This study aimed to assess dental care needs in Cluj region during the State of Emergency, declared due to the COVID-19 pandemic, compared to the same period of the year 2019. A descriptive retrospective analysis was conducted, which retrieved patients seeking emergency dental services at the Emergency Department of County General Hospital and “Iuliu Hațieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania, the only dental service available in April 2020. Recorded data cover the month of April 2020 and is compared with the same period of 2019. During April 2020, 724 patients received dental care, whereas only 160 patients were treated in April 2019 in the same facility. The number of patients with acute apical periodontitis, abscess, and acute pulpitis was significantly higher in 2020. The percentage of patients receiving sedative filling for the treatment of acute pulpitis in 2020 was significantly higher than in 2019, while the proportion of patients receiving pulpectomy was higher in 2019. The percentage of patients receiving endodontic drainage for the treatment of acute periapical periodontitis in 2020 was higher. This study demonstrates that the COVID-19 pandemic impacted the use of medical care services and could further impact the oral health and quality of life of patients. Since December 2019, various changes took place worldwide, due to COVID-19. It is known that COVID-19 is a respiratory disease caused by the virus: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [After SARS-CoV-2 occurrence in Wuhan, China . On 11 MRomania announced a State of Emergency on March 18th, through a Military Ordinance , which cCluj-Napoca metropolitan area consists of 1 major city (Cluj-Napoca) and the 19 surrounding communities totaling a population of 415,771 people and covering 1603 square kilometers. However, the census of the population is done only for people having their permanent residency, and in normal times, the population is increased by 13–15% with students, as Cluj-Napoca is one of Romania’s most important university centers.Post-extractional hemorrhage;Pain due to acute pulpitis;Pain due to acute apical periodontitis;Pericoronitis of the impacted teeth;Post-extractional alveolitis;Cellulitis/abscesses;Mandibular fractures;Temporomandibular joint dislocation;Dento-alveolar traumas ;Ulceronecrotic gingivostomatitis .The total number of dental offices in Cluj-Napoca, in December 2019, was of 1014. From those, only the Emergency Department of County General Hospital and “Iuliu Hațieganu” University of Medicine and Pharmacy dental setting could receive emergencies after the pandemic was declared for the period March 22 April 30. The County Clinical Hospital declared two locations open for dental emergencies: one for the general population, where non-COVID-19 patients were treated, and one for patients that were suspects of having been infected with COVID-19 or had positive results for COVID-19 infection testing. The Romanian College of Dentists adopted the plan of measures for performing emergency dentistry interventions (17/3/BExN/2020), in which only the following pathologies were considered emergencies:A strict protocol was applied in the dental care service: the first step was the phone triage, general health triage before entering the dental office and then dental triage. On the phone questionnaire, the patients were asked if they presented COVID-19 symptoms or had any contact with individuals who returned from other countries severely affected by COVID-19 and they were also asked about their dental symptoms, in order to determine if they were truly in need of an emergency treatment. If the dental problem could not be treated or postponed telephonically, through guidance or medication, the patient was invited to the emergency dental office. If the patient was considered to be a suspect of COVID-19 infection or had previously tested positive for COVID-19 infection they were redirected to a secondary location which was prepared to provide dental care for infected patients.In light of the major changes, the present study aimed to assess the need of dental treatment in Cluj region during the State of Emergency declared due to the COVID-19 pandemic, compared to the same period of the year 2019.A descriptive retrospective analysis was conducted in the present study which retrieved patients seeking emergency dental services in a public dental setting at the Emergency Department of County General Hospital and “Iuliu Hațieganu” University of Medicine and Pharmacy dental setting in April 2020 compared to April 2019. This dental setting was the main one from Cluj Metropolitan Area as it is placed in Cluj-Napoca, the major city of Cluj County. It was set to receive patients that were not considered to be a suspect of being infected with the SARS-CoV-2 virus, nor had previous positive COVID-19 tests.The study received the approval of the Ethics Commission of “Iuliu Hațieganu” University of Medicine and Pharmacy, Cluj-Napoca (no. 132/24.03.2020). Recorded data cover the period from April 1st to May 1st, 2020 compared to April 1st to May 1st, 2019. April 2020 was the period of Romania’s State of Emergency when the private practices were not accredited to receive patients, only the Emergency Department of County General Hospital and “Iuliu Hațieganu” University of Medicine and Pharmacy dental setting was accredited to receive emergencies. However, in April 2019, the same dental setting was providing dental treatments, together with another 1014 dental offices.All patients who received emergency dental services in the previously mentioned institution, between April 1st and May 1st, 2019 and 2020, were included in the study. Information about demographic characteristics , dental pathology, and treatment was recorded and introduced into an Excel sheet. SPSS 20.0 was used for the statistical analysis: descriptive statistics and chi-square calculator.In April 2019, 160 patients visited the Emergency Department of County General Hospital and “Iuliu Hațieganu” University of Medicine and Pharmacy, whereas in April 2020, 2131 patients sought dental treatment in this department, as other dental emergency centers and private practices were closed by the State of Emergency dispositions. In April 2020, patients were triaged on the phone; this procedure involved 2131 patients. From those patients, 1400 were postponed or they had a dental problem that could be dealt with telephonically; 7 were redirected to the emergency service of oro-maxillo-facial surgery, because they were suspected to be SARS-CoV-2 positive; and 724 were treated in the secondary location Emergency Department of County General Hospital and “Iuliu Hațieganu” University of Medicine and Pharmacy. Gender distribution of the emergency cases from April 2019 and 2020 is represented in Comparing the frequency of patients in the dental office, it was observed that during both periods of time, male patients needed dental treatment in a higher percentage than female patients. However, comparing the attendance of female patients to the dental office, it is to be noticed that a higher percentage (46.41%) sought dental treatments during the Emergency state, compared to 2019, whereas the percentage of male patients in need of dental treatment decreased from 2019 to 2020. During the State of Emergency, a higher percentage of male patients sought dental treatments (53.59%) than female patients. The only difference was recorded for the 20–29 years age group, where the percentage of female patients outnumbered the male patients.X2 = 25.9527, p = 0.001002) and 10–19 years , where the number of patients decreased during the Emergency state. No statistically significant differences were recorded between the other age groups.The youngest patient seeking dental treatment in 2019/2020 was 2 years old, the median age of patients was 20 years in 2019 and 32 in 2020, and the eldest patients was 78 years old in 2019 and 96 years old in 2020. Statistically significant differences were recorded for the age groups 0–9 years : post-extractional bleeding; pain due to acute pulpitis; pain due to acute apical periodontitis; pericoronitis of the impacted teeth; post-extractional alveolitis; cellulitis/abscesses; jaw/mandible fractures and dento-alveolar traumas ; ulceronecrotic gingivostomatitis. In total, 9.49% of all patients from 2019, and 6.91% of the patients from 2020 registered at the Emergency Department of County General Hospital and “Iuliu Hațieganu” University of Medicine and Pharmacy, had two pathological conditions in need of treatment.2 = 19.2139, p = 0.00012, X2 = 6.7688, p = 0.009277, X2 = 4.51, p = 0.0337). The proportion of caries was significantly higher in 2019 .The most common emergency problems among patients during April 2019 and 2020 were acute pulpitis, acute apical periodontitis, abscess, and caries. The proportions of patients with acute apical periodontitis, abscess, and acute pulpitis were significantly higher in 2020 than in 2019 . The same age population was also affected by acute apical periodontitis (45.74%). The age group 20–29 sought dental treatment for pericoronitis of impacted teeth: 81.82% of all pericoronitis diagnosis was found in this age group. They also presented the highest percentage of dento-alveolar traumas—36.36%. Forty percent of ulceronecrotic gingivitis was found in the 60–69-year-old population, but it was also present in 20% of the 2–9-year-old group, 10–19, and 20–29-year-old patients, respectively.From the “Other” pathologies that led patients to seeking emergency treatments, 42.86% of injuries due to orthodontic appliances were found in the 30–39 age group with a higher prevalence in female patients, and 45.45% of pathological dental mobility was found in the 60–69 years of age group.Comparing pathology distribution in gender groups for patients seeking dental treatment in April 2020, as indicated in It was observed that in April 2019 there was no data entry for diagnosis such as pericoronitis of impacted teeth, dislocation of the temporo-mandibular joint, and irritation due to orthodontic appliances, and the most plausible cause for this is that such cases that had small incidence even in 2020 sought treatment in other dental offices and private practices.2 = 23.421, p < 0.0001), while the proportion of patients receiving pulpectomy was higher in 2019 . The percentage of patients receiving endodontic drainage for the treatment of acute periapical periodontitis in 2020 was significantly higher than that in 2019 . The percentage of patients receiving temporary fillings for the treatment of caries in 2019 was significantly higher than that in 2020, but without any statistical significance, instead, the sedative filling was statistically significantly more often performed in the emergency status . Sedative filling was the most frequent treatment approach in April 2020 , acute pulpitis (33.3%), and cellulitis/abscess (9.3%) were the most frequent diagnosis during the State of Emergency in Cluj-Napoca, Romania, but were also the most common diagnostics in 2019, as indicated by other researchers ,26,27. POur results correlate with those registered by Guo H. et al., 2020, and Bai J. et al., 2020, indicating similarities in dental problems worldwide. Some particularities for different age groups were registered. In the age group 10–19, the percentage of pulpitis exceeded that of apical acute periodontitis. This indicates that in this age group dental pathologies might be intercepted in early stages. In this group, irritations due to orthodontic appliances appear, indicating inclusion of this age group in orthodontic treatment. In the groups between 50 and 69 years, we found 72.72% of all pathological tooth mobility as the reason for emergency care attendance. As social activities were limited by authorities, the percentage of trauma was low, and 36.36% was encountered in the age group 20–29 years. Assessing dental pathology correlated to gender, the results of our study indicate higher percentages of acute pulpitis, acute apical periodontitis, and abscess in males, whereas female patients were diagnosed with pericoronitis, temporomandibular dislocation, and caries. Dental pathology registered in women could indicate a better oral status and more dental care . As a re2 = 23.421, p < 0.0001), while the proportion of patients receiving pulpectomy was higher in 2019 . As pulpectomy is a dental procedure associated with high concentrations in aerosols, the limitation of this procedure can be associated with patients’ and dentists’ fear regarding the spread of COVID-19.The most frequent treatment performed for abscess was endodontic drainage, both in 2020 and in 2019, with no statistically significant differences. The percentage of patients receiving sedative filling for the treatment of acute pulpitis in 2020 was significantly higher than that in 2019 . In 2019, the majority of patients diagnosed with acute periapical periodontitis received endodontic treatment. As the endodontic treatment is also associated with aerosols, the use of this therapeutic procedure was limited.The percentage of patients receiving endodontic drainage for the treatment of acute periapical periodontitis in 2020 was significantly higher than that in 2019 (XThis study demonstrates that the COVID-19 pandemic impacted, besides the economic and social life of population, the use of medical care services. The main cause of attendance to the emergency dental office was acute apical periodontitis and acute pulpitis, whereas dental trauma incidence was low.The results of this study are helpful for predicting future dental needs. In the post-COVID period, people’s requirements for dental care could grow. In light of this, implementing prevention and control measures could be of paramount importance for the oral health status of the population.In the near future, supplementary measures for infection prevention have to be taken in the dental office, which can lead to increased costs for treatment, leading to a change of attendance to dental care services, thus impacting the oral health and the quality of life of the patients. Careful planning and management of dental healthcare are mandatory, in order to adapt to the new conditions.


The results suggested that VR-based rehabilitation is likely to be as effective as conventional rehabilitation for recovering function in a burned hand. VR-based rehabilitation may be considered as a treatment option for patients with burned hands.Hands are the most frequent burn injury sites. Appropriate rehabilitation is essential to ensure good functional recovery. Virtual reality (VR)-based rehabilitation has proven to be beneficial for the functional recovery of the upper extremities. We investigated and compared VR-based rehabilitation with conventional rehabilitation (CON) in patients with burned hands. Fifty-seven patients were randomized into a VR or CON group. Each intervention was applied to the affected hand for four weeks, and clinical and functional variables were evaluated. Hand function was evaluated before intervention and four weeks after intervention using the Jebsen-Taylor hand function test (JTT), Grasp and Pinch Power Test, Purdue Pegboard test (PPT), and Michigan Hand Outcomes Questionnaire (MHQ). The JTT scores for picking up small objects and the MHQ scores for hand function, functional ADL, work, pain, aesthetics, and patient satisfaction were significantly higher in the VR group than in the CON group ( The distal parts of the upper extremities are the most common sites of thermal injury. The hand is one of the three most common joints of scar contracture deformity following a burn injury ,2. Some Appropriate rehabilitation is important to ensure that good functional recovery is achieved ,5. BurneTM  is a VR rehabilitation tool designed for the distal upper extremities [Recent studies have recommended repetitive exercises using virtual reality (VR) for functional recovery from upper extremity disorders ,14 becauremities . VR is aremities . Recentlremities ,18. HoweThe present study was a single-blind, randomized controlled trial. We recruited 57 (54 men and 3 women) patients from the Department of Rehabilitation Medicine at Hangang Sacred Heart Hospital in Korea between June and October 2019. Our study was registered on ClinicalTrials (NCT03865641). The study was registered at the Ethics Committee of the Hangang Sacred Heart Hospital (2014-081). Patients provided written informed consent. All participants’ burn scars had re-epithelialized after split-thickness skin graft (STSG). To evaluate the effectiveness of VR rehabilitation accurately, the comparison was limited to the right hand and wrist. We included patients aged ≥18 years with a deep, partial-thickness (second-degree) burn or a full thickness (third-degree) burn with the involvement of >50% of the body surface area of the dominant right hand, with joint contracture (hand and wrist). In addition, these patients were transferred to the rehabilitation department after acute burn treatment and less than 6 months since the onset of the burn injury . n = 32) or the CON group (n = 34). One patient in the VR group completed 17 sessions before dropping out due to scheduling conflict. Two patients in the CON group were forced to drop out before completing the study, including one who completed 11 sessions before dropping out due to unrelated medical issues and one who completed 18 sessions before dropping out due to a personal scheduling conflict. Three patients in the VR group and three patients in the CON group dropped out of the study because they recovered function in the injured hand after 20 sessions and could return to their daily life; therefore, they did not want to undergo serial evaluations and did not visit the outpatient clinic. Data from these subjects were not included in the analyses. Thus, patients were divided into two groups (28 patients in the VR group and 29 patients in the CON group) , musculoskeletal diseases  involving the burned hand, neurological diseases , preexisting physical and psychologic disability (severe aphasia and cognitive impairment that could influence the intervention), or severe pain impeding hand rehabilitation. Numbers were assigned to 66 burn patients according to the order of admission who satisfied all the aforementioned criteria. A computer program was used to randomly divide them into the VR group (N group) . All patTM  system, which combined the use of an exoskeleton type glove and the VR system  was used to measure grip strength, and the Michigan Hand Outcomes Questionnaire (MHQ)  was usedt-test after testing for normality. Non-parametric data was analyzed using the Mann–Whitney test and the Wilcoxon signed-rank sum test. To examine the pretreatment homogeneity between the VR and CON groups, the Mann–Whitney test was used for age, time to treatment, Grasp and Pinch Power Test, PPT, all areas of the JTT, and all areas of the MHQ, with a significance level of p < 0.05. The changes before and after intervention were compared using the independent t-test for tip pinch strength between groups. The changes before and after intervention were compared using the Mann–Whitney test for all parameters except pinch strength, with a significance level of p < 0.05. The scores after intervention were compared between the two groups using the Mann–Whitney test for grasp strength, lateral pinch strength test, all areas of the PPT, all areas of the MHQ, and all areas of the JTT. As this was the first study to assess the efficacy of the VR-based rehabilitation in patients with burns, power calculation was based on a previous study, which applied VR-based rehabilitation for the distal upper extremity function in patients with stroke [Statistical analysis was performed using SPSS, version 23  Corp., Armonk, NY, USA). Parametric data was analyzed using a paired h stroke . AccordiWithin six months after a burn injury, 57 patients had received rehabilitative therapy. Before the intervention, there were no differences in demographic and clinical characteristics between the patients in the VR and CON groups .p = 0.03, p = 0.002, p = 0.03, respectively)  (p < 0.001 and p = 0.04) (p = 0.01)    . There wctively) . In the  = 0.04) . The sub = 0.01) . There wctively) . There wctively) .p = 0.003 and p = 0.001)   . There w = 0.02)  No patieAfter the intervention, the subtest scores in the JTT  and subscale scores for ADL, work, pain, and satisfaction in the MHQ were significantly higher in the VR group than in the CON group. Minimum clinically important changes for scoring system in the JTT and MHQ have not been established in patients with burns. However, results of the JJT and MHQ showed significantly the improvements in VR group ,21. PartImportantly, significant changes in multiple outcome measures were observed in the VR group after intervention. Jeffery et al. reported that the VR system can be modified to maximize therapeutic benefits such as improving the ROM of the shoulder and elbow joints after burn injury . The tasWe found that VR rehabilitation was effective according to the MHQ scores for ADL and work. Park et al. reported that upper extremity rehabilitation improved hand function in patients, in addition to elbow and forearm improvement . FunctioMoreover, many reports regarding neurorehabilitation have suggested that for functional recovery in the upper and lower extremities, repetitive intervention using VR is helpful and induces neuroplasticity ,30,31,32VR-based rehabilitation may be as effective as conventional hand rehabilitation for improving hand power, hand function, and MHQ scores. Burn survivors with acute hand impairment after STSG were able to successfully use the VR system and had significantly better scores on pain, ADL, work and satisfaction scales on the MHQ than the control group. As a result of this study, VR-based intervention is likely to be a clinically useful rehabilitation tool for patients with burned hands. Furthermore, studies that include hand rehabilitation for fourth-degree burns with severe neuromuscular injuries along with treatment intensity, frequency, and VR-based intervention interval studies are needed.


In 2011, the Chinese government launched a disaster mitigation and preparedness program called the Resettlement of South Shaanxi (RSS). Due to the wide geographical scope and complex interests, the possibility of conflicts was increased during and after resettlement. Efficient risk communication improves the supply of information about risks and meets the risk-related information needs of individuals. Using the risk information seeking and processing (RISP) model, this research applied a structural equation model and survey with a structured questionnaire to study ways to improve risk communication in disaster resettlement. A total of 616 valid questionnaires were provided by study respondents in resettlement sites in Ziyang County, Ankang City, Shaanxi Province. The results indicated the following: (1) the public’s information seeking behavior relies more on village committees and village officials than other channels. Emerging information channels, such as Weibo and WeChat , do not play leading roles in disseminating risk information. (2) There are differences between the information channels used by residents and the channels that residents believe the most. (3) Relevant channel beliefs, information sufficiency, perceived hazard characteristics, and self-efficacy directly influence risk information seeking behavior. However, the capacity to gather information has non-significant direct influences on information seeking behavior. (4) Perceived hazard characteristics and self-efficacy drive risk information seeking behavior in both direct and indirect ways through information sufficiency.  Disaster resettlement is a recovery and preparedness measure for people that cannot live in their original location due to prevailing risks . Due to Communication and interactions inside and outside of communities are critical components of disaster management ,6,7,8. RThis study contributes to disaster resettlement research. Disaster resettlement has been discussed in the literature ,14,15,16This paper has six sections. Following this introduction, The risk information seeking and processing (RISP) model was proposed by Griffin et al. The model focuses on individual information search and processing behavior in a risk environment ,20. The Communication and interaction are critical components of emergency management. Access to information is critical for minimizing damage and casualties in disasters. Using global warming as an example, Kahlor et al. assessed attitudes toward behaviors, perceived behavioral control, and behavioral intent as new additions to the RISP model . That stSeveral studies have found differences in information seeking behavior and channels between different types of disasters. For instance, tornado survivors report being alerted by others ,32, teleMany studies have investigated information seeking behavior based on different disaster types. Research remains fragmented, however, with respect to the specific phases of disasters, from prevention, to preparedness, response, and recovery. Some studies have focused on the disaster preparedness phase  and respBased on the studies above, there are several determinants of information seeking behavior worth investigating. Crucial determinants include individual characteristics , perceived hazard characteristics, information insufficiency, channel beliefs, and information gathering capacity. Researchers also commonly add self-efficacy to the original RISP model. • Relevant Channel BeliefChannel beliefs refer to the degree to which an individual believes in an information channel. It relates to enthusiasm for using the channel, and considers both credibility and usefulness. The more people trust a channel, the more often they will use it when needed. Huurne and Gutteling found that channel beliefs were positively correlated with the willingness to search for information . The str• Information SufficiencyInformation sufficiency, also known as information needs, plays a central role in risk communication . This va• Perceived Hazard CharacteristicsPerceived hazard characteristics refer to the perception level of the risks themselves. This variable emphasizes the individual’s perception level of objective phenomena, and the individual’s direct perception and subjective risk judgment . The stu• Self-EfficacyRisk communication researchers have stressed the importance of considering one’s self-efficacy, or the belief that one can understand and execute certain actions to protect oneself from harm in the face of disasters. Kievik and Gutteling defined self-efficacy as the ability to successfully address a threat by seeking information that will help the person take adequate self-protective measures. They also proposed that self-efficacy is a trigger that can stimulate the public’s motivation to seek risk information . Kellens• Information-Gathering CapacityWhen an individual starts to learn more about a risk, information-gathering capacities are required ,11. A peBased on the determinants and their relationships discussed above, Hypothesis 1a (H1a).Relevant channel beliefs positively relate to risk information seeking behavior;Hypothesis 1b (H1b).Information sufficiency negatively relates to risk information seeking behavior;Hypothesis 1c (H1c).Information-gathering capacity positively relates to risk information seeking behavior;Hypothesis 1d (H1d).Perceived hazard characteristics positively relate to risk information seeking behavior;Hypothesis 1e (H1e).Self-efficacy negatively relates to risk information seeking behavior;Hypothesis 2a (H2a).Perceived hazard characteristics negatively relate to information sufficiency;Hypothesis 2b (H2b).Self-efficacy positively relates to information sufficiency;Hypothesis 3a (H3a).Information sufficiency mediates the relationship between perceived hazard characteristics and risk information seeking behavior (H1d);Hypothesis 3b (H3b).Information sufficiency mediates the relationship between self-efficacy and risk information seeking behavior (H1e).China has the largest population in the world, a fragile ecological environment, and frequent natural hazards . As such, it faces the arduous task of disaster mitigation. In addition to conventional measures, such as reservoir and dam construction, the Chinese government launched a disaster mitigation and preparedness program in 2011 called the Resettlement of South Shaanxi (RSS), which has been the largest disaster resettlement in the history of the country. The state requires governments at all levels to ensure that relocated people are actually willing to move. In addition, the state provides support policies and commercial loans, and encourages people to make flexible choices with respect to the time and method of relocation. Some studies ,52,53 haThe New York Times in the United States reported some problems, such as increased unemployment, as a result of resettlement. After losing farmland, peasants usually need more resources to maintain their family livelihoods after resettlement [However, the RSS remains controversial. ttlement . It is nData were collected using surveys from resettlement area respondents between June and August 2019. Respondents from four resettlement sites of Ziyang County, Ankang City, Shaanxi Province provided their practical feedback in the form of survey responses. Ziyang County has a high poverty level in China, and is one of the largest resettled areas in the RSS. Since the RSS was introduced in 2011, 37,200 households and 129,000 people in Ziyang county have moved from inhospitable and disaster-prone areas. By 2018, Ziyang county had completed the relocation of 26,817 households and 93,226 people, and the employment resettlement rate reached 80%. However, residents perceive different degrees of the probability of risk and its potential consequences in the post-disaster resettlement process (both disaster risks and livelihood risks). This has led to social conflicts in the county ,56. The The anonymous questionnaire consisted of two parts. The first part collected information about the respondents’ gender, age, education level, annual household income, etc. The second part asked questions about information seeking behavior and its influencing factors in the RSS. Questionnaires were collected from four resettlement sites in Ziyang County between June and August 2019: Songba (Site A), Jingjia (Site B), Lanjiaping (Site C), and Xiangyang (Site D). These four sites have many residents, most of whom are long-term residents with an average age distribution, achieving broad participant coverage. In addition, these sites have well-constructed public facilities and community management agencies.First, to verify the validity of the questionnaire, we first conducted field research. A total of 200 questionnaires were distributed in the early stage for pre-investigation. The questionnaire was subsequently revised and a total of 800 questionnaires were distributed using the quota sample method. A total of 682 questionnaires were completed, resulting in a response rate of 85.25%. There were 258 questionnaires from Site A, 100 from Site B, 202 from Site C, and 122 from Site D. After screening the returned surveys, 616 valid questionnaires remained. There were two possible reasons for the high response rate. The first reason was the recent flood and geological disasters (such as the Wenchuan earthquake in 2008 and Jiuzhaigou earthquake in 2017), making the survey highly relevant to residents’ daily lives. The second reason was that during the survey, the collected questionnaires were reviewed in real time. If any blank items were found, the respondents were asked to fill in the blank items.The statistical analysis was conducted using the following four steps: (1) a frequency analysis was used to show the characteristics of respondents. (2) An exploratory factor analysis (EFA) was used to extract the dimensions, and then a Kaiser–Mayer–Olkin (KMO) test was implemented to test whether the aforementioned EFA was appropriate. Then, the reliability and validity were evaluated by calculating Cronbach’s α coefficient. (3) Confirmatory factor analysis (CFA) was analyzed to assess the stability of the relationship between the structural factors and EFA measurement items, and to identify the presence of cross validity. (4) A structural equation model (SEM) was used to test the proposed conceptual model on disaster resettlement risk information seeking behavior. Of the survey respondents, there was a higher proportion of women than men, with women accounting for 60.1% of the sample. In the resettlement area, most men go to work, so there were slightly more women staying in the resettlement sites to respond to the survey. Among the survey respondents, participants aged 31 and above accounted for 77.6% of the total. This is because most young people go to work, leaving mainly middle-aged and elderly people as the available respondents. Approximately 86.6% of the participants had a junior high school education or below, and 57.1% of respondents earned less than RMB 8000 (approximately USD 1128) per family per year.After EFA was used to extract the dimensions, the results of the KMO test and Bartlett’s test of sphericity indicated that KMO almost exceeded 0.70 see . This inp < 0.001, exceeding the threshold value of 0.50) [of 0.50) . This inAfter the CFA, the structural model was assessed using model fit measurements. The model fit was at an acceptable level see . Table 5For the first research goal, Respondents reported significant differences in their beliefs about the different information channels. The mean values of the seven channels, from the highest to the lowest, for news broadcasts, relatives and family, village committees and officials, friends and neighbors, government officials, resettlement house developers and local entrepreneurs, and social model tools, were 3.84, 3.69, 3.67, 3.64, 3.52, 3.23, and 2.59, respectively. As such, news broadcasting was the channel most trusted by respondents.In terms of information sufficiency, the highest one related to the pros and cons of resettlement sites. The scope of resettlement ranked second. However, based on the absolute value of the mean value, respondents reported that information about the three categories of IS1 (relates to the scope of resettlement and relocation information), IS2 (relates to the pros and cons of each resettlement site), and IS3 (relates to the supporting policies and measures related to disaster resettlement) is all insufficient. This means that respondents perceive not knowing enough about the information related to the RSS, and perceive the possible harm, risk, and future impacts of RSS as unclear.In the information-gathering capacity, the order from high to low, is the capacity to obtain information (IGC1), the capacity to understand information (IGC2), and the capacity to evaluate information (IGC3). Since the mean values of all items are greater than 3, respondents had a high degree of recognition for their information-gathering capacities.Perceived hazard characteristics emphasize an individual’s perception level of risks. As For self-efficacy, when the relevant policies and measures of RSS specifically affected respondents (often in a negative way that causes problems), most respondents reported not having the professional knowledge, financial ability, or time to solve the problems they may face. This is reflected in the relatively low mean values of SE1, SE2, and SE3, at 2.17, 2.36, and 2.54, respectively.p < 0.05. Consistent with previous studies [p < 0.05. The more the public grasped the information, the less active they were in seeking information in the RSS process. Perceived hazard characteristics had a significantly positive effect on public information seeking behavior (H1d), with a standardized coefficient of 0.64, p < 0.001. The higher the public’s perception of the possible risks brought by RSS was, the more likely they were to conduct information seeking behavior to avoid risks. Self-efficacy had a significantly positive effect on information seeking behavior in the RSS, which is consistent with the results of Bronstein et al. (H1e), with a standardized coefficient of −0.15, p < 0.001. The higher the self-efficacy of the public was, the less active the information seeking behavior was.For the second research goal, hypotheses H1a, H1b, H1c, H1d, and H1e were tested using the SEM.  studies , the higHowever, information-gathering capacity had non-significant direct influences on public information seeking behavior in the RSS (H1c), with a standardized coefficient of −0.05. These direct relationships have not been consistently found in previous research. p < 0.001; information sufficiency significantly negatively influenced public information seeking behavior (H1b), with a standardized coefficient of −0.24, p < 0.05; and perceived hazard characteristics had a significantly positive effect on public information seeking behavior (H1d), with a standardized coefficient of 0.64, p < 0.001. Therefore, information sufficiency had a mediating role between perceived hazard characteristics and information seeking behaviors, supporting H3a. Additionally, self-efficacy significantly positively affected information sufficiency (H2b), with a standardized coefficient of 0.39, p < 0.001; information sufficiency significantly negatively influenced public information seeking behavior (H1b), with a standardized coefficient of −0.24, p < 0.05; and self-efficacy significantly positively affected information seeking behavior (H1e). As such, information sufficiency was found to play a mediating role between self-efficacy and information eeking behaviors, supporting H3b.This study also explored the mediating effect of information sufficiency. First, perceived hazard characteristics had a significantly negative effect on information sufficiency (H2a), with a standardized coefficient of −0.28, This study focused on the public’s information seeking behavior in the context of resettlement in South Shaanxi, China. Based on previous information seeking models, the study tested empirical relationships between information seeking behavior and other determinants. The mediating role of information sufficiency has also been examined in the information seeking process. A total of 616 valid surveys were collected from respondents in Ziyang County in Ankang City, China. A structural equation model was used to statistically test several hypotheses, reflecting the different relationships of the hypothesized model in Firstly, there is currently one primary channel to support resident information seeking in the RSS, which mainly relies on the village committees and officials. Moreover, residents invest significantly greater effort compared to other methods to seek information through this channel. ICTs, such as Weibo and WeChat, are underutilized. The main channel for information seeking, however, differs from the level of trust associated with the channel. In addition, there is a mismatch between the primary channel and the most trusted channel associated with information seeking behavior. The main channel for information is village committees and officials; however, residents trust news broadcasts most. This deviation often significantly affects the efficiency of information dissemination and the reliability of information content, hindering the effective circulation of RSS information. Secondly, relevant channel beliefs, information sufficiency, perceived hazard characteristics, and self-efficacy significantly directly influence risk information seeking behavior in the RSS: (1) relevant channel beliefs significantly positively impact information seeking behavior. According to the specific situation of the RSS, the public has a higher level of trust in news broadcasts, relatives and family, and village committees and officials. The study found the public is more willing to obtain RSS-related information using the above traditional information channels and is willing to invest time, money, and effort to obtain that information. In the process of visiting residents, we found that this result was mainly due to the low acceptance and utilization rate of modern information channels and the insufficiency of network infrastructure in rural areas. (2) Information sufficiency significantly negatively influences public information seeking behaviors in the RSS. This result aligns with previous research. The more thoroughly the public understands the content and possible problems with RSS-related policies and measures, and the more fully the relevant background information is obtained, the fewer efforts they will make to seek information. (3) Perceived hazard characteristics significantly positively impact public information seeking behavior. In implementing RSS-related policies and measures, the public will actively search for possible risks or harms caused by the RSS to avoid losses caused by a lack of information. Moreover, the stronger the sense of crisis and insecurity is, the more active and positive information seeking behavior is. This is embodied in the increasing frequency of searching for and exploring policy supporting measures, compensation standards, and future planning of the RSS. (4) Self-efficacy has a significantly positive effect on information seeking behavior in the RSS. The stronger the public’s sense of control over the possible risks brought by the RSS is, and the more confident they are in dealing with the risks, the lower the frequency of information seeking behavior, and the less effort they will invest in information seeking behavior.However, information-gathering capacity has non-significant direct influences on information seeking behavior of the RSS which have not been consistently found in previous research. There are two possible reasons for this: (1) previous studies mainly focused on potential risk settings. Ziyang County in the RSS was selected as the focus of the study because it is located in a plate fault zone, and has experienced numerous disasters, including earthquakes, floods, and mudslides. Local governments and relevant departments have made continuous efforts to communicate disaster information and emergency preparedness plans to local residents through different channels. The rich information environment has led some residents to feel they have enough knowledge about disaster avoidance and resettlement. This leads to a reduced need for information and a cessation of information seeking behavior. This may explain why information-gathering capacity has a non-significant direct influence on the public information seeking behavior of the RSS. (2) With the increase in the frequency of earthquakes, floods, and mudslides and the change of resettlement policies, residents’ attitudes towards RSS have evolved from initial nervousness, worry, and anxiety to numbness and less attention. This has led to a decrease in information seeking activities.Lastly, in the exploration of a mediating effect, perceived hazard characteristics and self-efficacy drive risk information seeking behavior in both direct and indirect ways through information sufficiency. In the RSS, respondents reported that the higher the level of perceived unknown risks and uncertainties is, the lower the level of information they have about RSS policies and future livelihood restoration measures. At the same time, under the threat of unknown risks and uncertainties, people are motivated to actively search for information, such as resettlement planning and subsidy standards. Additionally, when the respondents’ perceptions of the unknown risk of resettlement is certain, and if the respondents believe they can control the negative impact of the unknown risk to themselves and reasonably resolve it, then their confidence level is relatively high. This reduces their efforts to conduct information seeking behavior. Therefore, in contrast to other contexts ,62, in tSeveral implications emerge from this study: (1) post-disaster resettlement is an important step in improving the resilience of communities and regions. Resettlement protects residents from future disasters, including earthquakes and floods, and engages the sustainable development of residents’ livelihoods. Research results indicated that information sufficiency played a noteworthy mediating role in the RSS process. Therefore, disaster resettlement should pay more attention to information disclosure and risk communication during the process. (2) The difference between the information channels used by residents, and the channels most trusted by residents, was highlighted. This difference may greatly affect the efficiency of information dissemination and the reliability of information content in disaster resettlement. In the future, risk managers can make timely adjustments to information disclosure channels, based on the characteristics of the different stages of disaster management and risk governance. For example, in the emergency preparedness stage, information channels with large coverage and low costs can be used, such as village committee notices and posters and emergency training and lectures. During the emergency response stage, channels with strong persistence and high resident trust can be adopted. This includes news broadcasts, household notifications, and visits. In the disaster resettlement and recovery stage, sustainable and diversified information dissemination channels should be adopted, such as enhancing the use of ICT platforms. This would include paying attention to classification guidance, based on different residents’ information-gathering capacities, willingness, and preferences in choosing the most suitable channels.Additionally, we recommend that communication strategies and content should also be focused on during the disaster resettlement process. In terms of communication strategies, as most resettlement occurs in rural areas, residents have a low level of knowledge and poor livelihoods. This greatly affects the ability to understand policy content, compensation schemes, and future planning. This, in turn, causes cognitive gaps and potential risks between the government and the public. Therefore, in the disaster resettlement process, especially in rural areas, risk managers should avoid using obscure official jargon and encourage mass media to promote more user-friendly images, videos, and other information via ICT platforms based on playing a leading role in traditional information channels, like news broadcasts. In terms of communication content, based on the results in Like all studies, this research had some limitations, which should be considered when reviewing its conclusions and implications: (1) resettlements in Shaanxi Province involve Ankang City, Hanzhong City, and Shangluo City in the south of Shaanxi Province, and some regions in the north of Shaanxi Province. This study included only respondents in Ankang City; no other regions were involved. Future studies should consider other areas. (2) The study involved respondents in Ankang City in August 2019, but the estimated duration of the RSS is 10 years. Therefore, information seeking behavior by immigrant respondents has not been assessed during different stages of RSS. This is an opportunity for future studies. Despite these limitations, this study is important because it enriches the risk information seeking behavior and risk communication research in the context of disaster resettlement.


Nonspecific chronic low back pain (NCLBP) became a public health and economic problem. Acupoint injection was used widely for patients with NCLBP. However, there were inconsistent results on the efficacy for these people. Therefore, this review was performed to systematically assess the efficacy and safety of acupoint injection. Cochrane Handbook for Systematic Reviews of Interventions. Data extraction was performed by one reviewer and verified by another reviewer. Any disagreement was addressed via consulting with a third reviewer in the abovementioned processes. All procedures were performed according to the Cochrane Handbook for Systematic Reviews of Interventions.  The literature sources were collected via EMBASE, Medline, CENTRAL, CINAHL, CNKI, VIP, Wanfang, and Sino-Med Database from their inception to October 13, 2019. Endnote X7, widely used document management software, was used to manage and screen the literature sources. Each record was screened according to the predetermined inclusion criteria by two review authors independently. Quality assessment tool, “Risk of table,” was used to assess the quality of the included studies according to the recommendation of the P=0.18, random-effect model). When assessing the effectiveness of acupoint injection therapy, the results indicated that acupoint injection can improve the effective rate for nonspecific chronic low back pain .  This review included 13 studies involving 1381 patients with NCLBP. Quantitative analysis results indicated that there is no sufficient evidence that acupoint injection can improve the pain of patients with low back pain based on two trails: Visual Analogue Scale  −3.30 to 0.64,  There is insufficient evidence to indicate that acupoint injection therapy could improve the pain for patients with NCLBP. However, the level of evidence was downgraded to “very low quality” because of the poor methodological quality and clinical heterogeneity. The results should be interpreted with caution. Higher quality RCTs with more appropriate comparison, more objective outcome instruments, and adequate follow-up periods are necessary to assess the efficacy of acupoint injection for NCLBP. The PROSPERO Research registration identifying number is CRD42019119158. The low back pain (LBP) refers to pain occurring between the 12th rib and the inferior gluteal fold . Most paChronic low back pain (CLBP) is defined as LBP over 3 months. The main symptom of CLBP is pain, and only 42% of patients were pain free after one year . The cauMany interventions were used to improve the pain of CLBP, including surgery, drugs, and exercise . HoweverAcupuncture has been used to treat CLBP for thousands of years , 14 and https://www.crd.york.ac.uk/PROSPERO/), and the protocol of this study was published previously [The Research registration number of this study is CRD42019119158 (eviously . For theembase.com), Cochrane Central Register of Controlled Trials (CENTRAL) of Cochrane Library, and CINAHL via EBSCOhost. The four Chinese databases are the China National Knowledge Infrastructure (CNKI) database, Wanfang Database, Chinese Science and Technology Periodical (VIP) Database, and Sino-Med Database. The English terms such as “acupuncture point injection,” “acupoint injection,” “pharmacoacupuncture,” “hydroacupuncture,” “pharmacoacupuncture,” “LBP,” “low back pain,” and “chronic low back pain” were used individually or combined in English databases. The terms including “shu xue zhu she (acupoint injection),” “shui zhen (acupoint injection),” and “xue wei zhu she (acupoint injection)” were used in Chinese databases. The search strategy for Medline via PubMed is shown in We searched eight online databases from their inception until October 13, 2019, with no language restrictions, including four English databases and four Chinese databases. The four English databases are Medline (PubMed), EMBASE (The studies were screened according to the inclusion criteria as follows: (1) patients: ≥18 years of age and suffering from nonspecific CLBP (persists for longer than 12 weeks); (2) intervention: acupuncture point injection therapy without limitation in drug and acupuncture point; (3) comparison: placebo-controlled or other nonacupoint injection therapy; (4) outcomes: the outcomes reported were not limited. The pain intensity was considered as the primary outcome such as the visual analogue scale (VAS) and proportion of pain-free patients; and (5) publication type: randomized controlled trials (RCTs). Exclusion was defined as follows: (1) patients: without nonspecific chronic low back pain; (2) intervention: nonacupoint injection was used, or acupoint injection was one part of a treatment package; (3) comparison: just different acupoint injection intervention methods, or treatment package in which the acupoint injection was used as one part of package acupoint injection; and (4) publication type: quasi-RCTs, non-RCTs such as case reports, systematic reviews, and letters to editors.EndNote X7, widely used literature management software, was used to manage records. The duplicate records were removed according to the title, author, journal, and publication date. After that, two reviewer authors screened the records independently. The irrelevant literature was excluded according to the inclusion criteria and exclusion criteria via browsing the title and abstract of the article. Two independent review authors evaluate whether the study can be included according to predetermined selection criteria via reading the full text. In order to extract data accuracy and reliability, only full-text literature in English or Chinese were included in this study. The original author was contacted to obtain additional information when it is needed to make a judgment. Any inconsistencies were resolved with a third reviewer via discussion and consultation. The details of literature screening have been reported using the PRISMA flow diagram  accordinA predesigned, verified, and formatted table was used to extract information. The extracted information includes five parts for each study. The information of the title, author, journal, and publishing year was extracted as basic information. The characteristics of participants of each study, including gender, age, inclusion, and exclusion criteria, were collected as the second part. The details of intervention used in the experimental and control groups such as the frequency, intervention time, follow-up period, injection content, dosage, and volume of injection at each point were extracted as the third part. The design information of each study, including the random sequence generation, randomization method, allocation concealment, blinding of participants and personnel, and blinding of outcome assessment was also extracted. The outcomes reported in each study such as outcome indicators, assessment tools, adverse events, and dropouts were extracted as the fifth part. The extraction of information was performed by two reviewers independently. One of them extracted the data and another checked the data. For the missing data, we have contacted the original author. For the studies that had more than two intervention groups, the data of intervention groups related to this review were extracted. For the studies that have two or more experimental groups, we combined the groups to create a single pairwise comparison.The Cochrane Collaboration's tool, “Risk of bias,” was used to assess the quality of included studies by two reviewers independently . Review For the missing data that were not reported in the manuscript, the original author was contacted to request additional data via e-mail. If the acquisition fails, only the available information and data were analyzed.P < 0.1) was used to assess the statistical heterogeneity, and I2 statistic was used to be quantified. If the I2 value is greater than 75%, the significant heterogeneity between the included studies was demonstrated according to the Cochrane Handbook for Systematic Reviews of Interventions [Data analysis was performed by the Cochrane Review Manager (RevMan 5.3). The results were shown using mean difference (MD) with 95% confidence intervals (95% CIs) for continuous data. The results were shown using Odds Ratio (OR) with 95% CI for the enumeration data. The pooled effect was estimated using the fixed-effect model when the results indicate there is no significant heterogeneity between the included studies. If not, the pooled effect was estimated using the random-effect model. The chi-square test  system, which rates the quality as very low, low, moderate, or high levels .A total of 7,479 records were obtained from online databases in this study. Among them, 724 records were deleted because they were identified as duplicate records. Other 6755 records were excluded after screening the abstracts and titles by two reviewers. Finally, twelve full texts were included for this review according to our inclusion/exclusion criteria. The details of the literature screening are described in The points of acupoint used in each trial were diverse. The number of selected acupoints varies from 3 to 9. The Ashi acupuncture point in the low back was selected as the site of operation in nine of the twelve studies , 35, 36.Cervus and Cucumis Polypeptide injection [The substance used for acupoint injection was diverse from each other. A single substance or a mixture of substances was used in the studies. Three trials used single substance including Angelica injection , 36, Dannjection . Each acnjection , once a njection , 26, 36,njection , once a njection , 21, thenjection , the nexnjection , twice anjection , and evenjection . The intnjection , 36, acunjection , 26, 35,njection , and planjection .The visual analogue scale (VAS) was used to assess the effect of acupoint injection for nonspecific chronic low back pain in three trials , 25, 27.The risk of bias summary is shown in n = 243, MD = −1.33, 95% CI −3.30 to 0.64, P=0.18, the random-effect model), with a substantial heterogeneity (I2 = 98%) as shown in Three of twelve trials reported the effects of acupoint injection in terms of pain for patients with NCLBP using the VAS , 25, 27,The effectiveness of acupoint injection in terms of subjective effective rate for patients with NCLBP.n = 1261, OR = 3.64, 95% CI 2.54 to 5.21, P < 0.00001, the fixed-effect model), with homogeneity (I2 = 0%) as shown in Eleven trials reported the effect of acupoint injection therapy using a subjective effective rate for NCLBP , 35, 36.The number and reasons for dropout were reported in one study . The intThe adverse reactions were reported in two trials which reported that skin flair, edema, and skin rash have occurred in the experimental group and skin rash, headache, hand-foot tingling occurred in the placebo control group , 27. TheThe publication bias was performed for the subjective effective rate reported by eleven trials in this review . AlthougThe quality of evidence for outcomes was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, which rates the quality as very low, low, moderate, or high levels . For thiThis study assessed the efficacy of acupoint injection therapy on pain for patients with NCLBP collating evidence from RCTs. A total of 12 RCTs were included in this review involving 1381 patients. Based on our meta-analysis, there was not enough evidence to indicate that acupoint injection can improve pain for patients with nonspecific CLBP. However, acupuncture point injection therapy can improve the subjective effective rate for patients with nonspecific CLBP. The adverse reactions include skin flair, edema, and skin rash. All adverse reactions disappeared after the study without the use of antihistamines or medical interventions.There was no reason to upgrade the strength of evidence. However, due to the limitations in the design and implementation inherent imprecision  and publication bias (there were less than ten studies reported the primary outcome), the level of evidence was downgraded. Finally, the quality of the evidence was downgraded to “very low quality” for the primary outcomes of pain.This review and meta-analysis was performed according to the Cochrane Handbook for Systematic Reviews of Intervention. The formulation of the search strategy for each online database is helpful for the comprehensiveness and extensiveness of literature collection. The study protocol predetermined was helpful to select studies, extract data, and synthesize data. According to the study protocol, two independent review authors complete the literature screening, data extraction, quality assessment of the included trials. When encountering a contradiction, we discuss with a third reviewer to make a final decision. These methods reduced bias and transcription errors.1, Vitamin B12, Triamcinolone Acetonide Acetate, and Cervus and Cucumis Polypeptide injection were used in different trials. The type of acupuncture point injection was different between trials including single acupoint injection and combined with acupuncture, electroacupuncture, or functional training. All these factors make it difficult to confirm a distinct relationship between acupuncture point injection and the improvement of pain. Although eleven of the included twelve trials reported the effectiveness of acupoint injection for the patients with NCLBP, the subjective instrument used in trials challenged the reliability and validity of the results. Only full-text records in English or Chinese were included, and unpublished materials were not retrieved in this study, which will also bring limitations to the results.At the same time, there are some limitations we should note. The different interventions, different acupuncture points, intervention frequency, and duration lead to the high clinical heterogeneity between included studies. Another source of clinical heterogeneity is the diversification of the substance injected into points. The Angelica injection, Lidocaine injection, Oxygen-ozone, Tong xi tong, Vitamin BThere is no sufficient evidence to indicate that acupuncture point injection can improve the pain of nonspecific CLBP. Acupuncture can improve the subjective effective rate for patients with nonspecific CLBP. But, the results have been challenged due to the subjective instruments used in the trials.In future studies, the following issues need to be noted. To explore the optimal intervention intensity, frequency, and dosage of substances for acupoint injection may be the future research direction. The intervention of the control group should be set according to the purpose of research. For the studies whose aim is to demonstrate the effect of the injected drugs, the control groups should be placebo control. For the studies whose aim is to demonstrate the effect of the acupuncture points, the control groups should be nonacupuncture point control. The selection of instruments to assess the clinical effect of acupoint injection therapy is important. Assessment tools that are more objective and sensitive should be used in future studies. The long-term outcomes should be of concern, and other outcomes such as quality of life and recurrence of low back pain also should be of concern. The factors that influence the effects such as profession and daily activities, should be considered in future trials. Finally, and most importantly, the CONSORT guidelines should be followed to report the trials to allow a better evaluation of the methodological quality. Higher quality RCTs with more appropriate comparison, more objective outcome instruments, and adequate follow-up periods are necessary to assess the efficacy of acupoint injection for NCLBP.In conclusion, there is no sufficient evidence to indicate that acupuncture point injection can improve pain for patients with nonspecific CLBP using the VAS. The acupuncture point injection may have a positive effect for the subjective effective rate. The adverse events reported included skin flair, edema, and skin rash. These adverse events disappeared spontaneously without intervention. However, due to the differences in the acupoints, drugs, injection doses, frequencies, durations of acupuncture point injection, and the poor quality of the included studies, caution is needed when interpreting these results. Higher quality RCTs with more appropriate comparison, more objective outcome instruments, and adequate follow-up periods are necessary to assess the efficacy of acupoint injection for NCLBP.


Candida albicans was found in samples collected from 36 patients, without any drug-resistant strains. Age (P = 0.018), malignancy , cigarette smoking , and the use of antibiotics  or immunosuppressants  were independently associated with esophageal candidiasis. Fluconazole had a better curative effect than nystatin  or simple observation . In conclusion, fungal esophagitis primarily affects men and elderly individuals; it develops in the setting of malignancy, smoking, and certain previous medication use. Candida albicans is the most common pathogen and is sensitive to antifungal agents. Fluconazole has a good therapeutic effect.Fungal esophagitis is a common infectious disease, although the pathogenic clinical characteristics remain incompletely clear, especially in South China. The goal of this study was to investigate the pathogenic clinical characteristics of fungal esophagitis and the efficacy of different therapeutic strategies at a tertiary hospital in South China. A retrospective study was conducted from January 2007 to December 2017. Data from 113,390 patients who were treated in the endoscopic unit were retrieved and analyzed. To further understand the pathogen and risk factors for fungal esophagitis, we performed a case-control analysis of 101 patients and 202 controls. Of the 113,390 patients, 932 (0.82%) were positive. The annual detection rate ranged from 0.345% to 1.106%, showing an initially increasing and subsequently decreasing trend. The patients' median age was 49 years (range from 8 to 85), and most were men .  Fungal esophagitis (FE) is an infectious disease caused by fungi adhering to and invading the epithelial cells of the esophagus . As a reTherefore, in the present study, we report the results of a large, endoscopy-based, retrospective study and a case-control study aimed at investigating the epidemiology, clinical features, therapeutic interventions, and outcomes associated with FE.The study was approved by the ethics committee of the Third Affiliated Hospital of Sun Yat-sen University and was in accordance with the later amendments of the 1964 Helsinki Declaration. Before the case-control study began, we explained the purpose of the analysis to the FE patients in person or over the telephone and asked for their permission to use their physical data; all patients signed a consent form. Patients who refused were excluded from the study. Informed consent was exempted by the ethics committee of the Third Affiliated Hospital of Sun Yat-sen University for the retrospective study.The general information and endoscopic diagnosis of 113,390 patients treated in the endoscopy unit between January 2007 and December 2017 in the Third Affiliated Hospital of Sun Yat-sen University were reviewed. Among them, 932 patients were diagnosed with FE. General information such as age, sex, and therapy strategy, as well as therapeutic efficacy, was collected and confirmed by medical records.To further understand the pathogen and risk factors for FE, a case-control analysis was conducted from August 2018 to February 2019. Whenever FE was diagnosed, two other participants whose numbers were next to the FE patient were randomly checked simultaneously; these participants were defined as controls. General information such as the age, sex, and clinical data of the patients and controls was collected through questionnaires. Finally, 101 FE patients and 202 controls were enrolled after 9 patients and 18 controls were excluded for refusing or failing to complete the questionnaires. Each subject provided informed consent for participation in the study, and the research protocol was approved by the ethics committee of the Third Affiliated Hospital of Sun Yat-sen University.The diagnosis of FE was made if white Candida plaques in the esophagus, as detected by endoscopy, could not be washed away, and fungal constituents, such as pseudohyphae or spores, were identified , 12. TheWe obtained clinical data through a questionnaire that included questions about symptoms; lifestyle habits, such as cigarette smoking; history of medication use ; and history of chronic diseases, specifically HIV, diabetes, cirrhosis, and malignant tumors. Overall, 101 FE patients and 202 controls completed the questionnaires in person or over the telephone.The use of any PPI at a standard dose for at least 3 days was considered positive PPI use . SimilarSamples of white esophageal plaques were collected from 55 FE patients; the samples underwent fungal culture and type identification. The antifungal sensitivity of yeast pathogens was determined. At least two samples from every FE patient were taken with a disposable cytology brush  for analysis. The specimens were transferred to two Sabouraud glucose agar plates  and incubated at 28°C and 35°C simultaneously. Then, we identified Candida, filamentous or diphasic fungi after 24, 48, and 72 hours, respectively, according to the color and shape of the colony on the agar. When Candida was identified, the colony was transplanted to CHROMagar  to further confirm the subtype, as different Candida strains display different colors. The Candida colony was put into 0.85% saline, and an antimicrobial sensitivity test was performed with the ATB FUNGUS 3 method .P values <0.05 were considered statistically significant. All analyses were conducted with the SPSS 20.0 software package .The quantitative variable is presented as the median. For the comparison of qualitative data, such as the detection rate and clinical manifestations of FE, chi-square tests were performed. To analyze the associations, the Spearman rank correlation coefficient was calculated for ordinal variables, including the age group in the exploration of risk factors and the age stratification, initial disease severity, and recheck time period in the evaluation of therapeutic efficacy. For the multivariable analysis, a multiple logistic regression model was used to identify the different factors contributing to FE and therapeutic efficacy. The odds ratio (OR) and 95% CI were estimated. Two-tailed vs. 2010~2013: χ2 = 6.478, P = 0.011; 2010~2013 vs. 2014~2017: χ2 = 12.727, P < 0.001) . The median age of FE patients was 49 years old (range from 8 to 85). Among the different age groups, the detection rates varied, ranging from 0.55% to 1.25% . Similar to other infectious diseases, elderly individuals were more susceptible to FE than young individuals. The detection rate in people over 60 years old was higher than those in the age groups of 31~40 and 41~50 years old, while it was lowest in the group under 30 years old  . Regardiears old .vs. controls: χ2 = 6.48, P = 0.012), especially older males . Regarding comorbidities, malignant tumor was more frequent in the FE patients than in the controls. Other comorbidities, such as HBV, cirrhosis, high blood pressure, and diabetes, were observed equally in both groups. Endoscopic comorbidities such as reflux esophagitis, bile reflux, esophageal varices, and esophageal polyps or papillomas were common. Among them, only esophageal polyps or papillomas were significantly different between the FE patients and controls; they were usually more common in the FE group.In the case-control study including 101 FE patients and 202 controls, most of the FE patients were male (up to 70%) , malignancy , cigarette smoking , and the use of antibiotics  or immunosuppressants  independently contributed to esophageal candidiasis. Esophageal polyps or papillomas  and a foreign sensation when swallowing were also associated with the disease   .Candida albicans was the causative agent for all 36 microbiologically confirmed cases. Specimen susceptibility testing against antifungal agents was performed. All of the specimens were sensitive to 5-flurocytosine, amphotericin B, fluconazole, itraconazole, and voriconazole.Samples of white esophageal plaques were collected from 55 FE patients from August to December 2018; the samples were subjected to fungal culture. P = 0.026). After the modification of this factor, we found that fluconazole had a better curative effect than nystatin  or simple observation . No significant difference was found between the nystatin and observation groups (P = 0.125)  .Little information about FE trends in China has been available in recent years. Here, we found that, over an almost 10-year period from 2007 to 2017, the detection rate of FE was 0.82%, and the prevalence significantly increased. The highest prevalence occurred from 2010 to 2013 but decreased in the last 4 years. The FE prevalence in immunocompetent individuals has been reported 0.3-8.7% , which iIn this study, we found that elderly individuals accounted for a high proportion of FE patients. Increasing age is a risk factor for the onset of the disease, as well as an unfavorable factor for treatment. This may be caused by factors such as declining epithelial cell immunity in elderly people. Current research has confirmed that with increasing age, the number of T cells and B cells in the human body decreases, the antigen presentation ability of dendritic cells decreases, and both innate immunity and acquired immune function decrease , 17, 18.In our study, the proportion of patients who had dysphagia or foreign body sensation, which have been previously reported as typical presenting symptoms of FE, was significantly higher in the FE patient group than in the control group. Epigastric pain was more common in the control group than in the FE patient group. This is not surprising since epigastric pain is the most common complaint leading to endoscopy. For comorbidities, we found that malignant tumors were more frequent in FE patients than in control patients, while HBV, cirrhosis, high blood pressure, and diabetes were found equally in both groups. Thus far, there is concern that malignant tumors or chemotherapy will lead to immune suppression, resulting in Candida infection . Additioμl, has been consistently demonstrated μl, has bnstrated –27 due tnstrated , 29. In nstrated . HoweverCandida albicans [Notably, cigarette smoking was also a risk factor for FE in the multivariate analysis. To date, smoking has been demonstrated to disrupt the proliferation and transformation of immune cells and downregulate the secretion of cytokines, thereby inhibiting innate and adaptive immunity. This enhances the pathological inflammatory response and inhibits normal anti-infection immunity . Abdelhaalbicans , 32.Candida albicans was the causative agent, and all the specimens were sensitive to antifungal agents.The comparison of different therapeutic strategies showed that fluconazole had a particularly positive effect on improving the esophageal appearance, while nystatin was also effective. Fluconazole at a dosage of 200 to 400 mg/d for 7 to 14 days is recommended for fungal infections by the guidelines in China, the United States, and Taiwan , 33–35. The study has the following limitations. In the retrospective case-control study, the information we collected was inevitably influenced by patients' unclear memory, tending to increase the risk of recall bias. In regard to the treatment effect evaluation, only patients with completed therapeutic information were included, resulting in the data loss of others who received therapy elsewhere or without reevaluation, likely increasing the risk of selection bias. As a study in a single-center, these results might elaborate only a single aspect of FE, and a well-designed multicenter study would be helpful to better understand this issue.Candida albicans was the causative pathogen in patients with FE in South China, without apparent drug resistance. “Dysphagia” and “foreign body sensation” were the most common symptoms and had a certain suggestive effect for this disease. Increased age, smoking, and the use of antibiotics, corticosteroids, or immunosuppressive agents were independent risk factors for FE. Although fluconazole has a good therapeutic effect on fungal esophagitis, we still should pay more attention to FE treatment, given that individuals in today's rapidly aging society and elderly individuals tend to have comorbidities and take multiple drugs.In conclusion, this study found that


The internet has caused the explosive growth of medical information and has greatly improved the availability of medical knowledge. This makes the internet one of the main ways for residents to obtain medical information and knowledge before seeking medical treatment. However, little has been researched on how the internet affects medical decisions.The purpose of this study was to explore the associations between internet behaviors and medical decisions among Chinese adults aged 18 or over, including whether to go to the hospital and which level of medical institution to choose.With the adult residents (≥18 years old) in 12 regions including urban and rural areas taken as the research objects, the differences in medical choices of adults with various characteristics were analyzed, and generalized linear mixed models were adopted to analyze the longitudinal data of the China Health Nutrition Survey from 2006 to 2015.P<.05). After controlling for these potential confounding factors and taking self-care as the reference, the probability of Chinese adults who participated in online browsing activities selecting hospital care was 0.82  times that of residents who did not participate in online browsing activities. In terms of medical institution choices, adults who participated in online browsing activities were 1.86  times more likely to opt for municipal medical treatment than primary care. However, the effect of online browsing on the selection probability of county-level hospitals was not significant compared with primary hospitals (P=.59). Robust analysis verified that accessing the internet had a similar effect on Chinese adults’ medical decisions.Adult groups with different ages, genders, education levels, regions, places of residence, severities of illness and injury, years of suffering from hypertension, and history of chronic diseases showed diverse medical decisions, and the differences were statistically significant (Chinese adults who use the internet are a little less likely to go to the hospital than self-care. The internet has broken down the barriers to obtain knowledge of common diseases and thus has a slight substitution effect of self-care on hospital care. Internet use may increase the probability of adults going to municipal hospitals. The rising tendency of visiting high-level medical institutions may be consequently exacerbated due to knowledge monopoly of severe and complicated diseases that is difficult to eliminate, and the increase in inconsistent and incomplete medical information online will blur the residents’ cognitive boundary of common diseases and severe diseases. Exploring the substantive impact of the internet on medical decision making is of great significance for further rational planning and utilization of the internet, in order to guide patients to appropriate medical institution. Internet & health care, a crucial development strategy which regards the internet as an important means to promote the implementation of HMP and optimize allocation of health care resources [Medical resources have been unequally distributed in different levels of hospitals in China for a long time, and this has resulted in the chaos of residents’ health-seeking behaviors ,2. Accoresources .Baidu, and professional medical websites such as Good Doctor Online and Weiyi. The statistical report on internet development in China has suggested that internet penetration has continued to grow and the popularity of the internet has gradually spread to the elderly from the young [The period from 2006 to 2011 represents the initial development stage of China’s internet health care. Telemedicine gradually emerged in 2015, while online medicine and remote consultation were not widely used. However, patients or healthy people can obtain disease knowledge online through search engines such as he young . Given the young . People Studies have shown that an increasing number of people tend to use the internet to obtain health care information -12, inclHowever, there is limited evidence about how internet affects adult hospital choices. When it comes to the factors influencing residents’ choice of medical treatment, most previous studies have focused more on hospital-related factors, including hospital equipment, distance, time, cost, reputation, doctor level, etc -22. A suSeveral studies that involve internet use indicate that the relationship between the internet and medical decision making still needs to be clarified. Lee et al  pointed Therefore, the purpose of this study was to explore residents’ decision-making behavior under the background of the internet era, and to analyze whether the internet could guide and channel patients to the suitable medical institution, so as to achieve hierarchical treatment. Based on measurements of longitudinal data from 2006 to 2015, the generalized linear mixed model was employed to explore the associations between internet use and medical decisions in general Chinese adult population, combined with other relevant factors influencing patients’ preference for hospital types.Data were extracted from the China Health and Nutrition Survey , an inteQuestions about internet behaviors have been set in the original Chinese questionnaire after 2006, such as the internet location, online browsing, online chat, online game playing, and the duration of internet behaviors. Thus, this paper selected 2006-2015 longitudinal data. Because the medical treatment of minors is often decided by the guardian rather than by the minors themselves, residents younger than 18 years were excluded, and the research object included only the adult group. After data cleaning, the records with missing key variables, such as health care–seeking behavior and internet use, were excluded. The final analysis included 10,164 records, of which there were 2032, 2280, 3145, and 2707 records in 2006, 2009, 2011, and 2015, respectively. Among them, 4877 records were obtained from the same individuals by repeated observations. A total of 7408 adult participants were involved in the analysis and 2121 participants had records that were repeated at least twice. Each participant was followed up for 1, 2, 3, or 4 times , which suggests unbalanced longitudinal data.The internet behavior was obtained through the questions “Do you participate in surfing the internet? (Yes/No)” and “Can you access the internet? (Yes/No)” on the questionnaire. Browsing online was chosen as a proxy variable for internet usage, because only individuals who participated in online browsing activities had the opportunity to access the internet medical information. At the same time, in order to test the robustness of the association between internet use and health care–seeking behaviors, internet access was used as another explanatory variable in the robustness analysis.Health-seeking behaviors were obtained from the questions “What did you do when you felt ill?” and “Which medical institution did you seek first?” The patients made medical decisions in the following 2 steps: (1) Whether to go to the hospital and (2) Which hospital to go to. Therefore, the analysis of the impact of the internet on medical behavior was divided into 2 parts according to the decision-making process. First, did it affect the patient’s choice of whether to seek medical treatment, self-care, or hospital care? This was a 2-category event. Second, based on the level of medical institutions, we classified health care provider choices into primary-level hospital, county-level hospital, and municipal-level hospital, which was a 3-category event.Some other factors might influence residents’ decision to seek medical treatment. For example, people of different ages and genders show distinct preferences for hospitals. Geographical differences indicate diverse levels of modernization as well as economic and medical development, and thus residents’ choice of the hospital may be affected by the supply of local medical resources. Given the potential confounders, it is not enough to consider only the single-factor influence of internet behavior on medical decision making. Thus, the adjusted model included sociodemographic characteristics , health supply , health needs , and other factors as covariates to in-depth verify the influence of internet behavior. Details of the variables are presented in Data collation and cleaning were performed using RStudio 1.1.456 software . The random forest algorithm was applied to fill in the missing values of potential confounders (<10%) after removing duplicate records and missing samples of key variables. In descriptive statistical analysis, statistical charts and tables were adopted to analyze the changes in health care provider choices among Chinese adults, and the differences in health-seeking behaviors among adults with different characteristics. The quantitative data were described by mean and standard deviation, whereas qualitative data were analyzed using rate or composition ratio. Univariate analysis was performed by Wilcoxon rank-sum test, multisample Kruskal–Wallis rank-sum test, chi-square test, and Cochran–Mantel–Haenszel test. In multivariate analysis, because the data were longitudinal and the health care–seeking behaviors were characterized with 2 categories in the first step and 3 categories in the second step as the dependent variable, the mixed-effects binary or multinomial logit model,  was perhaps the most appropriate statistical perspective for analyzing such data when accounting for the potential lack of independence in longitudinal data ,28.ik  was introduced and the logit link function was selected in the model. With k=0 serving as the reference, the model was expressed using the following equation [Methodologically, combining the strengths of both the generalized linear model and linear mixed model, the generalized linear mixed model extends the generalized linear model further to account for variation and correlation of longitudinal data. A random effect bequation :ijk denotes the probability that adult i makes a medical decision of k in survey year j, Pijk=Pr(Yij=k|Xij); εijk is the within-subject random error and was normally distributed as N; bik is the between-subjects random effect on the kth logit component, and was assumed to be distributed as N; and Xij is the covariate vector. The mixed-effects binomial logit model (K=1) and mixed-effects multinomial logit model (K=2) were established by GLIMMIX Proc Step in SAS software, version 9.4 (SAS Institute Inc.) [P<.05 indicated statistical significance.where Pte Inc.) . All tesOn the whole, primary care and self-care were the main medical treatment choices for Chinese adults after they were sick or injured, accounting for 37.80%  and 37.05%  of the total records, respectively, followed by municipal and county hospitals. From 2006 to 2015, the proportion of consultations at primary medical institutions increased by 1.64% (from 35.97% to 37.61%), which indicated the moderate effects of HMP. The proportion of residents choosing municipal hospitals grew by 4.36% (from 10.97% to 15.33%), whereas the figures for choosing self-care and county hospitals both decreased .Taking the data in 2015 as an example, people with different characteristics had various preferences for health care  and 3.23=63.0, P<.001). The factor of disease or injury severity was also found to be statistically significantly associated with medical choices. Patients with more severe illness or injury were more likely to choose hospital care . In addition, education levels (P=.005), residence sites (P<.001), years of suffering from hypertension (P<.001), and history of chronic diseases (P<.001) differed significantly between those who chose self-care and those who chose hospital care (α=.05). However, gender, marital status, medical insurance, and BMI were not significantly associated with the choice of self-care or hospital care in univariate analysis . For instance, those with higher education mainly selected municipal hospitals . The proportions of urban residents’ choices of hospital were ranked as primary hospitals, municipal hospitals, county-level hospitals, whereas rural residents’ choices of hospitals were ranked as primary hospitals, county hospitals, municipal hospitals .Second, for the tier of hospital care in 23=170.4, P<.001).Adults who did not browse the internet presented an obvious preference for primary hospitals, supplemented by self-diagnosis and treatment. By contrast, people who browsed the internet had different medical treatment–seeking behaviors, and they preferred self-care, followed by medical care from primary hospitals and municipal hospitals . With the–0.20; 95% CI 0.69-0.98; P=.03) in the group that participated in online browsing activities compared with those that did not participate in online browsing activities  times more likely to opt for municipal medical treatment than those who did not participate in online browsing activities (P=.59).Taking the primary medical institution as the reference group, 3 mixed-effects multinomial logit models (Models 4-6) were established by using different factors that might affect hospital choices as control variables. All parameter estimates of the models were shown in tivities . Howevere–0.16; 95% CI 0.74-0.99, P=.03) in the group that could access the internet compared with that which could not access the internet. Model 12 showed that compared with primary hospital, the probability of residents who could access the internet selecting municipal hospital was 1.57  times that of residents who did not access the internet. Besides, there was no preference gap for primary and county hospitals (P=.98). Robust analysis verified similar results that the internet had a certain effect on adults’ medical choices.Based on longitudinal data from 2006 to 2015, this paper analyzed the impact of internet on the medical decisions among Chinese adults through generalized linear mixed models. The results showed that the internet had a certain effect on adults’ medical decisions. First, regarding the impact of whether to go to the hospital, adults with internet behaviors  were less likely to go to the hospital. Patients tended to self-care, which presented a partial substitutive effect of self-diagnosis and treatment on hospital care. Second, in terms of hospital selection, compared with primary hospitals, the use of the internet might not change the probability of choosing county hospitals, but it might increase the probability of going to municipal hospitals for advanced treatment. The study has theoretical and practical implications on how to regulate internet health care and guide patients to seek medical institutions, and has a reference to the promotion and application of internet medical treatment.P<.001) [Chinese adults with internet behaviors are more likely to self-diagnose and treat at home than visiting hospitals, which is consistent with some research descriptions ,31. YangP<.001) . ConcernP<.001) ,33,34. OP<.001) . All in r=0.34, 95% CI 0.20-0.48, P<.001) [By contrast, this study found that the internet might exacerbate the tendency of going to higher-level medical institutions for medical treatment. The information browsed on the internet is not able to resolve the monopoly of knowledge about intractable and severe diseases. In addition, residents’ misunderstanding of medical expertise can cause health anxiety, for instance, misinterpretation of physical symptoms as signs of serious diseases, accompanied by persistent fear of serious illness . Some st P<.001) . At the  P<.001) . An obse P<.001) . The stuUnlike previous studies that have paid more attention to the impact of hospital-related factors on patients’ medical decision making, our study focused on internet use. Especially in the internet era, as mentioned previously, the internet has played a vital role in residents’ decision making on their choice of hospitals . Li et aThis study has employed the generalized linear mixed models to delve into the associations between internet use and medical decisions with longitudinal data, which fills in the gaps of current related research and provides a reference for policy makers. To our knowledge, this is the first time that the mixed-effects multinomial logit regression, an appropriate method for processing longitudinally correlated multiclass data ,43, is aWith the advent of the internet, the availability of health care information has improved. The internet has become a pivotal source of medical information for Chinese residents ,44. This