The quality of economic studies was assessed using the CHEERS (2022) 28-point checklist. A total of 17 studies met our eligibility criteria. The median (IQR) of total childhood cancer costs by region was $909.5  and ranged from $88803.10 for neuroblastoma to $163.80 for lymphoma. No significant differences (p < 0.05) were observed for comparisons of the direct cost of childhood cancer between the geopolitical zone of sub-Saharan Africa. Differences in the direct costs of childhood cancer were significant for different cancer types (p < 0.05). In the majority of 17 out of 54 countries on Africa the continent, the economic burden of childhood cancer exceeds 80% of GDP per capita, PPP, up to 345.38% of Nigeria’s GDP for Rhabdomyosarcoma. The cost of treating childhood cancers is high in Africa is catastrophic, if not downright prohibitive for households in Sub-Saharan Africa. We believe that the data from our study will be able to help make different objective advocacy allowing it to be provided with funds based of the evidence that can strengthen this program in order to install cancerology structures in the countries and by following the system plan. Cost reduction in the treatment of childhood cancer in particular and in general all types of cancer.The high costs of cancer treatment and the lack of investment in health care are significant barriers to public health on the African continent. The objective of this study was to investigate the financial cost of children cancer treating in sub-Saharan Africa. We systematically searched PubMed, Cochrane, and Google Scholar to identify relevant studies between March 2000 and December 2022. We selected articles that specifically addressed the US dollar financial costs of childhood cancer in African countries. Medians and interquartile ranges (IQR) were calculated. We also calculated the economic burden of childhood cancer at the individual level, by dividing the direct costs of cancer per patient by the GDP Approval of the study was given by the ethics committee of the Faculty of Medicine of the University of Lubumbashi (UNILU/CEM/135/2018) and (UNILU/CEM/096/2019). Nowadays, cancer no longer spares Africa, where the numbers of new cases and deaths are sky rocketing (a nearly 100% increase is expected by 2030) . Public Researchers, clinicians and families know that cancer is a costly disease. Health professionals and policy makers in the health system at both national and regional level need data on the costs of cancer in general and those relating to childhood and adolescent cancer treatment in order to determine a distribution of health resources that meets to the needs of families, and better alignment in the adaptation of available resources. According to the Global Task Force on Expanded Access to Cancer Care and Control, only 5% of global cancer resources are spent in developing countries, and each country must develop its own multi-year cancer control plans adapted to their own socio-economic situation . Thus, o2.This is a systematic review, the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines , were ad2.1.2 , PubMed, Cochrane Library, CISMeF, and Google Scholar. Additionally, we performed a standard search using search bots. We searched for article titles, summaries, reports, briefs, and any other electronic presentation for data on Africa without restriction on format type or year. The searched keywords were as follows: “cost of cancer”, “childhood cancer—socioeconomic factors”, “cancer financing in Africa”, “prospective study” and “African continent” using the logical separators AND (AND) and OR (OR).The selected articles supported the evaluation of the cost of cancer in children aged 0–17 years in African countries. The inclusion criteria for the articles were (a) retrospective or prospective descriptive studies, (b) carried out in any type of health structure in sub-Saharan Africa between March 2000 and December 2022 in which the subjects were (c) children (d) with cancer regardless of type, younger than 17 years, (e) included descriptive information on pediatric cancer management; we did not include the different islands of the African continent in the study.per capita, PPP of the country studied. This measure would indicate how catastrophic these costs could be for an average citizen (GDP per capita)  .per capita based on purchasing power parity (PPP) is gross domestic product converted to international dollars using purchasing power parity rates. It is calculated without deduction for depreciation of manufactured assets or for depletion and degradation of natural resources. Data are expressed in constant 2017 international dollars . The direct cost of childhood cancer in Sub-Saharan Africa was calculated by geopolitical zone ; and by type of cancer. The descriptive data are expressed in median and Interquartile range. The Kruskal Wallis rank sum test was performed for the direct cost of multiple groups. AP value <0.05 was the threshold.per capita of countries where the studies were conducted was considered and converted into the international dollars by purchasing power party (2021).To calculate the percentage burden of cost of pediatric cancer, the GDP 2.3.Methodological quality of retrieved articles was assessed using the 2022 CHEERS Checklist . The Con3.3.1.The number of abstracts of studies based on the Financial costs of pediatric cancer management identified from the databases was 3,624 . After adjustment 1,594 duplicates and 1,831 irrelevant were excluded. Of the 30 reports sought for retrieval, based on the review, three reports were retrieved and 27 were rejected. Of the 202 relevant articles assessed for eligibility, 184 did not meet the inclusion criteria . Seventeen articles fulfilling all the inclusion criteria were finally selected (PRIMA diagram 3.2.n = 12), CHEERS checklist score for each study. The median CHEERS checklist score was 19 out of 28 (16–22). The median (IQR) the direct cost associated with childhood cancer was 909.5 $ ($455.3–$1765).The general characteristics of the studies on the financial costs of pediatric cancer management included are presented in However, nine studies were nationwide identified , 30, 31.n = 9), multiple cancers (n = 8), Wilms tumors (n = 5), leukemia (n = 4), retinoblastoma (n = 3), nephroblastoma (n = 1) and rhabdomyosarcoma (n = 1).Only 2 out of 17 articles included , 20 repo3.3.p < 0.05) was observed for comparisons of the direct cost related to childhood cancer between the Geopolitical zone sub-Saharan Africa .To explore the direct cost of childhood cancer in sub-Saharan Africa, we stratified costs by study region . The dir3.4.n = 9), multiple cancers (n = 8), Wilms tumors (n = 5), leukemia (n = 4) and other cancers  (p < 0.05). Costs for leukemia patients ($1831.2) are significantly higher than costs for lymphoma patients ($103.8). The median cost (IQR) of patients with Wilms tumor was $388 ($211–$416). The associated median (IQR) costs of multiple cancers and other cancers  were $1875  and $1,690  respectively.All studies have differentiated costs by type of cancer, namely lymphoma ((n = 1)] . DiffereThe cost of cancer varied between $88,803.10 for neuroblastoma and $163.80 for lymphoma . The CosRegarding the cost of Nephroblastoma represents, respectively, 88.34%  and 85.09%  of the GDP of the DRC , 16 and 4.Our systematic review highlights the economic impact of childhood cancer as a burden in sub-Saharan Africa. Despite the increasing morbidity and mortality related to childhood cancer, data on its health care costs are limited in a resource-scarce health care environment like sub-Saharan Africa.We performed a systematic review of studies reporting direct cost on Heinrich’s operational definitions –10. Studper capita, PPP  recommends that the results of COI studies be reported in international dollars at PPP, to better support country-to-country comparisons of costs . In the ita, PPP , 24, 25,ita, PPP , 23. Takfamilies , this isAssessing the economic costs of cancer to the health care system has its share of difficulties. Several researchers in the studies we identified reported high costs of cancer management in oncology units, the presence of which varied from country to country in Africa . In thisThe direct costs of cancer treatment can be influenced by the complexity and availability of treatment (chemotherapy and/or surgery), the duration of chemotherapy, and the need for supportive care . TreatmeIn the Democratic Republic of Congo (DRC), for example, the highest cost was for retinoblastoma  , althougGenerally, the cost of care depends on the country, its standard of living and its health policy. Countries with an oncology-centric system pay 10 times the average of countries without government subsidies , and conIn Mauritania, a fixed price system was combined with user payment in public hospitals . The RwaThrough these different methods of financing health systems, different countries have succeeded in guaranteeing real access to care in pediatric oncology . ResultsIn our assessment of costing methods, we used the method CONGRATULATIONS 2022.The main limitation of this systematic review concerns the quality of the existing literature in this area. Few of the economic evaluations in our study were of high methodological rigor, as evidenced by their scores on the CHEERS checklist. Future economic evaluations should adhere to the CHEERS Checklist, which consolidates previous economic evaluation guidelines and provides recommendations for optimizing the design and reporting of health economic evaluations .The development of protocols for the economic evaluation of cancer should be thought out while taking into account the complexity and depend on the objectives of the studies. The protocols can contribute to reduce heterogeneity, by favoring the comparison between the different regions and the different health systems, in order to obtain a more precise calculation of the cost of oral cancer (…).n = 2) out of 17 articles included . This program would be a valuable contribution to the existing employment insurance system and essential to ensure that households do not feel the great cost of cancer pathology; because, the fight is double financially and psychologically.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.CM and CD were responsible for the concept, design, and literature search of the study. MN, CM, and CD collected data. CM and CD performed the statistical analysis. MN, CM, CD, BI, DK, and ON drafted the manuscript. BI, DK, and ON supervised the study. CM, DK, ON, MN, DB, CD, and BI participated in the analysis and interpretation of the manuscript. All authors contributed to the article and approved the submitted version.


This study examines the relationship between emotional intelligence (EI) and academic stress among tertiary-level students who continued academic activities remotely during the pandemic and the mediating role of social support (SS) in the relationship.Using a cross-sectional survey design, 429 students studying business, engineering, social science, and science in Bangladesh provided data via Qualtrics. Using the Structural Equation Modeling in SmartPLS 4 (4.0.8.9), we modeled emotional intelligence as the reflective-formative and social support  and perceived academic stress as the reflective-reflective, second-order constructs. We also conducted a one-way between-groups analysis of variance (ANOVA) to investigate the impact of gender  and current stage of academic study (Undergraduate year one to four and post-graduation) on emotional intelligence and academic stress, respectively.Results show that all the hypothesized relationships are statistically significant: EI is negatively related to perceived academic stress, and SS significantly mediates the relationship between EI and academic stress. Hence, essential strategies are suggested to help students for managing academic stress. UniversThe pandemic-induced online class has adversely affected students’ psychological wellbeing, characterized by isolation and minimal or no social support . In addiIn response to online class difficulties caused by the pandemic, students have used emotional intelligence (EI) to manage their academic stress ; therefoSocial support, on the other hand, is an essential resource for coping with stress, and it refers to the assistance provided by others in terms of emotional, informational, and tangible support . PandemiDoes emotional intelligence significantly reduce academic stress caused by online learning during the COVID-19 pandemic, and to what extent does social support mediate the relationship?Emotional intelligence can positively predict resilience that helps to reduce academic stress among the students . AlthougThis study uses the JD-R model as its conceptual framework to address the research question. It selects a sample from Bangladesh, where universities suspended face-to-face academic activities in March 2020  and intrIn addition, the influence of demographic factors (gender and current academic year) on the relationship between EI and academic stress during uncertain times remains largely unexplored. Consequently, this study also intends to delve deeper into this issue and investigate the potential impact of these demographic factors on the relationship between EI and academic stress. Specifically, by examining the role of gender and study stage, the study aims to identify potential differences in the relationship between EI and academic stress among various subgroups of university students. The results of this analysis can provide valuable insights into creating focused intervention strategies that can adequately meet the varying requirements of university students, especially in uncertain times. Besides, the overall findings of this study can contribute to the development of effective interventions and support systems to assist students in managing academic stress and achieving academic success on online platforms.2.2.1.Academic stress refers to students’ attitudes and behaviour toward the pressure of accomplishing academic demands and achievements . StudentStress has become a widespread phenomenon during the COVID-19 pandemic. COVID-19 resulted in fear, mental stress, anxiety, and depression among university students in Bangladesh . The panThe term emotional intelligence has been used occasionally and inconsistent basis before 1990  and in 1EI has been found as an important interpreter of students’ activities, such as managing health and academic achievements. Higher levels of emotional intelligence help students to deal with the transition challenges from primary to secondary school . Por et H1: Emotional intelligence has a negative relationship with academic stress2.2.Social support refers to the experience of how an individual is appreciated, loved, and taken care of by the persons present in someone’s life . DeficieSocial distancing and isolation created the need for social support during this pandemic, and EI may contribute positively . ValentiH2: Social support mediates the relationship between emotional intelligence and academic stressH2(a): Friends support mediates the relationship between emotional intelligence and academic stressH2(b): Family support mediates the relationship between emotional intelligence and academic stressH2(c): Significant others support mediates the relationship between emotional intelligence and academic stress3.3.1.In this study, a deductive approach is used with a quantitative research design because quantitative research is best for analyzing the relationships between quantitative data and looking into the causes of empirical results . The tarThe respondent pool was limited to the four public universities in Bangladesh: University of Dhaka, Jahangirnagar University, Rajshahi University, and Chittagong University. These institutions were chosen because they represent the nation’s largest and most prestigious public universities. A public university is a higher education institution funded and regulated by the government. Besides, these institutions hold a great deal of sway in higher education because of their self-regulated status, which gives them more freedom in running their own academic and administrative operations. Furthermore, respondents were only included if they willingly agreed to engage in the study, provided responses in English, and were prepared to spend 10 to 15 min completing the survey.We chose graduate and undergraduate students in business, engineering, social science, and science as the target respondents for this study because these fields are offered at our chosen university. Besides, these disciplines are prevalent and extensively represented in the country’s higher education institutions. In addition, we selected university-level students because of their degree of maturity and ability to take an active role in the survey process. Furthermore, the recent pandemic has significantly impacted university students, especially those attending public universities.Through a convenience sampling technique, 500 questionnaire survey forms were given via Qualtrics to the targeted respondents, who were assured that their identities would remain confidential and that their responses would be used solely for research reasons. Besides, they were also notified that their participation is voluntary and that they may opt-out at any moment. While conducting the survey, we followed up with calls and emails after 1 week, 1 month, and 2 months to ensure a prompt response and full collaboration. Despite the attempt, 59 students out of 500 did not return the survey, and 14 responses were eliminated.Out of the 427 respondents, 57% were male, and the rest were female. 33% of respondents were graduate students, but the majority, 67%, were undergraduate students from various academic levels. Since undergraduate students make up the bulk of the intended audience, most respondents fall within the age range of 21 to 25. In addition, the remaining 12.1 and 11.7% of the respondents fall within the age range of  20 years and  26 years, respectively. On the other hand, roughly half of the respondents who participated in the survey completed their schooling in the city area, while the remainder were from towns and villages. Most of the respondents (54.3%) live with their parents or other family members (8.2%), while the rest of the students live in dorms (26.6%) and with friends in shared private houses 11%; .This study employed the G*Power to conduct power analyses specific to model setups. As the model could only have two predictors, this study required 138 participants to test the hypothesis. Besides a sample size of 200 responses or above is appropriate for a sophisticated path model . However3.2.In the current study, the conceptual model was evaluated using SmartPLS 4 (4.0.8.9). PLS-SEM was chosen because CB-SEM is often impractical for estimating complicated models with many latent variables . A complTypically, PLS models are studied and interpreted in two steps : the mea3.2.1.p < 0.01) and kurtosis  in the structural model, making the PLS Path model more compact and easier to comprehend . We emplEmotional intelligence, on the contrary, was modeled as Type II second-order measurement (reflective-formative); the accuracy of this formative measurement was assessed by looking at the weights, t-values, and the variance inflation factor (VIF). 4.2.p < 0.05). Therefore, H1 is supported. Likewise, it is evident from p < 0.05). Besides, the direct effect of EI on SS  and SS on PAS  are also significant. Thus, H2 is supported, and it can be said that SS mediates the relationship between EI and PAS, and the mediation is partial mediation.t = 0.803, p > 0.05, CI has value 0 included) and significant others support  is not statistically significant. So, FRS and SOS do not mediate the EI-PAS linkage. Thus H2(a) and H2(c) are not supported. However, t = 0.803, p > 0.05). Besides, the direct effect of EI on FMS  and FMS on PAS  are also significant. Thus, H2 (b) is supported, and it can be said that FMS mediates the relationship between EI and PAS, and the mediation is also partial mediation.Moreover, the study delves deeper and examines the mediating effect of family, friends and significant other support in the linkage between EI-PAS under social support. In the current study, the e in PLS . AccordiIn structural models, on the other hand, the effect size is regarded as one of the most crucial indicators of statistical power. Therefore, problems .4.3.F  = 1.788, p = 0.0.182] and PAS ; hence the assumption of homogeneity variance can be made.A one-way between-groups analysis of variance (ANOVA) was performed to investigate the impact of gender  and current tier of academic study  on emotional intelligence and perceived academic stress, respectively. Investigation of the skewness, kurtosis, and Shapiro–Wilk statistics showed that the assumption of normality for the dependent variable  was not violated. Besides, Levene’s statistics were not significant for both EI  was not required to participate in this study in accordance with the national legislation and the institutional requirements.MU: conceptualization of Idea, writing of paper  and overall coordination. SA: data collection, writing of paper , and editing. MA: Conceptualization of idea, data collection, and cleaning, writing of the paper . MI: data cleaning and analysis, writing of paper . All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Chronic inflammation plays a significant role in the etiology of endometriosis, which might be affected by dietary intake. This study aimed to investigate the association between dietary inflammatory index (DII) and the risk of endometriosis.A cross-sectional analysis using data from the National Health and Nutrition Examination Survey (1999–2006) was conducted on 3,410 American participants, among whom 265 reported a diagnosis of endometriosis. DII scores were calculated based on the dietary questionnaire. The association of DII scores with endometriosis was evaluated by adjusted multivariate logistic regression analyzes, which were further investigated in the subgroups.Ptrend = 0.007). In subgroup analyzes, the significant positive association between DII scores and the endometriosis risk was also observed in non-obese women , women without diabetes , women with hypertension , parous women , and women using oral contraceptives .In the fully adjusted models, the odds ratio (OR) for endometriosis participants in the highest and middle tertiles of DII scores were 1.57 [95% confidence interval (CI): 1.14–2.17] and 1.18 (95% CI: 0.84–1.65), compared to the lowest tertile (This nationally representative study found that increased intake of the pro-inflammatory diet, as a higher DII score, was positively associated with endometriosis risk among American adults. Our results suggested anti-inflammatory dietary interventions may be promising in the prevention of endometriosis. Further prospective studies are necessary to confirm these findings. The disRegarded as a chronic, inflammatory, endocrine, immunological, systemic and heterogeneous disease, the etiology of endometriosis remains largely elusive. However, chronic inflammation has been proposed as a well-established facilitator of the pathophysiological mechanism , 3. OverThe dietary inflammatory index (DII) , a literOur study aims to provide the first data on the relationship between DII and the risk of endometriosis by using data from the National Health and Nutrition Examination Survey (NHANES) , a large2.2.1.The study used a nationally representative sample from the NHANES, a cross-sectional series of interviews as well as physical and laboratory examinations conducted on the non-institutionalized US population . Aiming 2.2.n = 15,653), and missing or unreliable dietary interview data (n = 322). In addition, those with incomplete data on the potential covariates (described below) were also excluded . After exclusions, a total of 3,410 female participants were available for final analysis. The flowchart of the sample selection and study design is presented in For the current study, data from 4 cycles of NHANES  were collected. A total of 21,210 female participants were enrolled, among whom women were excluded if they had missing data for the diagnosis of endometriosis  were calculated based on the value of the first-day dietary interview data, since only the first-day dietary interview was conducted from 1999 to 2002. DII scores of NHANES (2003–2006) were calculated based on the mean value of the first-and second-day dietary interview data.The DII food parameters available in the NHANES database included energy, total fat, dietary fiber, protein, carbohydrates, saturated fatty acids, monounsaturated fatty acids, polyunsaturated fatty acids, omega 3, omega 6, cholesterol, vitamin A, vitamins B1, vitamins B2, vitamin B6, vitamin B12, vitamin C, vitamin D, vitamin E, β-carotene, niacin, folic acid, Mg, Fe, Zn, Se, alcohol and caffeine. First, the Z-score of each food parameter for each participant was calculated. Second, each individual Z-score was converted to a centered percentile. Next, each centered percentile was multiplied by the standardized overall inflammatory effect score. Finally, all of the food-parameter-specific DII scores were summed to create the total DII score for each participant. The final DII score in the study was a continuous value, ranging from 4.812 (the most pro-inflammatory diet score) to -4.827 (the most anti-inflammatory diet score).2.5.According to the previous studies , 27 and Demographic data: age (years), ethnicity , educational level , marital status ;2), and obesity was identified according to the BMI ;Examination data: body mass index (BMI) was calculated as weight in kilograms divided by the square of height in meters , smoking status ;Reproductive health data: status of parity (nulliparous or ≥ one birth), use of oral contraceptives (yes or no);Comprehensive data: hypertension (yes or no), diabetes (yes or no);Hypertension was defined according to the following criteria: being told hypertension by a doctor, use of anti-hypertensive medication, the mean value of measured diastolic blood pressure ≥ 90 mmHg or the mean value of measured systolic pressure ≥ 140 mmHg .Diabetes was defined according to the following criteria: being told diabetes by a doctor, glycated hemoglobin A1c ≥6.5%, fasting glucose ≥7.0 mmol/l, random blood glucose ≥11.1 mmol/l, 2-h oral glucose tolerance test blood glucose ≥11.1 mmol/l, use of diabetes medication or use of insulin.2.6.All analyzes were conducted following the NHANES analytic guidelines. The distribution of categorical covariates between endometriosis and non-endometriosis groups was compared by the chi-square test. The distribution of continuous variables was compared by the Wilcoxon rank sum nonparametric test or t-test according to the results of the normality test.DII scores were categorized into three tertiles according to the distribution, and subsequent analyzes were performed. Multivariate logistic regression models were applied to estimate odd ratios (OR) and 95% confidence intervals (CI) for the associations between DII scores and endometriosis, using the lowest tertile of DII scores as the reference category. We started by fitting a crude model with only DII scores, and then further adopted 3 adjusted models. Model 1 was adjusted for age, ethnicity, education level and obesity. Model 2 included the covariates of model 1 with additional adjustment for drinking status, smoking status, diabetes and hypertension. Model 3 included the covariates of model 2 with additional adjustment for marital status, fertility status and use of oral contraceptives. Linear trends across tertiles of DII scores were examined by modeling the median value in each tertile as a continuous variable in regression models. In addition, the association between the DII scores and endometriosis risk was tested on a continuous scale by the restricted cubic spline (RCS) curve with 4 knots  based on the logistic regression model. Stratified analyzes were conducted by obesity , diabetes , hypertension , fertility status , and use of oral contraceptives .p value <0.05 was considered statistically significant (two-sided). All statistical analyzes were performed using R software (version 4.1.3).A 3.3.1.The distributions of baseline characteristics between endometriosis and non-endometriosis groups are presented in p = 0.003). Moreover, a higher percentage of participants in the endometriosis group (41.1%) were found in the highest tertile of DII scores (the strongest pro-inflammatory diet) compared with 32.7% in the non-endometriosis group. The baseline characteristics of the participants according to tertile categories of DII scores are presented in The median DII score in the entire study sample was 1.86. Cases with endometriosis have significantly higher median DII score than those without endometriosis . Similarly, in adjusted multivariate models 1, 2 and 3, we identified that participants within the highest tertile of DII score were significantly associated with a higher risk of endometriosis compared to those within the lowest tertile. Furthermore, in the final fully-adjusted model (model 3) adjusted by all covariates, participants within the highest tertile of DII scores had a 57% increased risk of endometriosis compared to those within the lowest tertiles (p = 0.007). The trend analysis showed that the adjusted odds of endometriosis increased across increasing tertiles of DII scores in all models .The associations between DII scores and endometriosis in the total cohort, are depicted in p = 0.017; In addition, we also detected the relationship between the DII scores and endometriosis on a continuous scale by the RCS analysis, which also showed similar results , in women without diabetes , in women with hypertension , in parous women , and in women using oral contraceptives . The increasing odds of endometriosis across increasing tertiles of DII scores in the above-mentioned subgroups were observed (Ptrend < 0.05).The final adjusted model also showed a significant positive association between tertiles of DII scores and the endometriosis risk in non-obese women , in women with diabetes , in women without hypertension , in nulliparous women , and in women without the use of oral contraceptives .Nevertheless, no significant association was observed in obese women  and in the fully adjusted  models, compared with those in the total population and other subgroups.4.4.1.In this large population-based cohort from NHANES (1999–2006), a total of 3,410 participants were enrolled in the final analysis, with a 7.8% prevalence of endometriosis. We used the tool of DII score and found a significantly positive association between dietary inflammatory load and risk of endometriosis, which suggested a promising anti-inflammatory dietary intervention for the prevention of endometriosis.4.2.To the best of our knowledge, this is the first study to determine the relationship between DII scores and the risk of endometriosis. As a common benign gynecologic disease, endometriosis exerts tremendous physical and psychological effects on the quality of life, compromises social relationships, and greatly decreases the economic productivity of society . Given tFor instance, alcohol use , a high Based on the previous studies, our study adopted the DII score, which integrated the mixed effect of whole food parameters on inflammation , confirmThe possible pathophysiological mechanisms of the positive relationship between DII scores and endometriosis risk might be explained by higher levels of systemic inflammation caused by the pro-inflammatory diet. Higher DII score, referring to a stronger pro-inflammatory diet, could increase the values of CRP , 12, IL-Specifically, the association between the pro-inflammatory diet and the risk of endometriosis varied in subgroups in this study. When stratified by diabetes, no significant association between DII and endometriosis was observed; however, we found higher tertile of DII scores was associated with a higher risk of endometriosis among women without diabetes. Similar to endometriosis, the pathophysiology of diabetes is also closely linked to chronic inflammation triggered by the over-activation of the immune response –36. It iRegarding the stratified analysis by obesity, prior researches have reported a strong and consistent inverse relationship between obesity and endometriosis risk, which demonstrated that obesity might be a protective factor against endometriosis . In the In the subgroup analysis stratified according to hypertension, a significant 2.25 times the risk possibility of endometriosis among women within the highest tertiles of DII scores compared with those within the lowest tertiles was observed in the hypertension subgroup. However, no significant association between DII scores and endometriosis was found among participants without hypertension. From a large prospective cohort study by Mu et al. in 2017, women with hypertension had a relatively higher risk for endometriosis , compared to those without hypertension . SimilarAmong the subgroups of nulliparous participants and those without the use of oral contraceptives, although there was a higher risk of endometriosis associated with higher tertiles of DII scores, the results were not statistically significant. Based on the previous studies, nulliparous women and women without using oral contraceptives were associated with a higher risk of endometriosis, compared to parous women and those using oral contraceptives , 27, 40.4.3.The strength of this study lies in the nationally representative sample of the US population from NHANES, which allows the findings to be generalized to the total population in the US. Additionally, a wide range of potential confounding variables were adjusted in the analyzes to decrease the bias, and subgroups were performed to evaluate the association between DII scores and endometriosis in different specific populations. Moreover, to our knowledge, this study was the first to detect the association between DII scores and endometriosis, which posed a possibility of the prevention of endometriosis by an anti-inflammatory diet, contributing significantly to the reduction of health and economic burdens related to endometriosis.Similarly, several limitations also should be considered. One limitation of this study is that the cause and effect of the association between DII scores and endometriosis could not be identified. Another limitation is that the diagnosis of endometriosis was self-reported, and was not all confirmed laparoscopically in the NHANES. Prospective randomized controlled trials are necessary to verify the association of DII with endometriosis.5.This nationally representative study found that increased intake of the pro-inflammatory diet, as a higher DII score, was positively associated with endometriosis risk in American adults. Our findings suggested anti-inflammatory dietary interventions may be promising in the prevention of endometriosis. Further prospective studies are necessary to confirm these findings.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by Centers for Disease Control and Prevention National Center for Health Statistics Research Ethics Review Board. The patients/participants provided their written informed consent to participate in this study.JM: conceptualization and supervision. PL and JM: data curation and writing—review and editing. RM and YW: investigation. PL and RM: methodology. PL: software, formal analysis, and writing—original draft preparation. YuZ and YaZ: visualization. CX and YG: validation. All authors contributed to the article and approved the submitted version.This work was supported by National Natural Science Foundation of China (grant number: 82271677); Beijing Hospitals Authority’s Ascent Plan (Code: DFL20221201); Gynecological Tumor Precise Diagnosis and Treatment Innovation Studio.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The great saphenous varicose vein was managed with high ligation and stripping conventionally, but with the development of minimally invasive surgical techniques like endovascular laser ablation (EVLA), they have become popular. This systematic review and meta-analysis of randomized controlled trials aim to compare the short-term and long-term outcomes of these two modalities on headings like procedural time, technical success, recovery time, recurrences, cost-effectiveness, and complications.The protocol followed in this study was registered prospectively in the Registry of Systematic Reviews/Meta-analyses. Electronic databases were searched with appropriate search terms for relevant studies, and after their screening, data was extracted. The odds ratio was used for dichotomous data, and the mean difference or standardized mean difference was used for continuous variables.This study identified 18 publications  with a total of 1936 patients. There was no difference in procedural time, recovery time, recurrences at 1, 2, and 5 years, or clinical severity score. The surgery group had 4.35 times higher statistically significant odds of being technically successful at 2 years, while pooling data on bruising, hematoma, sensory disturbance, infection, and phlebitis showed that the EVLA group was less likely to develop postoperative complications.Technical failures were more common in the EVLA, whereas postoperative complications were more common in the surgery group. Both have comparable clinical effectiveness, and neither modality has clear superiority over the other. Parameters like cost-effectiveness must be assessed at the hospital level before choosing the right procedure for the patients. HighlightsThe varicose vein was managed with high ligation and stripping conventionally, but modalities like endovascular laser ablation are becoming popular.There was no significant difference in procedural time, recovery time, recurrences at 1, 2, and 5 years, or clinical severity score.Technical failures were more common in the endovascular laser ablation, whereas postoperative complications were more common in the surgery group.Other parameters like cost-effectiveness needed to be assessed at the hospital level before choosing the best modality for a patient.1. While a large proportion of people may remain asymptomatic initially, the common symptoms encountered as the disease progresses are leg pain, swelling, heaviness, itching, and cramping in the calf, most of which improve with rest, leg elevation, and the use of compression stockings. More severe presentations include skin pigmentation, dermatitis, venous ulcer formation, cellulitis, superficial thrombophlebitis, and lipodermatosclerosis3. Varicose veins also cause significant deterioration in the quality of life, particularly at later stages of the disease, which improves after the management of the disease5. Conventionally, varicosity in the great saphenous vein was managed with high ligation and stripping, and with the advent of minimally invasive surgery, other techniques like endovascular laser ablation (EVLA) became popular6. EVLA and conventional surgery are both effective management options, but EVLA provides those benefits as any other minimally invasive surgery in terms of less postoperative pain and an early return to normal activity and work7. But the chances of reopening of the great saphenous vein and recurrences are also higher following EVLA8. The short-term and long-term outcomes of these two modalities were needed to be studied to provide a concrete base with the data to facilitate evidence based practice.Varicose veins are a common disorder with an estimated prevalence of less than 1–73%, varying widely among different ages, sexes, races, and geographiesThis systematic review and meta-analysis of randomized controlled trials compared the short-term and long-term outcomes of the EVLA and conventional surgery groups. This present study aimed to study outcomes like procedural time, technical success, recovery time, recurrences, cost-effectiveness, and postoperative complications.9  and AMSTAR guidelines10 .This study is in line with the PRISMA guidelines11.The protocol followed in this systematic review and meta-analysis was registered prospectively in the Registry of Systematic Reviews/Meta-analyseshttp://links.lww.com/MS9/A197).Electronic databases  were searched with the use of terms like (‘endovenous laser ablation’), (EVLA), (ablation), , , (‘high ligation’), (‘varicose vein’) combined with appropriate Boolean operators. No time filters were used at the time of the electronic database search. Search details and the results of each database search are available as Supplementary File 1  for dichotomous variables and the standardized mean difference or mean difference for continuous variables were used as effect measures. The The risk of bias assessment was carried out using the ROB tool. Two independent reviewers did the assessment and any disparity that was seen was solved by a third reviewer. The assessment of bias is shown in Figure A sensitivity analysis was carried out for the results obtained by excluding each study at a time for every outcome.This study of 10 randomized controlled trials, whose outcomes were published in 18 different studies, involved a total of 1936 patients. The search of databases yielded 578 studies, and an additional 4 studies were added from other sources. After the removal of duplicates, 388 studies were screened. After the screening, 18 studies were identified as matching the inclusion and exclusion criteria of this study. Details are shown in Figure This study included nine randomized controlled trials, and studies that reported the outcomes of the same randomized controlled trials are shown in the same section. A summary of the details of the included studies is shown in Table n=525; I2=89%; P-value=0.09) .Pooling data from two trials using a random-effect model for the duration of the procedure showed that ligation and stripping took 13.02 min less time compared to EVLA on average, but the result was not statistically significant   .Five trials reported the time taken to return to normal activities, and pooling of the data using the random-effect model did not show a statistically significant difference between the two groups   showed a significant rise in the odds of ligation and stripping being technically successful  .Pooling the data from three trials reporting technical failure outcomes at 2 years by using the fixed effect model showed that the ligation and stripping group had 4.35 times more odds of remaining technically successful  Fig. . Sensitihttp://links.lww.com/MS9/A199). Sensitivity analysis of results of 1 and 2 years showed no significant difference; however, sensitivity analysis of the result of 5 years by excluding one study  significantly favored EVLA  .When the data on recurrence at 1 year was pooled from three trials, it showed that the difference between the two groups was not statistically significant. Also, pooling data on recurrence at 2 and 5 years showed no significant difference between the two groups. Details are provided in Supplementary File 3 . A sensitivity analysis of both results by excluding each study at a time showed no significant changes.Three trials reported the varicose vein clinical severity score at one year, and pooling of those trials using the mean difference effect measure showed no significant difference. Also, three trials reported the data of clinical severity scores at 5 years and pooling of which by using a standardized mean difference showed no significant difference. Details and forest plots are given in Supplementary File 3 .Pooling data on bruising, hematoma, sensory disturbance, infection, and phlebitis showed that the EVLA group was less likely to develop postoperative complications compared to the ligation and stripping group. The results were statistically significant except for sensory disturbance and phlebitis outcomes. Details are shown in Table http://links.lww.com/MS9/A198).Publication bias was assessed with the use of funnel plots. The funnel plot showed a symmetrical distribution for recurrence at 1 year, postoperative complications, and technical failure. Other outcomes  showed an asymmetrical distribution of studies depicting significant publication bias. Funnel plots are shown in Supplementary File 2  and the breakage of the great saphenous vein during stripping or inadequate stripping26. Recurrence outcome was also studied, and it showed no difference between the two groups. Recurrences developing at 1 year, 2 years, and 5 years had no statistically significant difference. Only one of the included studies had follow-up results up to 10 years, which showed that total recurrence was 66% in the EVLA group and 30.18% in the surgery group, with 36% of the patients in the EVLA group and 16.98% of the patients in the surgery group needing reintervention18. Recurrence in the EVLA group is mainly attributed to technical failure and reflux into the anterior accessory greater saphenous vein, whereas recurrence in the surgery group is attributed to neo-vascularization and technical errors35.Three trials reported the technical failure outcome measured at 2 years, and a meta-analysis of the outcome showed that the ligation and stripping group was four times more likely to be technically successful compared to EVLA. The main reason for technical failure in the EVLA group is early recanalisation36 was pooled and analyzed. It showed that clinical severity scores at 1 year and 5 years showed no significant difference between the two groups. Postoperative complications like bruising, hematoma, sensory disturbance, infection, and phlebitis were analyzed. This study found that the surgery group had statistically significantly higher complication rates compared to the EVLA group. This study also aimed to analyze and compare the cost of care, but due to the paucity of data, it could not be performed. However, two studies reported the cost of care, and they showed that the EVLA group had a higher cost of care compared to the surgery group. A cost-effectiveness study concluded that surgical treatment offered robust health benefits at a relatively lower cost than EVLA37. Also, the cost of care can go much higher in patients treated with EVLA, as the need for reintervention is greater in this group. The cost of care seems to vary in different regions, as some studies favor the EVLA while others favor conventional surgery38.Data from clinical severity score outcomes that assessed the severity of the disease on headings like pain, varicose vein, venous edema, skin pigmentation, inflammation, induration, number of active ulcers, ulcer duration, active ulcer size, and compression therapyEVLA and conventional surgery are both equal in terms of procedural time outcome, time taken to return to normal activities or work, short-term and long-term recurrences, and clinical severity score. Differences existed in EVLA being more likely to have technical failures, needing more reintervention in the long-term, and having fewer postoperative complications. When choosing a treatment option for a patient, all these factors must be considered. Postoperative complications are less common in EVLA, but its cost and risk of the need for reintervention are the barriers that need to be assessed before choosing it over conventional surgery.This study did not consider the intervention as per the amount of energy used in the EVLA, and this study did not consider whether USG marking was done preoperatively or not in the surgery group. Also, the procedures performed across the study were by different experts of different caliber, which may have brought heterogeneity to the studies. Another limitation of this study is that the reintervention outcome and cost of care outcome could not be included in the meta-analysis. Trials that included these parameters at their endpoints are needed to study them more promptly.EVLA and conventional surgery have no difference in short-term and long-term outcomes like procedural time, recovery time, technical failure, or clinical severity score. Technical failures were more common in the EVLA, whereas postoperative complications were more common in the surgery group. Both have comparable clinical effectiveness, and neither modality has clear superiority over the other. Other parameters, like cost-effectiveness, must be assessed at the hospital level before choosing the right procedure for the patients.Ethical approval was not required for this systematic review and meta-analysis.Informed consent was not required for this systematic review and meta-analysis.No funding received.O.S. and S.B.: contributed to conceptualization of the study and protocol development; O.S., N.T., and S.K.: contributed to the literature search and screening; N.T., S.K., P.P., and S.P.: contributed to data extraction; O.S. and S.B.: performed analysis and interpreted the data; O.S., N.T., S.K., P.P., and S.P.: drafted the initial version of the manuscript; S.B.: revised the manuscript intellectually. All authors were involved in drafting and revising the manuscript and approved the final version.The authors declare no conflicts of interest.https://www.researchregistry.com/browse-theregistry#registryofsystematicreviewsmeta-analyses/registryofsystematicreviewsmetaanalysesdetails/6441621b06cb1c0028468e32/).Registry of Systematic Reviews/Meta-analyses with the unique identifying number reviewregistry1583. .


Although global HIV pandemic has stabilized, it continues to rise in Eastern Europe and Central Asia due to exponential growth of newly acquired cases. Based on UNAIDS, there are currently 35,000 people living with HIV (PLWH) in Kazakhstan. This alarming HIV epidemiologic situation mandates urgent investigation of causes, routes of transmission and other characteristics in order to halt the epidemic. We aimed to analyze the data of all hospitalized patients for the period of 2014–2019 who tested positive for HIV from the Unified National Electronic Health System (UNEHS) of Kazakhstan.This cohort study extracted data for all HIV positive patients during 2014–2019 from UNEHS of Kazakhstan to apply descriptive, Kaplan–Meier estimation, and Cox proportional hazards regression model. Crosscheck of the target population data was conducted with tuberculosis, viral hepatitis, alcohol abuse and intravenous drug user (IDU) cohorts in order to create a comprehensive database. All survival functions and factors associated with mortality were tested for significance.n = 2,213) mean age was 33.3 ± 13.3 years with 1,375 males (62.1%) and 838 females (37.9%). Incidence rate decreased from 2.05 in 2014 to 1.88 in 2019, however, prevalence and mortality continues to escalate every year, the mortality raised significantly from 0.39 in 2014 to 0.97 in 2019. People aged >50 years, males, retired people, patients from tuberculosis hospital profile had much lower survival probabilities than the corresponding groups. Adjusted Cox regression model death hazard showed strong association of HIV patients with tuberculosis coinfection .The cohort population (The results of this study demonstrate high rates of HIV mortality, strong association of HIV with TB coinfection, regional, age specific, gender, hospital profile and social status differences that significantly affect HIV prevalence. Since the prevalence of HIV is continuing to increase, more information is necessary for evaluation and implementation of prevention procedures. Since its first discovery in 1983, HIV rapidly became an epidemic affecting every country in the world, with the most disastrous impact in Subarian Africa, accounting for half of the global cases. Based on the UNAIDS report, 38 million people live with HIV, and 680 thousand lives were lost due to AIDS-related illnesses. Although the global situation of HIV is stabilized and new cases decreasing for the past decade, in Eastern Europe and Central Asia the epidemic accelerating its growth with newly acquired HIV increased to 72%  in Kazakhstan, with prevalence of 0,3%. There were 3,600 newly acquired cases in 2020, which is a 73% increase for the past decade indicating exponential increase of epidemic in the country . While tDespite the alarming numbers of HIV epidemic in Kazakhstan, published data on analysis of clinical presentation, characteristics of HIV, adherence to ART and outcomes of HIV in Kazakhstan is scarce. Analysis of specific sub-population such as HIV and Tuberculosis patients in Almaty region , and socWith a goal of filling that gap, we investigated all hospitalized patients for the period of 2014–2019 who tested positive for HIV. The data was drawn from Unified National Electronic Health System (UNEHS), which provides comprehensive data from major hospitals from all regions of Kazakhstan. To our knowledge, this is the first study describing detailed sociodemographic characteristics of HIV, coinfection with Tuberculosis and viral hepatitis and all-cause mortality of HIV patients who are admitted to the hospital in Kazakhstan.2.2.1.In this retrospective study, data on HIV-infected people who were admitted to the hospital from 2014–2019 were obtained from UNEHS of Kazakhstan. These are the hospital admissions of HIV-infected patients due to different complications or comorbidities. Data included demographic characteristics, clinical ; whereas tuberculosis profiles were classified separately (22.3%)) and behavioral factors  along with the crosscheck of the target population data with tuberculosis, viral hepatitis, alcohol abuse and intravenous drug user (IDU) cohorts in order to create a comprehensive database. Matching the same patients in different databases was conducted by using unique RpnID numbers assigned to each patient registered in a UNEHS registry. Death was defined as outcome variable, and other demographic, clinical and behavioral variables were defined as explanatory variables. For quantitative variables interval scale was used, whereas for qualitative variables (yes/no) categories were used.2.2.Cohort included data of all adult patients and patients less than 18 years of age with HIV infection registered in the electronic registry for the period of 2014–2019. Patients were selected by first recorded HIV infection diagnosis or by first hospital admission and ended at the date of discharge prior December 31, 2019 or, at the date of death. All remaining observations were censored. The data cleaning and management procedures are represented in the flow chart , where o2.3.Statistical analyses were conducted using Stata MP2 16.1 version. Descriptive analyses  were performed to describe the socio-demographic, clinical and behavioral characteristics of the study population. Two sided t-tests for parametric and Mann–Whitney U tests for nonparametric data were performed to compare means. Pearson’s chi-square tests were used for comparison of proportions. For time-to-event analysis Kaplan Meier survival function was used to define survival probabilities of HIV infected patients. For the parameters the date of admission until the date of death was set. Different independent groups were statistically compared by log rank test.The Cox proportional hazards (PH) regression analysis was performed to estimate unadjusted and adjusted socio-demographic, clinical and behavioral hazard functions for prediction of survival probabilities of HIV-infected patients as well as investigation of associations with other risk factors such as tuberculosis, viral hepatitis, alcohol abuse and intravenous drug use. Magnitude of hazard ratios (HR) and the width of their 95% confidence intervals (CI) were considered in order to decide whether associations are statistically and clinically significant.Incidence rate, prevalence, mortality rate were calculated for all HIV registered regions of Kazakhstan based on available data from hospital admissions. According to that, maps of Kazakhstan with HIV-infected patients were created for visualization of incidence rate, prevalence and mortality rate in different regions of Kazakhstan using QGIS 3.14 software. In further analysis regions were classified into 5 categories: west, east, south, north and central Kazakhstan. Mangystau, Atyrau, Aktobe belong to West Kazakhstan region; Kostanay, Akmola, Pavlodar and Nur-Sultan city belong to North Kazakhstan; Karaganda belongs to Central Kazakhstan; Kyzylorda, Zhambyl, Almaty along with Almaty city, Shymkent city belong to South Kazakhstan region and East Kazakhstan region.2.4.The study was approved by the Institutional Review Ethics Committee (NU-IREC 315/21092020 on 23/09/2020) of Nazarbayev University, with exemption from informed consent.3.3.1.n = 1,375) were men. The mean age of HIV-infected patients was 33.3 ± 13.3 years. The largest proportion  of the cohort were middle aged people, aged 35–44 years. 49.3% of HIV-infected patients were Russian  and most of the patients live in urban areas (73.1%). The vast majority of patients (77.3%) were admitted to hospital urgently. All-cause mortality for the cohort was almost 40%. In regards to social status, a little over half of HIV-infected patients were unemployed . Moreover, 479 (21.6%) patients had tuberculosis diagnosis, 368 (16.6%) patients had alcohol abuse and IDU and only 113 (5.1%) patients had viral hepatitis diagnosis as comorbidities.From 3.2.Observed prevalence is increasing dramatically every year and continues to escalate, whereas the incidence rate of HIV infection remains quite stable with small fluctuations . OverallThe geographic distribution of HIV represented the highest incidence rate of hospitalized patients  and prevalence  in Pavlodar, East Kazakhstan regions and in Shymkent, Almaty cities in 2019. Whereas Atyrau, Aktobe, Mangystau and Kyzylorda regions showed the lowest incidence (0–0.018 per 100′000 population) and prevalence  of HIV infection in 2019. All-cause mortality of HIV-infected patients for 2019 was the highest in North Kazakhstan, Pavlodar, East Kazakhstan regions and in Almaty city  –C.3.3.In the Cox proportional hazard model , people 4.This study provides a comprehensive assessment of dynamics of hospital admissions of HIV-infected patients in Kazakhstan. Analysis indicated that prevalence and mortality of HIV continually increased each year in Kazakhstan, and showed regional, age, gender, hospital profile and social status significant differences. Thus, it requires controlling the spread of HIV infection in Kazakhstan which needs implementation of more effective prevention strategies to reduce HIV incidence.Results demonstrate that middle aged people (35–44 years) are the most important risk groups in terms of transmitting HIV infection in Kazakhstan. The age distribution varies considerably in different studies, but in most studies sexually active young people aged 20–45 years are in risk groups. The HIV infection is diagnosed at younger ages mostly in countries where the incidence of HIV is high and in many developed countries . In our Males comprise the majority of HIV patients in published studies from US, Turkey, China and Sub-Saharan Africa –12. Our All-cause mortality rates for the cohort was relatively high  and most patients hospitalized urgently, it suggests that the disease is diagnosed in more advanced periods or in the terminal stages. It can be the result of low coverage of population testing for HIV infection in Kazakhstan. According to the report on prevention of infectious diseases and treatment of HIV/AIDS and hepatitis among injecting drug users in Central Asia, in 2017 the coverage of population testing was only 13.9% in Kazakhstan . Correspondingly, there has been an increase in the mortality rate during this period of follow-up from 0.39 in 2014 to 0.97 in 2019. The main cause of the mortality in HIV-infected patients is late presentation to health institutions in most countries around the world .27. Corr, 14. HowThe most commonly reported opportunistic HIV co-infections were candidiasis, PCP, and tuberculosis –18. The In view of the fact that the primary route of transmission of HIV infection in Kazakhstan is IDU, it is important to consider the risk of coinfection with other blood-borne pathogens such as Hepatitis C and B viruses , 22. HowThis study faced several limitations. As this data obtained from the hospital admissions, it does not cover the whole HIV population in Kazakhstan, thus, the prevalence of HIV infected patients in our cohort cannot represent the real number of patients over the country. Low rate of HIV testing due to fear of stigma associated with the disease puts our society at a high risk of HIV infection and prevents infected patients from initiating early HIV treatment. Moreover, the deficiency of epidemiological data on HIV may result in bias in this study. The data is incomplete on route of transmission, other risk factors, drug use, prostitution and blood donation which is important for diagnosing HIV and implementing appropriate care. Results of multivariate analysis depend on the availability of collected information. Although the completion rates were relatively high for the used database with very low missed data (<5%), it was difficult to extract data on comorbidities. During linkage of different databases for coinfections some patients may have been missed. Therefore, the impact of comorbidities in the survival multivariable model may vary. Despite these limitations, this is the first study that analyses hospital admissions of HIV-infected patients and focuses on regional, gender, age, hospital profile and social status differences, as well as with other comorbidities. It is strongly recommended to develop behavioral surveillance data on known risk behaviors (eg. sex work and drug use), as well as surrogate markers of HIV risk, such as sexually transmitted infections. This is necessary so that intervention programs can be properly selected and evaluated.5.This study was performed to assess the dynamics of hospital admissions of HIV infected patients in Kazakhstan. The results of this study demonstrate high rates of HIV mortality and strong association of HIV with TB coinfections. It also concludes that regional, age specific, gender, hospital profile and social status differences of HIV prevalence significantly existed. Since the prevalence of HIV is continuing to increase, more information is necessary for evaluation and implementation of prevention procedures. It is considered that most patients were diagnosed at late stages of the disease due to the stigma, which confirms the importance of early diagnosis. Thus, more efficient and effective control programs of HIV transmission need to be investigated.The data analyzed in this study is subject to the following licenses/restrictions: not publicly available. Requests to access these datasets should be directed to Republican Center for Electronic Health of the Ministry of Health of the Republic of Kazakhstan.KM, AnA, YS, DS, ArG, AinA, AiyA, and AbG were involved in creating the study protocol. KM, AnA, and AbG drafted the manuscript. KM, AnA, DS, ArG, and YS involved in preliminary data design and assessment, literature review. ArG and YS collected data. AinA, AiyA, and AbG provide a critical revision and regular feedback of the manuscript. KM, AnA, YS, DS, ArG, AinA, AiyA, and AbG contributed to refinement of the study protocol. All authors contributed to the article and approved the submitted version.This study was supported by grants from the Ministry of Science and Higher Education of the Republic of Kazakhstan 2021–2023 (Funder Project Reference: AP09259016). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. AbG is a PI of the projects.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Heme and non-heme irons are two forms of iron in the diet. Few studies have evaluated the association between heme iron intake and the risk of gastric cancer (GC). We aimed to investigate the association between heme, non-heme and total iron intake and risk of GC in Iran.In a hospital-based case–control study, nutritionists interviewed 178 pathologically confirmed GC patients and 276 controls using a valid Diet History Questionnaire. Multiple logistic regression model was used to estimate Odds Ratios (OR) and 95% Confidence Intervals (CIs) for iron intake and risk of GC.Subjects in the highest tertile of total iron intake were 46% less likely to get GC than those in the lowest , however, the associations were not significant for intake of heme and non-heme iron. The risk of GC in the highest tertile of total meat intake was 2.51 times higher than the lowest. We found significant associations between GC and chicken  and fish intake , However, we found no associations between the risk of GC and intake of red meat, salted fish, and liver.Total iron intake was associated with a lower risk of GC which could be partly due to the high prevalence of anemia in Iran. Although, we could not find any significant association between the risk of GC and the intake of heme and non-hem iron among the Iranian population. Iron is a vital mineral for various physiological functions in the human body including DNA synthesis, proliferation, cell cycle regulation, and the function of proteins containing iron-sulfur clusters and as well as many redox processes . AlthougCancer is the second leading cause of death globally and was responsible for 9.6 million deaths in 2018 . GastricIn the literature to date, the relationship between meats, iron and heme iron intake and GC has been evaluated, but the results are often contradictory and inconsistent –13. The In the present study, we studied the association of heme iron and its dietary sources in the Iranian diet and the risk of GC. In addition, we investigated the association of total Iron and non-heme Iron intakes and GC exclusively.Data were derived from a hospital-based case–control study conducted at the Cancer Institute of Iran between May 2012 and June 2014. In brief, cases were 178 histopathologically confirmed incident GC patients  aged 40 years or older and were diagnosed maximum one prior to the interview. Patients were admitted to the Cancer Institute of Iran, Imam Khomeini Hospital Complex, which is a referral center admitting patients from all parts of Iran .Controls were 276 healthy individuals  visiting their relatives in the hospitals. We excluded the visitors who were visiting the cancer patients to avoid potential bias due to the shared environment. Every participant signed a written informed consent after the face-to-face description of the study protocol and aims. The study protocol was reviewed and approved by the Ethical Committee of Tehran University of Medical Sciences (No. 17198).H. pylori seropositivity using IgG antibody.Demographic and general information such as education, anthropometric measures, and selected lifestyle habits including tobacco smoking, alcohol consumption, and personal medical history were collected through a structured questionnaire Venus blood (10 cc) was collected from all participants to determine 2). Since GC causes extensive weight loss, we asked the subjects about weight one year before the interview rather than measuring their weight at the interview. Alcohol intake was asked in DHQ and was converted to grams/day of alcoholic drinks.Body Mass Index (BMI) was calculated as weight in kilograms divided by height in squared meters (kg/mTrained dietitians conducted face-to-face interviews to complete the Persian version of the Diet History Questionnaire (DHQ), which has been validated before . BrieflyDaily food intakes were used to calculate energy and nutrient intakes based on Food Composition Table in Access software. The Iranian Food Composition Table covers only raw foods and limited nutrients (20). Therefore, we used the McCance and Widdowson's Food Composition Table  and supplemented it with Iranian items for some special Iranian foods (20). Consumption of total meat , red meat (beef and lamb meat), chicken, and different types of fish and liver were assessed.To estimate the heme iron content of foods, we used published information on measured values in different types of meat . The intWe excluded 3 subjects who were outliers for the total energy intake from this analysis. We categorized participants into tertiles according to intake of red meat, chicken, fish, liver, total iron, non-heme, and heme iron. The lowest level of consumption (first tertile) was considered as the reference group in the regression models.H. pylori infection and BMI. We used Stata statistical software for analyses .Unconditional multiple logistic regression models were used to estimate ORs and corresponding 95% CIs as the measure of associations between intake of heme, non-heme, and total iron and different types of meat intake with GC. We used two regression models including model A, adjusted for age, sex, and energy; and model B in which we adjusted for several confounding variables including age, sex, education, smoking, alcohol intake, p-value =  < 0.0001).Demographic and nutritional characteristics of the study participants across tertile categories of heme iron intake are provided in Table P =  < 0.0001), had higher BMI . They were less likely to be educated , more married , and drink alcohol  than controls (data are not shown). Patients also had a lower intake of red meat and protein. The mean heme iron intake of participants was 0.60 ± 0.45 (0.61 ± 0.43 in cases and 0.60 ± 0.47 in controls). According to our results, participants consumed chicken more than red meat and fish respectively.Patients with GC were slightly older , chicken , and fish  intakes in the highest compared to the lowest tertiles . Albeit the associations were not statistically significant for heme (P trend = 0.72) and nonheme (P trend = 0.07) iron.In this hospital-based case–control study, we found that gastric cancer was directly associated with total meat, chicken and fish intake. The risk of GC decreased with an increase in the intake of total Iron. However, we found no associations between the risk of GC and intake of heme and non-heme iron, red meat, salted fish and liver.H. pylori infection that is an important risk factor for GC and may affect the absorption of nutrients including iron. In addition, we used DHQ, which is a dish-based questionnaire to collect nutrition data and allows estimation of the intake of different types of meat. However, our study had some limitations. The inability to examine risk by sub-type of GC (cardia and non-cardia) due to the small sample size is a potential limitation. Non-cardia GC is more prevalent in Asia and different nutritional risk factors have different effects in relation to cardia and non-cardia GC [The main strength of our study is the calculation of heme iron values based on Food Tables, while most of the previous studies applied a fixed value of 40% in meats to estimate heme Iron values . We adjuardia GC . In addiPrevious studies on the association between meat consumption and GC risk showed inconsistent results. In agreement with Larsson , we did It has been suggested that different chemicals in red meat can cause cancer; including N-nitroso-compounds, Poly-cyclic Aromatic Hydrocarbons, and Hetero Cyclic Aromatic Amines (HCA) , 29. TheTo our surprise, fish intake increased the risk of GC in our study. The results for fish consumption in our study are contradictory to previous results , 31, 32.We also observed a significant association between chicken intake and the risk of GC. Some studies reported that white meat increases the risk of colorectal cancer , while oAlthough we found a significant association between total iron intake and a decrease in the risk of GC, we found no associations with heme and non-heme iron. A few studies have been carried out to assess the relationship between iron intake and the risk of GC , 11, 13.Iron deficiency and anemia increase oxidative stress and DNA damage, which might increase the risk of carcinogenesis, especially in the GI tract , throughThe prevalence of anemia is 20–30% among the Iranian population , 46. TheWe conclude that total iron intake decreases the risk of GC. However, we did not find a significant association between the risk of GC and the use of heme and non-heme iron. We observed positive associations between GC and intakes of total meat, chicken, and fish. Findings from this study highlight the role of diet in the risk of GC among the Iranian population, where GC is the most common cancer among males and more than 10,000 patients die from this disease. Future studies should be large enough and collect more details about food items and cooking methods.


Despite the unquestionable advantages of digital transformation (DT) in organizations, the very process of DT could have an impact on the level of stress of the employees. The negative effects of the digital transformation process can be observed during the implementation of information and communication technologies (ICT) solutions. They are further enhanced by the effects of COVID-19 pandemic, as digital transformation has accelerated to allow for remote work. Herein we distinguish between general stress at the workplace and the very specific type of stress, namely digital transformation stress (DTS). We assumed that this type of stress appears when rapid implementation of ICT solutions is introduced with time pressure and incertitude of further results. To quantify this phenomenon, we developed a new self-report scale—the Digital Transformation Stress Scale (DTSS), measuring employees’ stress stemming from the process of digital transformation in organizations. The psychometric validity of the scale was evaluated in two studies: Study1 conducted at the beginning of COVID-19 pandemic in 2020 (N = 229) and Study 2 in 2021 (N = 558), after a year of mostly remote work. The results confirmed good reliability with Cronbach’s Alpha α = .91 in Study 1 and α = .90 in Study 2 and assumed unidimensional factorial validity of the scale in both studies. All items of the scale had good difficulty and discrimination values evaluated in Item Response Theory, i.e., IRT approach. The scale showed predicted convergent validity as the indicator of the digital transformation stress moderately correlated with general stress at work. Moreover, the assumption that even employees with high ICT skills could be affected by DTS was confirmed. Additionally, the results indicated that digital transformation stress was significantly higher among employees who reported both issues: ongoing digital solutions projects at the workplace and high impact of COVID-19 pandemic on their work. The scale could be used in future work on measuring and counteracting digital transformation stress at the workplace. Although digital transformation (DT) evokes organizational changes, recent observations suggest that DT deviates from the past organizational changes. Nowadays, changes related to Information Technology (IT) and Information Communication Technology (ICT) are much more generative, malleable and combinatorial in comparison to traditional ones , 2. ManyThe expected effects of DT are improvements in the work efficiency and effectiveness of organizations , 11, 12.The recent COVID-19 pandemic has accelerated the digital transformation in a wide range of areas, from business to education –23. The This situation has emphasized the paucity of tools and research evaluating employees stages of adaptation to digital solutions implementation process and potential factors that can affect this adaptation, with stress among others –34. MoniNowadays, job stress is by far the most significant source of stress for adults and it has been escalating over the past few decades –37. TherAccording to the literature and research, stress is a nonspecific response of a person to specific, individually assessed stressors , 41. In These two definitional elements are the basis of a commonly used scale assessing perceived stress, namely the Perceived Stress Scale , presentThe role of job demands in predicting dual ways of coping with stress was defined in the Job Demands-Resources (JD-R) model , 69. ThiWhile JD-R theory explores the role of demands-resources trade-off, the conservation of resources (COR) theory 55,56), being more general, shifts the emphasis from the balance between the job demands and employee’s resources into potential threat of losing valuable resources. In this approach, the psychological stress is defined as an individual’s reaction to an environment in which valuable resources are threatened. The COR theory underscores the critical role of gaining, retaining and protecting the valuable resources, namely personal, social and material resources in a stressful situation. Following this assumption, stress occurs when important resources are either threatened with loss, lost or not gained. Additionally, the basic principle of COR also states that resource loss is disproportionately more salient than resource gain , with ga, being mOne of the sources of job stress is organisational change , which hBased on previous research on job stress , 37, 69,Following the conservation of resources (CoR) theory , 75, we per se, or lack of ICT skills or competencies, but because of the occurrence of a set of factors such as: 1) an improper way of implementing digital solutions and changes in workplaces , SRMR = .043. Following suggestions based on modification indices, we added covariance between two items with similar wordings–item 5 and item 6. This modified model was well fitted to the data χ2 (8) = 14.90, p = .061, CFI = .99, TLI = .99, RMSEA = .039, p = .678, 90% CI., SRMR = .014. All factor loadings significantly loaded to one factor. Covariance between item 5 and item 6 equals .48. All factor loadings are presented in The CFA analysis indicated that the preliminary model was not well fitted to the data χ2 (WLMSV). Similarly to CFA, we used CFI, TLI, RMSEA, SRMR and χ2 test as measures of model fit with cut-off values described above to evaluate the goodness of the fit. Following the A two parameter model exhibited quite good fit measured by CFI = .963, TLI = .939 and SRMR = .036, but unacceptable fit by χ2 test of absolute fit χ2 (9) = 329.722, p < .001, and RMSEA = .253 . A reduced model in which with one parameter fit significantly worse DIFFTEST(5) 24.211 p < .001. Thus, the original model was retained for further examination using MML estimation instead.Psychometric assessment of the items discrimination and difficulty was conducted using Item Factor Analysis in Item Response Model approach . The curModel parameters obtained using MML and a logit link are shown in It can be seen that all the items have similar discrimination parameters and it can be assumed that they similarly discriminate participants with different levels of latent trait. Also, threshold parameters for all items have quite similar values with a similar spread across values of latent variable.We also present items information curves in To test the reliability, we calculated Cronbach’s Alpha in IBM SPSS Statistics 27.0. The reliability was high (Cronbach’s Alpha α = .90) and it was similar to the results obtained in the first study.r = .45, p < .001. Employees with a higher level of digital transformation stress indicated a higher level of general stress at work. As predicted, indicators of general stress and digital transformation stress shared a rather moderate percentage of common variance (R2 = .20) and, therefore, they can be identified as separate constructs.To present the convergent validity, we tested the association between general stress at work, measured with the Perceived Stress Scale (PSS) , 114 andOngoing IT implementation. We expected that employees working in organizations with an ongoing digital transformation process should present higher digital transformation stress than those working in organizations with no digital transformation. Thus, we compared the level of digital transformation stress in these two groups using Student’s t test for independent samples. The results revealed that the level of DTS in employees working in organizations who implemented IT solutions was higher  than for employees working in organizations without ongoing implementation  = 2.14; p < .001, Cohen’s d = .21).COVID-19 impact. The majority of participants (61.8%) stated that COVID-19 affected their professional lives, and we observed a significant difference in the level of DTS between the group of participants who did state that COVID-19 impacted their professional lives  in comparison to participants who did not state that COVID-19 modified their working conditions  = 3.72; p < .001, Cohen’s d = .32).ICT skills. We verified if self-assessment of ICT skills is the factor of DTS. Thus, we examined the correlation between the DTSS and self-assessment of ICT skills inventory. For the entire sample (N = 558), we observed no correlation between two indicators: r = -.04, p = .31. Additionally, we calculated the correlation between ICT skills and digital transformation stress only for those participants who declared that there is an ongoing IT solutions implementation in their organization  and resources  are imbalanced. Although the DTS scale includes items related to the assessment of personal resources, such as the sense of control or competence, they are of an emotional nature. Therefore, we see the need to compare the measurements of the perceived stress of digital transformation with a scale examining attitudes to digital transformation, consisting of cognitive, emotional, and behavioural dimensions. Similarly, this transactional nature of stress was unfortunately not captured precisely by the measure of ICT implementation used in our study, as we did not evaluate both job demands and resources in ongoing digital transformation process. In a further study, we would like to address this limitation by exploring the interaction of ICT demands  witFinally, we believe that the COVID-19 pandemic, being the global factor, had forced rapid digital transformation and changes in almost all organisations. Although switching to the remote work arrangement and technical adaptations processes as well as adaptation of the IT infrastructure could not be perceived as the ongoing implementation project per se, these processes could impact employees in the same way as IT solution projects and digital changes. Consequently, all the above may increase the digital transformation stress level. Because of that, observed differences between workers in organisations with ongoing implementations and those without implementations did not differ strongly in terms of DTS. All of these processes may explain why differences in DTS between these two groups of employees were not more noticeable.Summarizing, our studies showed that DTSS may serve as a reliable instrument in measuring employees’ perceived DT stress in response to the specific process of DT in organizations. Being a short scale, it may also be useful as an indicator of DTS change after introducing psychological interventions aimed to reduce this type of stress.The present study has several limitations which need to be discussed. Firstly, respondents, especially in the first study, were invited mainly via social media, particularly through LinkedIn, and this may seriously limit the generalizability of our findings. The online way of conducting the study might have reduced the number of participants who were very strongly affected by DTS. Therefore, further research on the role of different modes of survey administration are necessary to assess the influence of this factor on the level of DT stress observed at the workplaceSecondly, as stated above, some limitation of our research includes the measure used to identify organizations with ongoing digital transformation process. As it was based only on self-reports provided by employees, it might not precisely capture the higher level of DTS demands related to implementations. It would be very interesting to select organizations just as they start the process of digital implementation and evaluate changes in the level of digital transformation stress of their employees longitudinally. Such research design would enable us to provide more reliable information about its causal relationship between employees’ demands, resources and stress.Thirdly, as the preliminary set of items was rather short, quantitative research on DTS is required to identify such symptoms of DTS that may differentiate it from job stress and technostress. The following construction process may also include additional dimensions, related to secondary appraisals of stress evoked by change, identified in applied research on organisational change. As Olafsen et al.  proposedFinally, the phenomenon of DTS is conceptually larger than only emotional dimension therefore further research on digital transformation stress should be expected. We assess that deeper analysis on digital transformation stress and digital transformation attitudes should be conducted, taking into account the multidimensional construct of stress i.e., cognitive, behavioural and emotional.Further work should also examine how strongly DT stress impacts different work outcomes such as work commitment, job satisfaction, and burnout of employees. Additionally, more research is needed to examine the variables that allow to predict the level of DTS e.g., attitudes toward digital implementation, perceived work demands. This research should also be conducted after the COVID-19 pandemic, when DT processes will be simpler to plan and properly implemented in organizations.The general aim of our studies is to propose a self-descriptive and easy-to-administer measurement tool aimed to identify highly stressed employees who would benefit from specific psychological interventions reducing DT stress. The DTSS possesses satisfactory psychometric properties but is also attractive for reasons of cost and time effectiveness, especially in automated screening systems that might be constructed using this scale , 89. BeiIn the future, DTS scale may become a substantial part of an automated system consisting of three hierarchical elements: a) preliminary screening, based on a qualitative analysis of help-desk tickets sent by employees , b) evalMoreover, in project management area , 128, thFrom the theoretical standpoint, DTSS can be used to further elaborate psychological antecedents , and new sources of stress in various contexts e.g., at the workplace, in education, in the health-care systems—wherever the digital implementations are introduced in the hope of improving the effectiveness of the system. Research testing the associations between DTS and psychological well-being, burnout, disengagement is of great importance in understanding and evaluating the value of these costs.The COVID-19 pandemic has highlighted the importance of digitalization in many areas of business, accelerating the digital transformation process. Although the digital maturity of organizations and employees is increasing overall, there are considerable consequences of DT. The negative effects of DT on employees appear due to the process of introducing changes under time pressure, without proper planning, and gradual implementation , 133. InS1 Fig(DOCX)Click here for additional data file.S1 Data(SAV)Click here for additional data file.S2 Data(SAV)Click here for additional data file.