result was unexpected. Indeed, citrate buffer-induced pain at the injection site is a long-time known element with such an effect demonstrated for epoetin alfa injection in 1998  or in a Previous studies demonstrated the variable impact of disease duration on the retention of treatment with some demonstrating better retention in case of longer disease duration , while oLooking at predictive factors of retention, the multivariable analysis found that longer disease duration, bsDMARD prescription, attached practitioner prescription, early line of treatment, and male sex were associated with longer retention, while long disease duration and early line of treatment were found for bsDMARDs and only attached practitioner prescription for boDMARDs.The results of the analysis of side effects, particularly infections are quite surprising. Indeed, bsDMARDs are considered biologically similar to boDMARDs, thereby implying that the safety profile should be equivalent. In the literature, studies comparing the safety of bsDMARDs to boDMARDs did not find any difference in terms of adverse events, whatever the molecule –68. Our Our study has some limitations. Due to its retrospective nature, there were missing data, especially for disease activity, which was available only for 31.8% of patients, which did not allow us to analyze this point with precision. No sufficient data were available to evaluate comorbidities of patients, which is a known factor that impacts retention of treatments –71 and mTo conclude, despite the amount of knowledge supporting the efficacy and safety of bsDMARDs, their systematic prescription to initiate a new molecule is not a reflex among French rheumatologists. The maintenance of bsDMARDs is superior to boDMARDs, particularly for ETN, and in the context of RA. Citrate impact on the retention of treatment seems to still be full of mystery, which needs further studies to clarify its impact. bDMARD prescription in a long-standing disease as early line prescription is associated with better retention, as well as a prescription by a not fully hospital-based rheumatologist, probably reflecting the importance of a close and trusting relationship between patients and physicians. Future studies are needed to confirm those results while taking into account disease activity and comorbidities to assess with more precision underlying features of the treatment retention.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 Poitiers Local Ethic Committee. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.GB and EG: conceptualization. GL and AD: formal analysis and writing – original draft. GL, GB, AD, PC, VG, MG, LM, FM, EV, EH, J-HS, R-MF, and EG: investigation. GL and EG: methodology and writing – review and editing. EG: supervision. All authors contributed to the article and approved the submitted version.