Motor development plays an important role in human development throughout the lifespans, from conception to death, and has received increasing scholarly attention in recent years. However, valuable comprehensive reviews and literature analysis on this topic are still lacking. Here, this bibliometric study aimed to identify global motor development research hotspots and trends on preschool children’s motor development from 2012 to 2022.CiteSpace 6.1.R4 was used to visualize and analyze general bibliometric characteristics, research hotspots, and trends through a review of 2,583 articles on the motor development of preschool children, which were published from 2012 to 2022 and included in the Web of Science Core Collection.n = 319), intervention (n = 222), health (n = 196), and executive function (n = 165); The top five keywords in terms of centrality are academic achievement (0.22), low birth weight (0.16), association (0.14), brain (0.13), and cerebral palsy (0.13). Thirteen keyword clusters were produced from the log-likelihood ratio , and five research topics has been received focused attention in recent years. The keywords with the strongest citation bursts in the last 5 years are developing country (S = 5.92), school-aged children (S = 5.86), middle-income country (S = 3.46), efficacy (S = 5.41), readiness (S = 3.21), motor proficiency (S = 3.6), and screen time (S = 3.3), indicating newly emerging research trends.Research on motor development in preschool children has been carried out into a phase of rapid development. The top five frequently occurring keywords were physical activity (n = 489), performance (The results indicated that interventions involving fundamental movement skills, cognitive function, 24-h movement behaviors, neurodevelopmental disorders, and health-related fitness were hot topics in the field of motor development over the last decade. Emerging research trends generally center on school readiness, socioeconomic status, motor proficiency, and screen time. GabbardMotor skills, which include gross and fine motor skills and motor coordination, comprise a series of fluid and effective movements learned for the acquisition of specific skills . These sHealth characteristics during the preschool years, which is a crucial period for individual growth and development, has a significant bearing on subsequent development throughout the lifespan . This phIn recent years, there has been a surge in research on motor development, with more than 200 publications being produced annually and new research paradigms being continuously cited in this field. Consequently, research hotspots and trends in this field have evolved, posing a formidable analytical challenge for researchers. However, a comprehensive review of the literature in this field is still lacking, and new research methods are urgently required for the analysis of research hotspots and trends.Bibliometrics is an interdisciplinary field that applies mathematical and statistical methods to perform quantitative analyses of various knowledge repositories . As a reTherefore, this review focuses on the studies published during the period from 2012 to 2022 about preschool children’s motor development and included in the Web of Science Core Collection (WoSCC). Bibliometric and visual analyses are used to explore the general metrological characteristics, research hotspots, and development trends in this field, as quantitative analysis is currently lacking. The aim is to provide inputs and recommendations for future research in this field.2.2.1.We conducted a search for the articles published from 2012 to 2022 in the WoSCC database using the search terms listed in 2.2.The data extraction process was carried out by two researchers, who searched for, downloaded, and validated the articles. The authors also discussed any issues and collectively standardized the results. The extracted information included the names of the authors, article titles, full abstracts, publication sources, and cited references, which were downloaded in plain text format, and imported into the CiteSpace 6.1.R4 software. Data pre-processing primarily consisted of filtering and removal of duplicate data.2.3.We used CiteSpace 6.1.R4 to perform scientific collaboration network analysis, co-citation analysis, co-occurrence network analysis, and citation and keyword burst analysis on the content of the included literature. The analyses were aimed at identifying general bibliometrics, research hotspots, and developmental trends in the field . We visu3.3.1.2 = 0.98). The number of published articles gradually increased from 2012 to 2022, revealing a promising future growth trend in the field , Developmental Science , and Neuroscience and Biobehavioral Reviews . The research reports published in these journals enables researchers to comprehend the research hotspots and frontiers in this field.Of 747 co-cited academic journals, 10 journals were co-cited more than 500 times. All of them were established by research institutions and commercial companies in the United States and the United Kingdom . Accordi3.3.n = 324), and public environmental occupational health (n = 2 68). Research on this topic has also been conducted in the fields of sports sciences (n = 258), rehabilitation (n = 237), educational research (n = 205), clinical neurology (n = 140), and neurosciences (n = 124).The results of the disciplinary co-occurrence analysis revealed that research on international preschoolers’ motor development was not confined to the disciplines of pediatrics (n = 427), psychology  within a total of 13 identified and generalized clusters, yielding five research topics. These themes included typical development of basic motor skills interventions for preschool children, research On The correlation between motor development and cognitive function and mechanisms, and The influence of 24-h motor behavior On motor development and moderating factors  and the development of more complex motor skills, in addition to being a critical requirement for maintaining good health during childhood and adolescence . StudiesIn FMS intervention programs implemented for preschoolers, intervention outcomes may be influenced by variations in intervention type, models, content, and duration. Currently, FMS interventions are implemented in schools, families, or communities and are based on teacher-led, child-centered, and teacher-parent models. They may be structured or unstructured, with a single intervention lasting 30 to 50 min . An FMS FMS levels can be effectively enhanced through structured interventions, but they are more effective when the individual who implements the intervention has the necessary expertise, the possible reason is that non-expert implementers are unable to adapt the intervention content, to adapt the ongoing stimulation to the individual and context being treated. In addition, young children are difficult to maintain appropriate responses to ongoing stimulation . MoreoveIn conclusion, the effects of FMS interventions vary somewhat according to the subjects’ characteristics, the intervention measures, who is performing the intervention, and modes. Therefore, further research is required to determine the optimal intervention protocol and potential mechanisms. As a next step, high-quality randomized study should be conducted to determine an optimal intervention protocol. Moreover, research on the relevant variables influencing the intervention effect  should be conducted. Lastly, suitable FMS intervention protocols should be designed for the target populations of children of various ages and characteristics, as well as the influencing factors.4.2.2.Cluster #3 focused on the relationship between motor skills and cognitive function. The focal point of this research was indicated by high-frequency and highly-centered keywords, such as cognitive development, executive function, and language, associated with this cluster. Consequently, the title of this study is “Underlying mechanisms mediating the association between motor skills and cognitive function.”Cognitive function refers to the mental processes involved in acquiring knowledge and understanding through thought, experience, and the senses, including executive function (EF), language, intelligence, attention, perception, memory, and visuospatial ability . PreschoWeak to strong correlations exist between distinct types of motor skills and dimensions of cognitive function . PreviouThere has also been some debate regarding the mechanisms associated with motor skills and cognitive function in preschoolers. One theory is that multiple sclerosis and cognitive function are two distinct developmental processes that involve different brain regions . HoweverSeveral studies have investigated the association between motor skills and cognitive function and its mechanisms, but there are still many unanswered questions remain. Future studies should attempt to determine the correlation between motor skills and cognitive function in preschool children of varying ages and characteristics. Moreover, studies should explore the factors that influence the degree of correlation, including individual characteristics , family characteristics , and school characteristics. Lastly, anatomical and biological models should be developed for elucidating the associated biological mechanisms.4.2.3.Cluster #7 focused on the association between physical activity (PA), sedentary behavior (SB), and sleep duration (SLP) and their effects on FMS. The high-frequency and high-centered keywords associated with this cluster included PA, SB, and behavioral problems, which together constitute this research hotspot, with a primary focus on two aspects. The first is bidirectional relationships between PA and FMS and the second is combinations of PA, SB, and SLP and their associations with FMS.4.2.3.1.Lack of PA is an increasing public health issue, which impose a significant economic burden on countries worldwide. Therefore, it is essential to develop strategies to increase PA levels in preschool children, and one way of achieving this is by improving gross motor skills . AccordiThe findings of studies on the extent and direction of the association between PA and MC in preschool children are inconsistent. This association may be influenced by age, sex, various aspects of MC, and different types of PA . Low to The reasons for the lack of significant associations between FMS, object control and locomotor skills, and light physical activity, and the relationship between stability skills and different types of PA remain unclear. PA was not found to be associated with gross motor skills in infants aged 11 to 29 months . HoweverIn conclusion, the findings of previous studies do not fully support or refute a bidirectional relationship between PA and MC in early childhood, as posited by Stodden’s model. Additional RCTs or longitudinal evidence are required to investigate the temporal order, strength of association, and causality between MC and total physical activity and to establish the “dose-effect” relationship. In addition, an investigation of the mediating variables  and moderators  that influence the association between PA and MC is necessary to provide a basis for the specification of PA protocols for children of different ages and with varying characteristics.4.2.3.2.As research on PA continues to evolve, it is no longer sufficient to consider individual behaviors in isolation, as individuals’ daily behaviors are confined to 24 h. Thus, PA, SB, and SLP are collectively referred to as “24-h behaviors.” PA, SB, and SLP should be considered holistically since the time spent engaged in one behavior influences other behaviors during the rest of the day, and the combination of 24-h movement behaviors may have a greater effect on the physical and mental health of children , 50.Preschool children’s physical health and growth are adversely affected by insufficient PA, excessive SB, and insufficient SLP . GuideliIn conclusion, there is limited evidence that 24-h movement behaviors have an effect on FMS in preschoolers. Therefore, the next step is to determine the combined association between 24-h motor behaviors and different dimensions of FMS and to adjust the association between these behaviors, considered together, and after individual behaviors with FMS to determine more concisely the “dose-effect” relationship.4.2.4.Cluster #10 focused on motor skills in children with neurodevelopmental disorders (NDDs). Autism spectrum disorder (ASD), developmental coordination disorder, (DCD), and cerebral palsy were high-frequency and high-centered keywords associated with this cluster, constituting a research hotspot in this area. The title of this study is “Motor impairment and early interventions in children with neurodevelopmental disorders.”The most prevalent NDDs in preschool-aged children are DCD, ASD, cerebral palsy, and attention deficit hyperactivity disorder. Epidemiological surveys indicate that approximately 15% of children aged between 3 and 17 years are affected by NDDs worldwide, with DCD, attention deficit hyperactivity disorder, and ASD being the most prevalent disorders . In the Motor impairment is prevalent in children with NDDs , 61, whiInterventions can be therapeutic for children with NDDs of any age, but early interventions are the most effective. Currently, exercise therapy is the primary focus of early interventions for children with NDD and motor skill deficits. Exercise-based interventions can provide opportunities for children with NDDs to learn, practice, and consolidate their motor skills, resulting in higher skill levels . HoweverAlthough recent systematic reviews indicate that exercise-based interventions can potentially improve motor skills in children with NDDs, the effect is not statistically significant, and the quality and bias of the included literature may impact the credibility of the findings . FurtherIn conclusion, exercise-based interventions have the potential to improve motor impairment in children with NDDs, but the existing evidence is inconsistent. The next step is to identify the characteristics and subtypes of motor skill deficits inherent in children with various types of NDDs. Optimal intervention protocols for improving motor skills impairment in children with NDDs, as well as the variables influencing the effects of the interventions , should be investigated to elucidate the underlying mechanisms.4.2.5.The focus of Cluster #13 was MC and health-related fitness (HRF). Health, obesity and overweight, perceived competence, body composition, and fitness, which were high-frequency and high-centered keywords associated with this cluster, constitute the research hotspots in this area. Their combination indicated that topical issues were the relationships between MC and HRF and between weight status and MC in preschoolers.4.2.5.1.HRF consists of cardiorespiratory endurance, muscular strength and endurance, body composition, and flexibility, is regarded as a physical and physiological factor associated with current and future health outcomes . One stuOnly three empirical studies have investigated the relationship between MC levels and HRF in preschool children. Sigmundsson et al.  reportedIn conclusion, MC levels in preschoolers are associated with present and future HRF. However, the majority of current studies are cross-sectional and focus on the relationship between MC and muscular strength and endurance. Nevertheless, research about other aspects of HRF  is scant. Future research in this field should emphasize longitudinal trajectories of HRF in preschool children with different MC levels and their potential mechanisms.4.2.5.2.The preschool years are a critical period for children’s growth and development. Weight status during this period is predictive of weight status in adulthood, with behaviors associated with poor weight status persisting into adulthood . TherefoThe weight status of children is negatively correlated with their MC levels, and this association emerges during the preschool years, becoming stronger during the elementary school years , 71. HowOnly two studies have investigated the temporal and causal relationship between MC and BMI. Antunes conducted a follow-up study that revealed the association between BMI and MC in preschool children increased with age . AnotherIn conclusion, a correlation exists between MC and weight status in preschool children, but the results are inconsistent. In addition, the temporal order and causality of this correlation with various dimensions of MS remain unclear. Therefore, more high-quality RCTs and longitudinal studies should be conducted to investigate the temporal order and causality between various types of MS and obesity, utilizing different response obesity indicators .5.We used CiteSpace to identify keyword bursts as a method for indicating new research trends and frontiers. The blue lines indicated the timeline and the red lines indicated the time interval of a certain research burst, that is, the burst start time and duration. The keyword burst intensity represents the frequency of keywords used in the cited literature, namely keywords that are closely followed by scholars in a certain research area over a period of time .We conducted a keyword burst analysis of 2,583 studies on preschool children’s motor development included in WoSCC between 2012 and 2022 to identify the top 20 terms with the strongest burst . We focuResearch during this period focused on the following areas: the first was the characteristics of motor skills impairment inherent in children with various types of NDDs, the best intervention program to improve motor impairment in children with NDDs, and the factors influencing the intervention effect . The second was the correlation between motor skills and cognitive functions in preschool children of varying ages and characteristics as well as the underlying mechanisms and factors that influence the degree of correlation, such as personal characteristics , family characteristics , and school characteristics. The third focus of the research was the correlation between MC and weight status in preschoolers as well as the chronology and underlying reasons for this correlation.Research has a strong temporal component, and research hotspots are not constant. This issue can be effectively resolved using the citation burst test. The research frontiers and trends within a field can be determined by the focal research directions taken by researchers during a specific period , 13, 76.6.Research on preschool children’s motor development has been carried out into the period of rapid development and this research will continue to advance in the future. This research field is constituted by a stable core group of authors and members of the academic community, who have made substantial contributions to its expansion. FMS interventions, the underlying mechanisms mediating the association between motor skills and cognitive functions, 24-h movement behaviors and FMS, motor impairment and early interventions in children with NDDs, and MC and the effects on positive trajectories of HRF were identified as motor development research hotspots. Moreover, the main research trends include motor development patterns in preschool children of varying socioeconomic status, MC and SB causality assessments, the effect of 24-h movement behaviors on the FMS of preschoolers, the dose-effect association with FMS after adjusting for 24-h behavior as a whole and individual behaviors, and breaking motor proficiency. In addition, we analyzed the limitations of current research was analyzed, including optimal FMS intervention programs for children of different ages and characteristics, biological mechanisms associated with motor skills and cognitive functions, and the correlation between MC and other components of HRF . Whereas research on these topics is still preliminary, and emerge as the next set of research hot spots and trends. In summary, we reviewed and analyzed research hotspots and trends relating to motor development in preschool children, applying a bibliometric perspective. The findings of our review will contribute to broadening scholars’ research horizons and the promotion of intensive research on motor development among preschool children.The original contributions presented in the study are included in the article/supplementary materials, further inquiries can be directed to the corresponding author.D-ML designed the study and revised the manuscript. W-JS and W-DC collected the data. SQ and XZ searched for literature and analyzed the data. J-WW and Z-CZ wrote the original draft and interpreted the results. XL provided other contribution. All authors contributed to the article and approved the submitted version.This work was supported by the National Social Science Fund of China (grant numbers BLA200222 and BLA220235), the Laboratory of the Sports Medicine Innovation Project of the Institute of Sports Medicine and Health, Chengdu Sport University in China (grant numbers CX21B06 and CX21C06), the Sichuan Key Laboratory of Sports Medicine 2022-2023 Open Project Grant (Project No.: YY22KX05), the Key R&D Projects of Sichuan Provincial Science and Technology Plan Project (Grant No. 2022YFS0053) and the “14th Five Year Plan” Scientific Research and Innovation Team of Chengdu Sport University (Grant No. 23CXTD02).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Uncertainties persist about whether to aggressively and effectively treat tricuspid regurgitation (TR) during mitral valve (MV) surgery.Systematic literature searches were performed in five databases to collect all relevant studies published before May 2022 on whether the tricuspid valve was treated during MV surgery. Separate meta-analyses were performed on data from unmatched studies and randomized controlled trials (RCT)/adjusted studies.A total of 44 publications were included, of which eight were RCT studies and the rest were retrospective studies. There was no difference in 30-day mortality  or overall survival  in unmatched studies and RCT/adjusted studies. Late mortality  and cardiac-related mortality  were lower in the tricuspid valve repair (TVR) group in the RCT/adjusted studies. In the unmatched studies, overall cardiac mortality  was lower in the TVR group. In the late TR progression analysis, the late TR progression was lower among patients in the concomitantly intervened tricuspid group, and patients in the untreated tricuspid group were prone to TR progression in both studies .TVR concomitant with MV surgery is most effective in patients with significant TR and dilated tricuspid annulus, especially those with a significantly reduced risk of distant TR progression. HighlightsConcomitant tricuspid valve repair was associated with an improved late prognosis, particularly a reduced risk of late mortality, cardiac-related mortality, and tricuspid regurgitation (TR) progression.Patients will benefit from concomitant tricuspid valve repair, and the results might be even more promising, especially in patients with significant TR and tricuspid valve dilatation.For significant TR, the reason for concomitant performance was that TR might not resolve after mitral valve surgery.Repair of TR associated with annular dilatation was done to prevent the worsening of tricuspid annular dilatation, or the development of severe TR.1. In the 1960s, it was again demonstrated in a study by Braunwald et al.2 that FTR was resolved among patients with severe FTR who underwent MV replacement. Tricuspid regurgitation (TR) occurs in up to 64% of patients who undergo MV surgery for mitral regurgitation6. Carpentier et al.7 preference for routine tricuspid valve repair (TVR) for FTR, first described in the 1970s, also remains the prevailing view and it is accepted by most people, that severe TR may not improve effectively after MV surgery and should be addressed during MV surgery10. Although the American College of Cardiology/American Heart Association (ACC/AHA)11 and European Society of Cardiology/European Association for Cardio-Thoracic Surgery (ESC/EACTS)12 guidelines recommend that patients with severe TR should be treated with a TVR in conjunction with left ventricular surgery (Class I recommendation), and that symptomatic patients or right ventricular patients with severe enlargement be considered for tricuspid valve (TV) surgery in conjunction with left valve surgery (Class IIa recommendation), recommendations for managing TR during MV surgery are still largely based on observational data from clinical practice.The successful experience of undergoing mitral valve (MV) surgery for functional tricuspid regurgitation (FTR) was first reported in the 1950s16. The chief concern in the prognosis of patients with MV disease and concomitant TR include worsening of TR, impairment of right heart function, reduced quality of life, and consequently reduced life expectancy17. For this reason, many physicians believe that a more aggressive treatment and prophylactic approach to the TV is necessary alongside surgery in patients with concomitant MV disease concomitant TR19. A series of studies found that TVR was associated with less residual TR in the early postoperative period, and residual TR was associated with lower survival during follow-up22. Therefore, it is recommended that patients with FTR, particularly in the setting of a dilated tricuspid annulus, undergo concomitant TVR during MV surgery. However, Ro et al.23 and Gammie et al.24 suggested that there is no apparent significant advantage of TVR compared to patients who underwent MV surgery alone owing to risk factors such as age, diabetes, chronic renal failure, history of previous cardiac surgery, and concurrent Maze surgery for atrial fibrillation (AF). In addition, TVR leads to the more frequent implantation of permanent pacemakers24. Due to the scarcity of studies with rigorous long-term follow-up and insufficient follow-up data, uncertainties persist about whether to perform a combined valve procedure.It has been proven in many studies that up to 74% of patients who undergo successful left-sided valve surgery will develop TR over time with poor outcomesAlthough studies have been conducted on this issue over the past decades, reaching a unified conclusion has been challenging because scholars have varying understandings of MV disease secondary to TR. Whether TV should be repaired during MV surgery and the timing of prosthetic repair are debatable. This systematic review and meta-analysis was conducted to answer these questions by comparing clinical and follow-up data from patients who underwent TVR with or without concomitant surgery for MV disease.25, Supplemental Digital Content 1, http://links.lww.com/JS9/A674, Supplemental Digital Content 6, http://links.lww.com/JS9/A679 and Assessing the methodological quality of systematic reviews (AMSTAR) guidelines26, Supplemental Digital Content 2, http://links.lww.com/JS9/A675. The protocol for this overview was registered on PROSPERO (CRD42022380967) and is accessible on the PROSPERO website (https://www.crd.york.ac.uk/prospero/), Supplemental Digital Content 3, http://links.lww.com/JS9/A676. Because this was an analysis of previously published data, no ethical approval was required.This systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA)terms and keywords. The retrieval process is shown in Supplementary Table 1, Supplemental Digital Content 4, http://links.lww.com/JS9/A677, using PubMed as an example.A comprehensive search strategy was designed to search PubMed, Embase, Web of Science, the Cochrane Library, and the China National Knowledge Infrastructure (CNKI) and identify all relevant studies before May 2022. The search was performed by combining MeSH/Emtree The inclusion criteria were based on the PICO  statement. All comparative studies were eligible for inclusion.Clinical research question: Should TVR be performed during MV surgery?PICO statement: P-patients, problem or population: Patients with MV disease and TR. I-intervention or exposure: TVR. C-comparison, control or comparator: To compare postoperative survival and TR in patients with and without TVR. O-outcome: The primary outcome indicators were 30-day mortality, late mortality, cardiac-related mortality, the odds of TVR as a risk factor for death, and freedom from late TR. The secondary outcome indicators were the grade of TR, stroke, pulmonary artery systolic pressure , left ventricular ejection fraction , cardiopulmonary bypass (CPB) time, and aorta cross-clamp (ACC) time.The data extraction form was tested and revised before the extraction. Two researchers extracted and revised the data. If disagreements occurred during the extraction process, the decision was discussed with a third researcher. The main data extracted were: basic information about the study; basic patient characteristics and preoperative information; outcome indicators, including primary and secondary outcome indicators mentioned in the eligibility criteria.et al.27. The second was the extraction of hazard ratios (HRs) from the survival curves, which we have done using the method of Tierney et al.28.In addition, two other issues required special attention. The first was the transformation between quartiles and SD of means, which we subscribed to using the online tool designed by Wan The Cochrane Collaboration’s Tool for Risk of Bias29, which evaluates selection bias, performance bias, detection bias, attrition bias, and reporting bias. Each type of bias was rated as a ‘High’, ‘Low’, or ‘Unclear’ risk. For retrospective studies, the quality of each study was assessed with the Newcastle–Ottawa Scale30 and scored based on population selection, comparability, and exposure to risk factors. Studies with scores greater than or equal to 7 were considered to be of high quality. This work was independently cross-checked with the original publications for accuracy and completeness by two other researchers. The results of the quality assessment were presented using Review Manager 5.4.We assessed the risk of bias in randomized controlled trials (RCTs) using P-value of 0.05 was applied as the cut-off for determining statistical significance. Statistical heterogeneity was assessed with the Cochran Q-test and I2-test. If significant heterogeneity was observed (I2 > 50% or p(Q) < 0.05), pooled estimates were calculated using a random‐effects model. Otherwise, a fixed‐effect model was used.Eleven analyses were performed using the open‐source R software version 4.1.3, accessed via the RStudio server. Dichotomous variables were presented as odds ratios (ORs) with 95% CIs, and continuous variables were presented as weighted mean differences or standardized mean differences (Std. MD) with 95% CIs. Additionally, HR was meta-analyzed using the inverse variance method. A 31, and asymmetry was assessed using Begg’s and Egger’s regression tests. Where there was moderate to high heterogeneity between studies, sensitivity analyses were conducted by sequentially omitting individual studies to determine the impact of the excluded studies on the pooled results.Publication bias of combined risk ratio estimates was evaluated by visual assessment funnel when the meta-analysis included more than 10 studies69, of which eight52 were RCT studies and the rest were retrospective studies Figure et al.53 and He et al.56 classified different tricuspid valvuloplasty materials, so we included each of them as two separate studies. In the study by Zadok et al.55, three comparisons were made because of the different levels of TR, so we also included their study as three separate studies. Supplementary Table 2, Supplemental Digital Content 4, http://links.lww.com/JS9/A677, shows baseline information for all included studies and patients.We identified 2810 citations from five databases, and 1823 were reviewed for eligibility after removing duplicates. We ultimately included 44 studies52 are presented in Figure Newcastle–Ottawa Scale scores of the retrospective studies69 are presented in Figure The results of the quality evaluation of the RCTs69 unmatched studies in total, with 34 separate extracts of baseline and outcome information. The TR was less than or equal to mild in six studies69, less than or equal to moderate in 1369, greater than or equal to moderate in eight65, and unclassified in the remainder of the studies. Baseline comparisons of the results showed that patients with TVR were slightly more complex than those without. First, patients in the TVR group were about a year older  and were more likely to be women  and have AF  than those in the TVR group. In addition, the patients in the TVR group had a higher PASP  and a longer TV annulus diameter  than those in the TVR group. Moreover, the TR and NYHA classifications were higher in the TVR group than in the TVR- group (P < 0.01). At baseline, the two groups did not differ by the following: diabetes mellitus, hypertension, stroke, coronary artery disease, and LVEF (P > 0.05). The above results are all presented in Table There were 32P > 0.05). For late mortality, the results were meaningful in the group with TR greater than or equal to moderate . Compared to the TVR group, cardiac-related mortality was lower in the TVR group , especially in the TR less than or equal to mild  and TR less than or equal to moderate  groups. Regarding the analysis of overall survival, TVR was favorable in patients with significant TR, and the results were statistically significant . The results of freedom from late TR showed that concomitant TVR appears to be of great importance with a P-value of less than 0.05 for all groups . These results are presented in Table In the analysis of 30-day mortality, there was no difference between the two groups in either the total combined value  or the subgroup analysis according to TR (http://links.lww.com/JS9/A678). In addition, the time for CPB  and ACC  were both much longer for patients in the TVR group than for those in the TVR group. Stroke, PASP, and LVEF were not found to be different between the two groups .Results on the secondary outcomes are presented in Table 55 RCT/adjusted studies were included in this meta-analysis, including 20 outcome data. Baseline comparisons showed that more patients in the TVR group had AF  and TR > moderate  than those in the TVR group. In addition, the TV annulus diameter appeared to be a little longer in the TVR group . No other significant baseline differences (P > 0.05) were observed between the two groups (Table Eighteenhttp://links.lww.com/JS9/A678) and overall survival  between the two groups. In the subgroup analysis categorized by TR class, the TR greater than or equal to moderate group had significant results despite having only one study . Nevertheless, none of the other subgroup analyses for these two outcomes was significant.The results for the primary outcomes are presented in Table http://links.lww.com/JS9/A678) and cardiac-related mortality  showed that the TVR group had significantly better survival. In addition, the results of freedom from late TR, which was a key endpoint, remained significantly different , suggesting a significant effect of TVR, especially in the group of TR less than or equal to mild.Notably, the analysis of both late mortality , which was accompanied by longer CPB  and ACC  times. Stroke, PASP, and LVEF remained statistically insignificant . The results of the secondary outcomes are presented in Table Secondary outcome results were similar to the unmatched studies. More patients in the TVR group converted to TR less than or equal to moderate, and the number of high-grade TR decreased (TR ≤ moderate: 4.47(2.90–6.88) versus 0.24(0.04–1.25), Supplementary Figures 6–7, Supplemental Digital Content 5, P values greater than 0.05. In sensitivity analyses, the results of the primary outcome indicators were robust and did not change after excluding a particular study  and overall survival  in the group with TR less than or equal to 2. This was a further reminder that although aggressive and effective TVR could benefit patients, more care should be taken when performing MV surgery in conjunction with TVR, especially for mild and mild to moderate TR.In the analysis of overall survival, survival was better in patients with moderate-to-severe TR who received TVR, regardless of whether the studies were unmatched or RCT/adjusted. However, this seems to be widely accepted, and we are more interested in knowing whether there are positive outcomes for patients with mild or mild to moderate TR who receive TVR. This also suggests a direction for follow-up studies. The results of this meta-analysis, including subgroup analysis of TR as an independent risk factor for the poorer long-term prognosis of patients, showed that TR progression was less likely to occur in patients who underwent TVR, especially for the moderate-to-severe TR. This is in line with what we had hoped for and indicates that interventions for TV were meaningful. Clinical experience has shown that with a successful MV surgery, severe postoperative residual TR contributes to poor postoperative prognosis20. In addition, choosing an appropriate and effective repair has become an important issue. Currently, the main approaches to TVR are suture annuloplasty and prosthetic tricuspid annuloplasty80. Suture annuloplasties, such as the Kay method81 and the De Vega method82, have the advantage of technical simplicity and a low financial burden on the patient. However, the Kay method diastases TV and had a high rate of long-term postoperative regurgitation17, while the De Vega lacked strong support and reinforcement of the tricuspid annulus83, and both have unsatisfactory long-term results. In contrast, prosthetic tricuspid annuloplasty can better restore the TV85, particularly with its 3D rigid annuloplasty, which offers good early advantages87. In addition, transcatheter TV interventions offer a new way of thinking about FTR88. The latest ESC/EACTS provided the first recommendation for interventional treatment of TR in patients with symptomatic secondary TR who are unable to undergo surgery; interventional treatment of TV disease should be considered in the context of a discussion with heart valve center specialists (Class IIb recommendation)12. In recent years, studies in several centers have shown that TV interventional techniques were safe and feasible and could reduce the degree of regurgitation and improve the patient’s heart failure symptoms after the procedure89. However, longer follow-ups and future RCT studies of more patients are needed to evaluate these transcatheter TV repair techniques in this patient cohort before any real change can be made. For this reason, we believe that choosing the right approach at the right time to deal with TR during MV surgery would maximize the benefit to the patient.MV surgery with TVR is done to avoid the progression of TR and the potential risk of future TV repair or replacement. However, the in-hospital mortality rate for TVR reoperations has been reported to be over 13%The results of this meta-analysis must be interpreted with caution in the context of some significant limitations. First, the only eight RCTs we included in this study were more retrospectives in comparison. In addition, most of the studies did not use statistical techniques to adjust for potential differences in baseline demographics, which may have led to more heterogeneity. Although, we analyzed data from the RCT/adjusted and unmatched studies separately, we recognize that even with sophisticated statistical techniques, such as propensity score matching, our findings had unknown confounding factors. In particular, the patient’s presentation before the procedure, the surgeon’s understanding of the surgical expertise, and the completeness of the follow-up. Second, although the question of whether to manage the TV concomitantly was described in the ACC/AHA and ESC/EACTS guidelines, there was no strict criterion and the decision to operate concomitantly in most studies was based on the grade of the TR, whether the tricuspid annulus was dilated, the patient’s clinical symptoms and ultimately the surgeon’s decision. This would seem to leave comparability between patients open to concern. Although, we performed a comparability analysis of baseline information, the effect of confounding factors could not be avoided. Third, there was some bias in the extraction of data for HR from survival curves. While the data we extracted were consistent with the significance of the data reported in the article, it was still a secondary extraction performed by a machine or manually and is susceptible to bias.Concomitant TVR was associated with an improved late prognosis, particularly a reduced risk of late mortality, cardiac-related mortality, and TR progression. Patients will benefit from concomitant TVR, and the results may be even more promising, especially in patients with significant TR and TV dilatation. However, the single dilated tricuspid annulus should not be used as an indication for surgery. For significant TR, the reason for concomitant performance was that TR might not resolve after MV surgery. Repair of TR associated with annular dilatation was performed to prevent the worsening of tricuspid annular dilatation or the development of severe TR. If validated by forthcoming larger clinical trials, these results would certainly prompt a change in current guidelines for a more aggressive and effective approach to treating FTR during MV surgery.Not applicable.Written informed consent for publication was obtained from all participants.Natural Science Foundation of Gansu Province .K.Y., W.W., and T.Y.: wrote the main manuscript text; J.X., X.Z., W.W., C.L., and X.L.: prepared figures and tables. All authors reviewed the manuscript.The authors declared that there have no conflicts of interest in this work.PROSPERO, identifier: CRD42022380967.Kang Yi, Wei Wang and Tao You.All data generated or analyzed during this study are included in this published article.Not commissioned, externally peer-reviewed.


Staphylococcus aureus (Gram-positive bacteria) and Escherichia coli (Gram-negative bacteria). The system that was developed showed promising results, indicating an improved antibacterial efficacy and enhanced structural properties due to the presence of microcapsules. These findings suggest that the system may be an appropriate candidate for various applications, including, but not limited to, drug release, tissue engineering, and food packaging. Finally, this system demonstrates a strategy to stabilize the releasing of the volatile compounds for creating successful results.In this study, chitosan (Chi) was used to microencapsulate peppermint essential oil (PEO). A novel gelatin-based cryogel loaded with PEO microcapsules was further developed and characterized for potential applications. Four different cryogel systems were designed, and the morphological, molecular, physical and antibacterial properties were investigated. Additionally, the antimicrobial properties of PEO, alone and microcapsulated, incorporated into the cryogel network were evaluated. The observed gel structure of cryogels exhibited a highly porous morphology in the microcapsules. The highest values of the equilibrium swelling ratio were acquired for the GelCryo–ChiCap and GelCryo–PEO@ChiCap samples. The contact angle GelCryo–PEO@ChiCap sample was lower than the control (GelCryo) due to the water repelling of the essential oil. It has been found that the incorporation of encapsulated PEO into the cryogels would be more advantageous compared to its direct addition. Moreover, GelCryo–PEO@ChiCap cryogels showed the strongest antibacterial activities, especially against  Polymer-based materials under the name of “gel” are “polymer solvent” systems in which macromolecules form a 3D network with non-fluctuating bonds. They are relatively soft materials, and are generally robust when subjected to large deformations. While the morphology of the gels is determined using the fabrication method, the nature of the bonds is determined according to the nature of the polymers used. On the other hand, the chosen solvent prevents the collapse of the system and creates a 3D mesh network rather than a compact polymer mass . In geneCryotropic gels, commonly known as cryogels, are interlinked porous polymeric substrates fabricated as a result of the crytropic gelation (cryogelation) of monomers/polymers in a suitable solvent under freezing temperatures ,3. The cCryogel materials have gained significant attention in biomedical and biotechnological applications due to their unique combination of physicochemical properties and biological activity. The term “biologically active” refers to the ability of these materials to interact with biological systems and elicit specific biological responses. Three-dimensional cryogel structures are produced using natural polymers mainly composed of polysaccharides, proteins, and nucleic acids produced by microorganisms, and this structure is the survival mechanism of bacteria. Therefore, it is very important to improve the antibacterial properties of these unique materials. This can be achieved by using polymers with self-antibacterial properties, as well as antimicrobial substances  for the cryogel structure. The biological activity of cryogel materials in these applications is closely linked to their physicochemical properties, such as pore size, surface chemistry, mechanical strength, and biocompatibility. By tailoring these properties, cryogels can be designed to exhibit specific biological responses, making them versatile and promising materials in the field of biomedicine and biotechnology ,19.From this point of view, we aimed to improve the antibacterial properties of gelatin-based cryogels by adding peppermint essential oil (PEO), which contains bioactive molecules such as menthol, menthone, neomenthol, and iso-menthone . Gelatinv/v) glutaraldehyde solution, glacial acetic acid, and absolute ethanol were purchased from Sigma Aldrich, St. Louis, MO, USA. PEO was obtained from a local herbal market in Mersin, Türkiye. Pure sodium hydroxide (NaOH) pellets, tryptone soy broth (TSB) and plate count agar (PCA) were supplied from Merck, Darmstadt, Germany. All chemicals were of analytical grade. Distilled water was used for preparing the solutions, dilutions, and washing steps.Chitosan with a medium molecular weight, gelatin for microbiology, 25% (v/v) was added into the gelatin solution rapidly while stirring at room temperature. The solution was immediately poured into 1.0 cm diameter cylindrical plastic tubes to fill the mold, and put in the freezer to start forming ice crystals that act as porogens. After reaction at −20 °C in a refrigerator for 24 h, the product was thawed at room temperature, removed from the tube, and washed several times with high volumes of distilled water. The GelCryo was obtained after freeze-drying for 24 h  and PEO were added to the gelatin solution prepared before crosslinking. The product prepared at this stage was named PEO@GelCryo B.v/v) acetic acid solution. The homogeneously prepared solution was carefully placed in a plastic syringe with a 21 gauge needle, and dripped at a constant rate into the 10% wt. NaOH solution. The droplets were broken up into mono-dispersed droplets (1 droplet/second) by the shear force of the continuous flow in the NaOH solution. The resulting beads were soaked in the NaOH solution for at least 4 h to stabilize their shape. The beads were washed with distilled water until the washing water became neutral  glutaraldehyde solution was added, poured into cylindrical plastic tubes to take on the shape, and left overnight at −20 °C for crosslinking. The frozen gels were thawed at room temperature, washed to remove unreacted residues, and freeze-dried. In the continuation of the study, ChiCap-loaded cryogels were named GelCryo–ChiCap, and PEO@ChiCap-loaded cryogels PEO@ ChiCap–GelCryo.In the preparation of microcapsules-loaded gelatin cryogels, both ChiCap and PEO@ChiCap microcapsules produced in the previous step were dispersed in a gelatin solution and then crosslinked E. For th−1.The morphologies of the microcapsules were examined using an optical microscope . The average diameter of the beads was determined from optical microscopy images by analyzing about 50 particles using Image J software with version 1.53. The manual mode of the Image J analyzer was used for the measurement of the average diameter of the beads. Randomly selected beads were analyzed for both the long and short axes. The presence of PEO after encapsulation with chitosan was confirmed by using the FTIR spectra . The microcapsules were scanned within the frequency region of 400 to 4000 cm−1, and the characteristic peaks of IR transmission spectra were recorded.The chemical groups of cryogels were analyzed by using infrared (IR) spectra . Each cryogel specimen was scanned within the frequency region of 400 to 4000 cmScanning electron microscopy  was used to analyze the surface and inner morphology of cryogels. Before imaging, the samples were coated with a thin layer of platinum. SEM was used at the acceleration of 5 kV. The mean pore size of each cryogel was calculated by measuring the width of 50 pores using Image J software analysis from SEM images.The swelling ratio (SR%) of cryogels was monitored in phosphate buffer saline (PBS) at 37 °C, and calculated using Equation (1). Three samples  were used to calculate the average swelling ratio. Firstly, the dry weights of cryogels were recorded. Then, cryogels were immersed in PBS. At certain times, excess PBS from the surface of the cryogels was removed with filter paper, and then the cryogels were weighed. At different time intervals, this process was repeated and the SR% of cryogels was calculated considering time. The swelling ratio/capacity of the cryogels was calculated using the equation below:The cryogels were cut into 0.3 cm height and 1 cm diameter pieces, and then 5 μL deionized water droplets were added to the surfaces of the samples with a microinjector in an optical tensiometer . Images were captured at the end of the 5 s after contact of a droplet with the cryogels, by a camera levelled with the surface.Staphylococcus aureus (S. aureus)) and Gram-negative (Escherichia coli (E. coli)) bacteria. Bacteria were cultured in 10 mL of TSB and incubated at 37 °C for 24 h. Then, this culture for each bacterial species was diluted to the level of 108 CFU/mL, according to McFarland method, at 600 nm. The cryogels were sterilized under UV light for 30 min. Subsequently, 30 mg of sterilized cryogels were mixed with 10 mL bacterial suspensions and placed in a shaker incubator at 37 °C for 2 h, and 24 h. Afterward, the bacterial suspensions including cryogels underwent a series of dilutions, and 100 μL diluted solution was spread evenly on the plate count agar solid medium for inoculation and then incubated at 37 °C for 18 h. Finally, the colonies were counted and recorded.The antibacterial activities of the cryogels were analyzed according to Pan et al. , with slEssential oils are very sensitive to changes under external factors such as light, temperature, oxygen, and humidity, so they are unstable. The high volatility, hydrophobicity, poor stability, and reactivity of these compounds limit their direct use in longer-term applications. To overcome these limitations, a microencapsulation technique was used to preserve the functional and biological properties of these bioactive compounds while controlling their release ,36. Ther−1 have previously been ascribed to the presence of menthol and menthone, the two most significant constituents of peppermint oil [−1 correspond to C-O stretching vibrations, whereas the dense absorption bands between 700 and 1455 cm−1 result from C-H bond vibrations in the peppermint structure [The FTIR spectra of the plain chitosan microcapsules (ChiCap) and PEO-loaded chitosan microcapsules (PEO@ChiCap) are presented in mint oil . The wavtructure . AccordiIn this study, four different compositions of gelatin-based cryogels were succesfully fabricated as empty gelatin (GelCryo), PEO-incorporated gelatin (PEO@GelCryo), plain chitosan microcapsule-loaded gelatin cryogel (GelCryo–ChiCap) and PEO-encapsulated chitosan-microcapsule-loaded gelatin cryogel (GelCryo–PEO@ChiCap), as illustrated in The structural peculiarities of cryogels and cryogels filled with microcapsules were obtained by examining thin sections of these cryogels via SEM. Images in Due to the hydrophobic and immiscible properties of the essential oil, its particles can be seen on the material surface in SEM images. When The cryogel that draws attention in SEM images and that we will focus on in the next stages of our study is GelCryo–PEO@ChiCap, presented in The highly porous structure exposed as a result of adding PEO-loaded microcapsules  to the gelatin solution and co-produced under cryogenic conditions, is interesting.2) of the gelatin in the protein structure, proceeding beyond the stage of a simple Schiff base formation [The crosslinking of gelatin in the existence of glutaraldehyde, and the presence of PEO, ChiCap, and PEO@ChiCap were analyzed via ATR–FTIR. The common denominator of all gels is the crosslinking of gelatin with glutaraldehyde under cryogenic conditions. It is well known that the crosslinking reaction takes place between the aldehyde functional groups of glutaraldehyde and the unprotonated free amino groups , the band at 1531 cm−1 was the characteristic of amide II (N-H bending vibration), and the peak at 1239 cm−1 was due to the amide III (C-N stretch plus N-H in phase bending) [−1, was due to the C=N stretching vibration of the imine group of the Schiff base, which confirmed the crosslinking formation between gelatin chains by glutaraldehyde.The characteristic peaks of gelatin and peaks related with the crosslinking of gelatin and glutaraldehyde were successfully determined in all samples . A broadbending) ,48. One −1 have been attributed to the presence of menthol and menthone, the most important components of peppermint oil [For PEO-incorporated cryogels, the presence of PEO in the gels (for PEO@GelCryo and GelCryo–PEO@ChiCap) was also demonstrated in FTIR spectra. In previous studies, bands in the spectral range of 2849–2954 cmmint oil ,49. In oTo evaluate the swelling behavior properties of cryogels, we first evaluated the water uptake capacity of cryogels . The SR The assessment of the surface hydrophobic and hydrophilic properties of the cryogels was conducted through the utilization of water contact angle  measurements. The water contact angles of GelCryo, PEO@GelCryo, GelCryo–ChiCap, and GelCryo–PEO@ChiCap cryogels were 99.98°, 76.90°, 66.11°, and 70.91°, respectively, as shown in S. aureus and E. coli growth curves in relation to the aerogels. The Gelcryo displayed no growth inhibition effect, whereas the crygels loaded with PEO and chitosan microcapsules exhibited antibacterial efficiency. In the cryogels containing antibacterial agents (PEO and chitosan), the growth of bacterial cultures tended to diminish at 2 h and 24 h, whereas it increased in plain cryogels. Compare to the PEO@GelCryo which had the highest antimicrobial activity at 12.06% against S. aureus and 7.77% against E. coli at 2 h, GelCryo–PEO@ChiCap showed the lowest antimicrobial activity, at 0.93% and 1.29% against S. aureus and E. coli, respectively. However, after 24 h incubation, GelCryo–PEO@ChiCap exhibited the highest inhibition against S. aureus and E. coli. This result could be related to the control release of PEO encapsulated in microcapsules. Also, cryogels loaded with chitosan microcapsules demonstrated antibacterial activity against S. aureus (8.29%) and E. coli (5.22%) in growth inhibition for 24 h. Batista et al. [a et al.  formulatEssential oils have been studied extensively for their antibacterial properties, and this property has been linked to essential oils’ capacity to permeate the outer membranes and cytoplasmic membranes of bacterial cells, leading the cell structures to break down and become more permeable ,56. It iThe results of the present study demonstrate that microencapsulated antibacterial compounds loaded into cryogels can be a promising alternative for delivering higher antibacterial activity long-term. Furthermore, cryogels can be designed to have specific properties, such as pore size, surface chemistry, and mechanical strength, to optimize antibacterial activity. The choice of gel precursors and crosslinking agents during cryogel synthesis can be tailored to achieve the desired characteristics. Further research is needed to fully understand the mechanisms of action and potential applications of essential oils as antimicrobial agents.S. aureus and E. coli after one-day incubation due to PEO, assumed to control the release from microcapsules. This demonstrated that PEO was encapsulated in the chitosan microcapsules. The preliminary results obtained have proven that PEO-encapsulated chitosan-particle-loaded gelatin cryogels can be further evaluated for additional functional applications. Future research should look into the effects of loading these composite gels with different bioactive compounds on their release behavior and the investigation of microbial activities during the release period.The incorporation of bioactive compounds, such as essential oils and plant extracts, into gel matrices has gained significant attention for its potential applications in various fields, including the food industry, drug delivery, and tissue engineering. The main purpose is to provide antibacterial properties to existing systems. The primary challenge observed in this context pertains to the rapid and burst release of the incorporated bioactive substance from the material. These findings indicate that essential oils do not elicit a chemical reaction with polymers, but rather manifest only as a physical attachment. For this reason, it is of utmost significance for long-term activity that the oil can be held inside the material. Based on this idea, PEO was microencapsulated in chitosan and incorporated into gelatin cryogels. A crosslinking reaction with glutaraldehyde in the presence of microcapsules resulted in a highly porous structure of both the gelatin matrix and the chitosan microcapsules. As a result, the cryogels’ increased surface area as a result of porosity led to a high rate of water retention and the development of hydrophilic characteristics on their surfaces. GelCryo–PEO@ChiCap was shown to have the highest inhibition against


M = 38.84; SD = 5.03). Questionnaires were administered on sociodemographic and behavioral data of the children, as well as a brief scale to assess parenting. Mann–Whitney U and MANOVA were used to analyze the influence of gender on perceived changes in children’s behavior and perceived parenting, respectively. Mothers perceived more significant changes than fathers in their children’s behavior. In addition, women reported more parental stress, greater child school support, and greater perceived positive parenting compared to men. These findings support the hypothesis that parenting developed differently in fathers and mothers. These results imply the need for psycho-educational intervention programs aimed at promoting greater involvement of fathers in parenting and better management of parental stress in mothers’ and family psychological well-being.In a previous Argentine study, we found that, in the critical context of social isolation during the COVID-19 pandemic, there were changes in maternal practices that influenced the relationship with their children. We also found that the impact of mandatory isolation was moderated positively by protective factors such as positive parenting and maternal school support or negatively by risk factors such as maternal stress. Although this study only analyzed maternal behavior, we were interested in studying the behavior of both parents, comparing the parenting  of the father and mother and the perceived behavioral changes in their children. A quantitative ex post facto study was carried out. The sample consisted of 120 Argentinean parents (70 mothers and 50 fathers) aged between 27 and 56 ( The COVID-19 pandemic was an extraordinary and unprecedented phenomenon because of its global impact. Combating the disease and developing ways to prevent it in a short time was one of the greatest challenges the world has faced in recent decades. Consequently, many of the measures taken by governments to contain the virus  had a negative impact on the mental health of family groups. In this direction, previous studies, e.g., ref. ,3. In adDuring the COVID-19 pandemic, compulsory social isolation, social and work conditions, and changes in education negatively influenced parenting practices, e.g., ,7,8. ManThe literature in the area has pointed out that positive parenting can act as a protective factor for children against stressful events  and as aAs for the children, a study that analyzed the impact of quarantine on Italian and Spanish children and adolescents  showed tIn recent decades, we have witnessed important changes in favor of gender equality that have resulted in greater involvement of fathers in the care and education of children. Nonetheless, parenting remains the most gender-typed role during adulthood ,20. MothSpecifically, during the pandemic, women reported a greater load of child care and housework  and moreIn this context, the present study aimed to compare changes in children’s behaviors and different parenting aspects as perceived by fathers and mothers during the COVID-19 pandemic.Based on the proposed objectives, the following hypotheses were formulated:Hypothesis 1.There are differences between fathers and mothers regarding the perception of behavioral changes in children during the pandemic.Hypothesis 2.Mothers perceive higher levels of parental stress, involvement in children’s school support, and positive parenting compared to fathers during the pandemic.The study was quantitative based on empirical data, descriptive, ex post facto, as it involves a comparison of DV across groups classified according to categorized and assigned variables . In addiM = 38.84; SD = 5.03) from different Argentine provinces. A non-probabilistic availability sampling method was used [The sample consisted of 120 parents  who accessed the online form and answered it completely. Participants were parents of school children aged between 27 and 56 years (was used . In addiThe inclusion criteria used were: (a) being over 18 years of age and (b) being a parent of schoolchildren (+5 and 12 years of age). Parents or caregivers of children with psychological, developmental, or learning disorders were not included in the study.Sociodemographic questionnaire. To collect information on the sociodemographic characteristics of the participants, an ad hoc semi-structured questionnaire was used to collect data on gender, age, occupation, and educational level.Questionnaire of perceived behavior of children. A semi-structured questionnaire was designed to assess changes in children’s behavior as perceived by parents during the pandemic. In the questionnaire, parents were asked whether they observed variations in their children’s behavior. The questionnaire mainly inquired about (a) behaviors observed in the children concerning sleep, eating habits, mood, and relationship with siblings and friends, and (b) behaviors observed concerning the children’s school situation: online classes, relationship with classmates, and compliance with school assignments. Response options were: less, the same, or more than before the pandemic . The content validity of the instrument was studied based on the criteria of expert judges, who were asked whether the behaviors assessed were relevant to analyze in the context of a pandemic. An adequate Aiken’s V coefficient (between 0.8 and 1) was obtained .2/gL = 1.22; NFI = 0.93; NNFI = 0.99; CFI = 0.99; IFI = 0.99; GFI = 0.99) and an acceptable error (RMSEA = 0.02). The reliability  was acceptable for the three dimensions: positive parenting (ω = 0.79), parenting stress (ω = 0.77), and school support (ω = 0.75) [The brief scale of perceived parenting during the pandemic . This in = 0.75) .All actions performed in the setting of this study followed the international ethical recommendations for research involving human subjects . In all Due to the confinement conditions of the pandemic, the invitation to participate in the study was made through social networks (Facebook 289.0.0.20.120. and Instagram 161.0.0.41.122), email , and instant messaging services . Data collection was conducted during the social isolation phase between September and December 2020. The information was collected through an online form , which included the instruments described in the previous section.For the description of the sociodemographic variables and the study variables, descriptive statistics were calculated: measures of central tendency , frequencies, and percentages. In addition, the skewness and kurtosis of the dimensions of perceived parenting were calculated. A Multivariate Analysis of Variance (MANOVA) was performed to compare perceived parenting as a function of parental gender.Given the qualitative nature of the variables, the Mann–Whitney U test was used to analyze changes in behavior as a function of parental gender.Data analysis was performed with SPSS version 25 software.p < 0.001; η2 = 0.23). Both positive parenting  = 7.16; p = 0.009; η2 = 0.06), parental stress  = 19.09; p < 0.001; η2 = 0.14), and involvement in school support  = 18.44; p < 0.001; η2 = 0.14) presented higher scores for mothers than for fathers.  during the pandemic.Regarding behavioral changes in children during the pandemic, differences were observed in the perception of fathers and mothers. Mothers, in particular, perceived more changes in all the behaviors evaluated. We hypothesize that since, in our culture, the mother is usually the most influential figure in parenting  and is mOn the other hand, the results showed significant differences in perceived parenting between fathers and mothers. First, mothers perceived that they had more positive parenting practices than fathers during the pandemic. These results are consistent with pre-pandemic studies, so this aspect would seem to respond more to socio-cultural influences than to the pandemic context. For example, in a study conducted in the Netherlands, mothers reported significantly more positive parenting practices than fathers . In anotRegarding parental stress, it appeared more highlighted in mothers, possibly because they were mainly responsible for children’s care and housework , while mFinally, mothers reported providing significantly more school support to their children than fathers. In this direction, some studies  have poiThe results for the three parenting aspects that indicated higher values for mothers support our second hypothesis: Mothers perceive higher levels of parental stress, involvement in children’s school support, and positive parenting compared to fathers during the pandemic.The main strength of this study is that it allows us to know how a challenging context such as the COVID-19 pandemic affected some characteristics of parenting. In addition, it provides insight into the perceptions of fathers and mothers concerning parenting in Argentine culture.However, the study conducted has some limitations that should be considered. First, the sample was purposive and non-probabilistic, and its size was small, making it unrepresentative of the Argentine population. For example, families from other social strata were not represented in these results, which is an important limitation considering that families of low socioeconomic status and with pre-existing problems in family relationships or mental health were more affected by multiple collateral effects of the pandemic ,50.In addition, due to the conditions of social isolation, self-reports of the parents were used, and the children’s perspective could not be considered in the evaluation. Future studies should also assess parenting and behavioral changes perceived by the children themselves. Regarding the evaluation of behavioral changes, only content validity was studied. The stability of the instrument could not be studied due to the fluctuating conditions of the pandemic context. On the other hand, since this was a cross-sectional study, it is not possible to determine whether the changes in behavior and perceived parenting were maintained over time or were modified after the pandemic. Therefore, it would be advisable to conduct a post-pandemic evaluation to know the long-term effects of the pandemic on both caregivers and children. Also, in this paper, we have mainly analyzed the role of gender in parenting and the perception of children’s behavior. However, there are many other contextual variables and individual differences that could be analyzed in future studies, such as social status, gender of children, age of parents and children, occupation, and number of children, among others.The results of the present study allow for delineating intervention strategies in challenging contexts  in the future. At the same time, it highlights the need to design, implement and evaluate parenting intervention programs to mitigate the long-term negative effects of the COVID-19 pandemic on parenting. These approaches should consider the differences in parenting beliefs and practices that exist between fathers and mothers. Such proposals could promote greater involvement of men in parenting. In particular, they should provide psycho-educational training to parents or caregivers to contain children and prevent their psychological distress. Indeed, the protective role that caregivers can have in the face of fear and stress during a pandemic is important , so timeIn short, during the COVID-19 pandemic quarantine, mothers perceived more behavioral changes than fathers. They also reported more positive parenting, more parental stress, and more school support than fathers. In this sense, we could say that a risk context such as social isolation during the COVID-19 pandemic highlighted and exposed characteristics that are present in the usual conditions of families and that, therefore, are more determined by already existing social patterns, in this case referring to gender differences present in the different cultures according to the studies reviewed. These findings make visible the specific challenges faced by families, especially mothers, during the critical period of compulsory social isolation during the pandemic. In particular, they highlight the importance of addressing the gender differences that imposed additional loads on women in families.


Non-alcoholic liver steatosis is currently considered an epidemic. It involves a broad spectrum of liver diseases, in which older adults constitute a susceptible group. The aim of this study is to identify the role of waist circumference as a risk factor for non-alcoholic fatty liver disease. Methods: A cross-sectional study was carried out in 99 older adults who regularly attended five gerontological centers in the city of Guayaquil, Ecuador. The variables studied were age, gender, independent life, access to complete meals, waist circumference, and NAFLD diagnosed by ultrasound. Results: A significant relationship exists between waist circumference, body mass index, and fat mass percentage. However, only age and waist circumference were significant in the multivariate logistic regression model. Our results suggest that in the presence of waist circumference, body mass index loses its significance and age may be a protective factor due to adipose tissue loss and redistribution. Conclusion: Anthropometric measurements such as waist circumference can be used as complement indicators of NAFLD. Non-alcoholic fatty liver disease (NAFLD) is characterized by the formation of a cluster of lipid vesicles around the internal structure of hepatocytes. The term was first coined in 1980 by Ludwing J., describing liver diseases that usually develop in alcoholic patients, when these are present in individuals who do not reach a toxic alcoholism level . Within It is estimated that within the general population, between 20% and 30% suffer from NAFLD, and the percentage increases to 70–80% in diabetic individuals , which mIn Guayaquil, Ecuador, 30 out of every 100 older adults show signs of NAFLD . TherefoThe research was a cross-sectional observational study performed between October and May from 2014 to 2016. This study was approved by the ethics committee of Clinica Kennedy in Guayaquil, Ecuador, on 5 March 2014. The participants were selected by a non-probabilistic convenience sampling method from 5 gerontological centers in Guayaquil, Ecuador. Informed consent was obtained from all the individuals who agreed to participate in the study. The sample was selected based on the following inclusion criteria: age ≥ 65 years, able to attend one of the 5 selected gerontological centers, and able to sign the informed consent. Moreover, subjects with the following characteristics were excluded from the study: consumption of alcohol in quantities > 20 g/day, reporting flatulence at the time of WC measurement, individuals with significant cognitive impairment, and history of liver diseases .Once the analysis was completed, each one was given a report of these results with a brief explanation; in addition, the food and transportation expenses previously stipulated in the protocol were covered.The patients who agreed to participate in the study were scheduled on a specific date for the application of some questionnaires, and the measurement of abdominal circumference and fat mass. Demographic data were collected and the Mini Nutritional Assessment (MNA)  was applMild (Grade 1): slight, diffuse increase in fine echoes in liver parenchyma with normal visualization of diaphragm and intrahepatic vessel borders;Moderate (Grade 2): moderate, diffuse increase in fine echoes with slightly impaired visualization of intrahepatic vessels and diaphragm;Severe (Grade 3): marked increase in fine echoes with poor or non-visualization of the intrahepatic vessel borders, diaphragm, and posterior right lobe of the liver.The abdominal and pelvic ultrasound was performed by a certified sonographer at the “Fundacion Damas del Honorable Cuerpo Consular” medical center, using a Siemens Sonoline G40 ultrasound. Non-alcoholic liver steatosis was defined by the ultrasonographic as the increase in echogenicity of the liver parenchyma in comparison with the renal cortex and spleen ,15. MoreDescriptive statistics were compiled using frequency tables and measures of central tendency. Normality tests were performed, and parametric or non-parametric tests for association were applied as appropriate. For correlation analysis, Pearson or Spearman tests were performed according to the distribution of the data. Moreover, association analysis was performed with a chi-squared test. In addition, a univariate logistic regression and a multivariate logistic regression were run to assess the factors that may influence the development of NAFLD. The dependent variable was the presence or absence of NAFLD. On the other hand, covariates included age, WC, BMI, and the percentage of fat mass.A total of 100 patients who met the inclusion criteria were invited to participate in the study; however, only 99 patients agreed to participate. p = 0.014). On the other hand, associations between sex, independence, complete meals, and age group were non-statistically significant (p > 0.05).The presence of NAFLD determined by echography was associated with the anthropometric variables. Logistic regression was performed to assess the factors that may increase the possibility to develop NAFLD. Two regressions were performed: a univariate logistic regression and a multivariate logistic regression. The first one was performed to assess the odds ratio for each variable as a unique factor. Then, multivariate logistic regression was performed to assess a predictive model. The method used was “intro” with the variable NAFLD  as the dependent variable.p values = 0.024 and 0.007, respectively. In addition, the percentage of fat mass is a variable that increases the risk for NAFLD 1.11 times (CI: 1.04–1.2); this was statistically significant (p = 0.004).The univariate regression analysis shows that overweight and obesity are direct factors for developing NAFLD (OR: 4.65 (CI: 1.22–17.62) and 7.33 (CI: 1.72–31.34), respectively). Both were statistically significant with p < 0.001); moreover, the model fits well within the data . This model explained the range from 19.3% to 26.9% of the variance with a total correct prediction of 72.4%, a specificity of 87.9%, and a sensitivity of 40.6%. However, only the age and the waist circumference were statistically significant . Age presented a negative coefficient (B = −0.115), indicating a decrease in risk with increasing age. On the other hand, the waist circumference presented a positive coefficient (B = 0.092) which indicates an increased risk for NAFLD. Finally, the constant in the model was not statistically significant, which indicates that there are variables that affect the model which is not taken into consideration. For the multivariate analysis, the covariates were the anthropometric variables and age recollected from the participants. There were 98 cases analyzed from the total population . The model was statistically significant . In spite of that, the multivariate logistic regression showed age as a significant factor that may reduce the probability of NAFLD . The literature describes an increase in body fat percentage in proportion to muscular mass due to age-induced sarcopenia [Studies report that NAFLD affects men more than women ; howeverrcopenia . Howeverrcopenia  and Macercopenia  who founp = 0.152).Moreover, some studies have suggested that conditions such as malnutrition have an influence on the development of an aggressive NAFLD ,26. Howep = 0.001). Average WC presents a seven-point increase in patients with NAFLD (no-NAFLD = 87.5 vs. NAFLD = 94.5). This is consistent with previous studies indicating the relationship between adiposity indicators and NAFLD [p = 0.018), indicating that people with high WC have a range from 1.017 to 1.197 times the probability to present NAFLD (OR = 1.104).Another risk factor that stands out in the development of NAFLD is waist circumference , which ind NAFLD ,33. Morep = 0.005), the multivariate logistic regression was not statistically significant (p = 0.319). This indicates that in the presence of the waist circumference, as an evaluation of abdominal adiposity, the BMI categories lose their significance. This effect has already been explored and reported by several authors [In addition, some studies present a significant relationship between BMI and the presence of NAFLD ,32,34,35 authors ,39,40,41p = 0.009); however, the odds ratio was not significant (p = 0.186). In contrast to our results, some studies have investigated the predictor power of the fat mass for NAFLD with statistically significant values [Finally, the percentage of fat mass was another statistically significant variable when analyzing the relationship with the presence of NAFLD (31.98 vs. 36.55, t values ,43.The predictive model expressed the importance of abdominal obesity in the development of NAFLD see . This isMoreover, the hyperinsulinemia state due to insulin resistance produces an inhibition of free fatty acid beta-oxidation with the promotion of hepatic fat accumulation as the principal consequence. Moreover, the lower levels of adiponectin may result in the promotion of a pro-inflammatory state. This, in addition to the secretion of pro-inflammatory cytokines, such as IL-6 and TNF-alpha, induced by free fatty acids will increase the insulin resistance state of the adipocytes ,45,46,47Finally, our model suggests that there is a protective effect of age, which is supported by the changes and fat redistribution produced by aging ,24. ConsThis study has several limitations. The sample is not representative for the study population, which may limit the generalizability of the results. Many variables which may influence the presence of NAFLD were not taken into consideration for this study, such as skeletal muscle mass and comorbidities related to metabolic syndrome including diabetes mellitus, hypertension, and dyslipidemia ,19,51. SNAFLD represents a public health problem, due to population trends showing an increase in risk factors such as obesity, hypertension, and metabolic syndrome. The use of anthropometric measures such as waist circumference is an indicator of risk for the development of the disease. However, even though many studies show the predictor value of variables such as BMI and fat mass percentage, we found an association with the presence of NAFLD, but no predictor capacity. This implies the use of anthropometric measures as a complement to predict the development of NAFLD.


This study evaluated the quality and usefulness of interactive mobile health  applications (apps) for adults with cancer. The PRISMA guidelines were followed to add rigor to the search, as well as to the data collection and analysis. The apps available in the most used app stores (Google Play and Apple) with interactive tailored features were identified. To supplement this, a Google web search was also conducted. The apps were evaluated for their quality using the validated Mobile App Rating Scale (MARS) and for their usefulness using a checklist of end users‘ desired features derived from the literature. The searches returned 3046 apps and 17 were retained for evaluation. The average quality score of the apps across the sample was 3.62/5 , with Outcomes4me scoring the highest. On average, the apps scored 50%  on the usefulness checklist, with Cancer.net scoring the highest. The lowest-scoring categories were communications features on the usefulness checklist and “information” on the MARS, indicating areas for future work. The findings identified the apps of an acceptable quality and usefulness that could be recommended to those with cancer. A rapidly accelerating avenue to better meet the needs of the growing population of people with cancer is using mobile and wireless devices (primarily smartphones), known as mHealth ,2,3. SinApps designed for those with cancer are no exception, with an ever-increasing number becoming available for download . There hMany mHealth cancer apps include interactive features, such as tracking medications, symptoms, and side effects . Often, Where relevant, the methods followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRIMSA) guidelines to introduce rigor . These iThe apps of interest were those that patients would be likely to identify themselves. Therefore, the focus was on apps that were free of charge (as payment is a barrier to patients using an app) ,38,39, dAn initial search was conducted in June 2020 and then updated in June 2022 to identify the apps published in the interim two years. In 2020, the Google Play store was searched using a Samsung Galaxy S6, then the availability of the apps was checked in the Apple Store. The following search terms were used: cancer, cancer patient, cancer patient app, mHealth cancer, cancer aid, cancer support, apps for cancer, cancer management, and help with cancer. In 2022, the same search terms and methods were used. Prior to the searches, the cache and search history on the app stores were cleared to minimize the results tailored to the phone user.After searching the apps stores, the search terms were entered into the Google search engine. In 2020, the first ten pages of results were verified; however, as few new apps were returned beyond the first two pages, the 2022 search was restricted to only these initial pages . Google After de-duplication, all the identified apps were screened in three stages: by title, then by description and preview screenshots, and finally through a download and verification of the app’s entire content. In the initial 2020 search, the screening at the title stage was completed by one author (AA) and the screening at the second and third stages were completed independently by two authors (AA and SW), who then met to compare their results. Few discrepancies were identified, and consensus was sought through discussion between the two authors. Any uncertainties were discussed at team meetings. If there was insufficient information available at one stage to assess the inclusion/exclusion criteria, the app was carried forward to the next stage. Prior to publication, the availability of the included apps was verified. Any previously retained apps that were no longer available were removed from the sample.The included apps were then evaluated for their quality and usefulness. Each app identified in 2020 was evaluated independently by two authors (AA and SW). The scores were compared and any discrepancies were discussed until a consensus was reached between the raters. In 2022, one of the two authors (SW) involved in the initial extraction completed the updated data collection. Any questions were addressed at team meetings.Each app was evaluated for its quality using the standardized Mobile App Rating Scale (MARS) . The MARThe authors were unable to identify an existing usefulness measure for cancer apps. As such, a 16-item usefulness checklist was developed based on seven studies (including a systematic review) ,45,46,47The app characteristics were also extracted. This information included: the date the app was last updated, country of origin, language(s) in which the app was available, target audience(s) , learning styles , type of publisher , and app store star rating in both the Apple and Google Play stores. The app store star ratings were added to reflect the end-user reviews of the apps. In this case, if an app did not receive enough reviews , the apps were given a score of N/A. Additionally, the country in which an app was developed was not always indicated. In such cases, if the developers were named, a search was conducted for their location and included as a likely proxy. The characteristics of the apps were verified again in July 2023 to ensure the most updated information was available before publication. At this stage, two apps, Lyfe and Oncopadi, were removed from the sample, as they were no longer available in either app store.The descriptive analyses were undertaken using Microsoft Excel. The means and standard deviations of all the items, subsections, and totals of the MARS and usefulness checklists were calculated for each app, as well as across the sample. The apps were ranked based on these results and the findings are otherwise detailed descriptively.n = 2012), 1034 apps were screened by description. Of these, 605 were excluded based on description. The main reasons for exclusion were: requiring payment, unrelated to cancer, non-English or French, designed to prevent cancer, and no interactive or tailored features. A further 410 apps were excluded at the download stage. The main reasons for exclusion were: no interactive or tailored feature, intended for health professionals or students, or only available in one store. With 2 apps no longer available in either app store, a total of 17 apps were included from both the 2020 and 2022 searches. All apps were last accessed on 19 July 2023.The results from the 2020 and 2022 searches are presented separately in n = 10), whereas most others were updated in 2022 (n = 5). The remaining two apps, Mindful USC and Virtual Hope, were updated in 2021 and 2019, respectively. Nearly all the apps were from the United States (n = 15), and the remaining two were from the United Kingdom (UK).See n = 12) fell into three categories: (a) five apps  allowed caregivers to sign in to receive information on helping them with their caregiving role, with information targeted specifically towards the caregivers; (b) five apps  allowed caregivers to create an account to monitor what the patients inputted and used on the app (no information was offered to the caregiver themselves); and (c) two apps (Mindful USC and Smiling Mind) acknowledged in the description that caregivers could help patients with using the app (but no caregiver account and no information for the caregiver).Ten apps were only available in English, whereas the other seven had options for more than one language, most often Spanish and French. Notably, Medisafe was available in 16 languages. In total, 4 apps were designed for use by patients living with cancer, whereas 12 targeted both patients and their caregivers, and 1 app was for patients, caregivers, and healthcare professionals . The apps designed for patients and their caregivers (n = 3), written and graphics (n = 10), written, and graphics and audio (n = 4). Nine apps were developed by healthcare institutions, one by an educational institution, and the remaining seven were from private companies. In terms of the star ratings (out of 5) in both app stores, the average star rating for all the apps was 4.24/5. The top star rated apps were Smiling Mind (4.8), Belong—Beating Cancer Together (4.75), Bezzy BC (4.65), and Medisafe (4.65).Additionally, the content was delivered to the users in a variety of ways, including written only  see . The topWhen examining each section of the MARS separately, out of a possible score of five, the apps scored the highest on the functionality (3.99) and aesthetics (3.75) sections. Medisafe (4.75) and Cancer.net (4.50) were the most functional apps . Outocmes4me, LLS Health Manager, and HeadHelp: Self Care & Vent all scored 4.67, the highest score in terms of aesthetics .n = 1) and two in descriptive analyses). Two apps  received a score of 4/5  and only two (PatientMPower and Medisafe) received a score of 5/5 . The remaining ten apps in our sample had not been evaluated (score of 1/5). For information quality, Virtual Hope Box (4.14) scored the highest, followed by Medisafe (3.71) and OWise—Prostate Cancer Support (3.71). Of note, the “engagement” section scored low, even though all the apps had to have at least one interactive tailored feature. This could be attributed to the two other items in the engagement section scoring low . The most engaging app was Virtual Hope Box (4.40).The lowest-scoring sections on the MARS were information quality (3.26) and engagement (3.51). Within the information section, “evidence-based” (2.24) and “visual information” (2.65) were the items least addressed. To receive full points for being “evidence-based”, the apps would have to have been trialed, with their outcomes evaluated in three or more high-quality randomized controlled trials (RCTs) with a positive result. Three apps  received a score of 3/5  were available in more than one language. Only Outcomes4me had tailored educational content for the user. Four of the top scoring apps had a self-monitoring feature and included tailored feedback, with only Virtual Hope Box lacking this element.The average total usefulness score across the sample was 50%  see , indicatn = 1, The Cancer Coach), having a glossary of cancer terms , and including a question prompt list .The lowest-scoring items on the usefulness checklist were: communication with healthcare professionals (n = 17), free to access to all parts of the app, as some other apps were free to download but required payment for additional features (n = 14), and being password protected/requiring a PIN (n = 13). The overall top five rated apps on this checklist were Cancer.net (88%), OWise (63%), Outcomes4me (63%), Belong—beating cancer together (63%), and CancerAid (63%). The highest-scoring items on this checklist were: having a privacy protocol  unexpectedly, most apps were designed to be used by patients and their caregivers; (b) the area of highest quality was “functionality”; (c) the higher-quality apps were not necessarily the most useful ones; and (d) most apps were not evidence-based or did not accommodate different learning styles.Most apps were developed for use by both patients and their caregivers. This demonstrates an increased recognition of the important role that caregivers play in patients’ care and the management of cancer-related challenges. Caregivers provide 80% of the care for adults with chronic diseases , positivAnother notable finding was that the highest-rated section on the MARS was “functionality”, which is consistent with other studies that have evaluated cancer mHealth apps ,33,36. FThe average usefulness score of the top five highest-quality apps was 46%. Where two of the highest-quality apps were among the most useful (Outcomes4me and OWise), the other top three scored below average on the usefulness checklist. This indicates that, despite their level of quality, apps do not include many of the features desired by patients. The apps included communication features the least. Effective communication between patients, caregivers, and their healthcare professionals has been shown to reduce patient burden . PotentiPrevious app evaluation studies have also found that the lowest-rated quality sections are “information” ,36 and “The items in the “engagement” section of the MARS were entertainment, interest, customization, interactivity, and appropriate for the target audience. The lowest-scoring item was “entertainment”, indicating that many apps were not fun to use or would not stimulate repeated use and lacked features such as gamification. Though less common, apps with gamification to promote health behavior changes tend to be more effective than those without gamification ,60. GamiThis study was conducted using reproducible and transparent methods to ensure rigor. Despite this, some limitations are noted. A patient evaluation of the apps was not within the scope of this paper. However, to palliate this limitation, we included a usefulness checklist based on end users’ perspectives in our evaluation, as well as star ratings. Due to the high turnover of apps, in the time between when the search was completed and the publication of this paper, more apps may have been developed. The apps in this study were all still available in both the Apple and Google play app stores in July 2023. Apps requiring an institutional login could not be evaluated. The authors contacted the developers of three known apps requiring an institutional log in, but access was not granted for this evaluation. Apps that required payment to access any (rather than only some) of their content were excluded, as payment is a barrier to access ,38,39. PThis study evaluated 17 apps for patients with cancer, identifying the key strengths and weaknesses of each in terms of their quality, usefulness, and characteristics. Based on the findings, patients and healthcare professionals can identify the top-rated apps. While many mHealth apps still lack both high-quality information and patients’ desired features, those that scored the highest were: Outcomes4me and OWise , as well as Cancer.net (in terms of usefulness). These findings may be used to inform future research for developing interactive mHealth apps that better address patient needs.