Lactobacillus, Bacteroidetes and Helicobacter exhibited significant differences between the groups. We further found that Lactobacillus iners, Lactobacillus crispatus, Lactobacillus gasseri and Lactobacillus jensenii were the most dominant Lactobacillus species and that L. iners was significantly different between the groups. Receiver operating characteristic (ROC) curve analysis confirmed that Ensifer had the highest predictive value for early embryonic arrest. In the uterine cavity, we determined that Proteobacteria, Bacteroidetes, Firmicutes and Actinobacteria were the dominant bacteria at the phylum level and that Bacteroides, Pseudarthrobacter, Lactobacillus and Ralstonia were the dominant genera. Further classification of Lactobacillus revealed that L. iners, L. crispatus, L. gasseri, and L. jensenii were the main species. There was a significant difference in L. jensenii between the normal pregnancy group and early embryonic arrest group. Random forest analysis revealed 18 different genera in the uterus, and ROC curve analysis indicated that Candidatus Symbiobacter, Odoribacter, Blautia, Nocardioides and Ileibacterium had a certain predictive value.The aim of this study was to explore the microecological distribution and differences in the uterus and vaginal microbiome in women with early embryonic arrest and those with normal pregnancy by high-throughput sequencing. We systematically sampled the vaginal and uterine microbiomes of 56 pregnant women, namely, 38 patients with early embryonic arrest and 18 pregnant women with normal pregnancy-induced abortion. We obtained colonization data by 16S rRNA gene amplicon sequencing. In the vagina,  G. vaginalis in patients with embryo arrest is significantly higher than that in individuals without embryo arrest , Prevotella spp. and Lactobacillus crispatus (L. crispatus), and the endometrial bacteria are characterized by a polymicrobial ecosystem in the pregnant women (With the development of next-generation sequencing (NGS), it has become evident that the endometrium not a sterile environment and that the species diversity and richness of the endometrial community are significantly higher than those of the vaginal environment . The utent women . Changesnt women .Previous literature has reported the isolation of vaginal microorganisms from the endometrium in 31.4% of women with acute salpingitis and 14.3% of women with pregnancy loss . BacteriSamples were collected from December 2021 to April 2022 in the Obstetrics Clinic of Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China. 16S rRNA sequencing was performed on vaginal secretions and endometrial samples from 18 pregnant women with normal early pregnancy (N1–N18) and 38 patients with early pregnancy embryonic arrest (T1–T38). Both groups conceived naturally and needed negative pressure suction for artificial termination of pregnancy at 7–10 weeks of pregnancy. The inclusion criteria were as follows: (1) regular menstruation; (2) normal reproductive system development, no comorbidities such as immune diseases, chronic diseases or uterine organic lesions; and (3) no history of exposure to radioactivity or toxic substances, among others; (4) early pregnancy and the presence of a single intrauterine pregnancy sac by ultrasound; (5) exclusion of chromosomal disease in both parents and no family history of genetic conditions; (6) no obvious abnormalities by early laboratory testing, including positive indicators such as mycoplasma, chlamydia, syphilis, AIDS and hepatitis B virus; and (7) no history of sexual activity or vaginal lavage within 3 days before specimen collection, no history of antibiotic medication use in the previous 1 month, and no history of hormone medication in the previous 3 months.All participants who met the experimental standards and signed an informed consent form received a gynecological examination conducted by a professional obstetrician. All samples were collected before artificial termination of pregnancy by negative pressure suction. Two sterile cotton swabs were used to collect secretions of the inner wall of the vagina. One of them was tested for the morphology and physicochemical properties of the vaginal secretions, and the other was stored at −80°C for 16S rRNA sequencing. Before the collection of endometrial specimens, a sterile speculum was inserted into the vagina so that the external orifice of the cervix could be seen. To minimize contamination of the vaginal wall and external cervical os with the endometrial microbiome, the cervix was cleaned with gauze soaked in iodine solution prior to endometrial biopsy. According to the literature , we usedCandida spp. spores, blastospores and pseudohyphae, Trichomonas vaginalis counts, clue cell counts, bacterial density, flora diversity and dominant bacteria. Observations followed the National External Quality Assessment System (NSEQA) and College of American Pathologists (CAP) guidelines  was used to build the library. The Illumina HiSeq Rapid SBS Kit v2 was used for high-throughput sequencing. FLASH was used to splice double-ended sequences. QIIME was used to separate each sample sequence from raw reads based on the barcode, and the barcode sequence was cut off. Based on Usearch software,p < 0.05 indicated that the differences were statistically significant.The data were analyzed with SPSS statistical software SPSS 22.0 . The results of normal distribution between groups are expressed as the mean ± standard deviation, and the samples were analyzed by t test. The Kruskal–Wallis test was used for the analysis of microbial differences. p > 0.05).The clinical characteristics of the pregnant women enrolled in this study are shown in There was no significant difference in vaginal PH, vulvovaginal candidiasis (VVC) or trichomonas vaginitis (TV) between the early embryonic arrest group and the normal pregnancy-induced abortion group. However, the rates of bacterial vaginosis (BV) and vaginal microecological dysbiosis in the early embryonic arrest group were higher than those in the normal pregnancy induced-abortion group .p < 0.05; p = 0.01, r = 0.13) and the unweighted UniFrac index  exhibited significant differences in bacterial composition . At the genus level, the top 10 genera based on abundance are shown in lactobacilli in the normal pregnancy-induced abortion group was higher than that in the embryonic arrest group (p < 0.05). Accordingly, the abundance of Bacteroides and Helicobacter in the early embryonic arrest group was higher than that in the normal pregnancy-induced abortion group (p < 0.05). The abundances of Lactobacillus, Gardnerella, Helicobacter, Prevotella 9, Ralstonia, Bacteroides and Pseudomonas were higher than 1% in both the normal pregnancy and embryonic arrest groups . In the embryonic arrest group, the proportion of L. iners was significantly decreased  analyses with a linear discriminant analysis (LDA) value of 4.0 at the genus level to identify specific microbial communities in both groups . LEfSe ancreased . The Lacst group . We furtbacteria . There wecreased .Ensifer and Devosia had the highest predictive value. The AUC of Ensifer was 0.82, and the AUC of Devosia was 0.80. The AUCs of Bosea, Cellulomonas, Helicobacter and Sphingopyxis had a certain predictive value , the potential biomarkers of vaginal swabs for the predictive model of embryonic arrest occurrence were examined by the random forest algorithm among the ten different bacterial genera . The tarve value .p > 0.05; p > 0.05; Among the 56 intrauterine tissue samples, there were 38 intrauterine tissue samples in the early embryonic arrest group and 18 intrauterine tissue samples in the normal pregnancy group. A total of 1,920,598 reads were produced by Illumina MiSeq, with an average read count of approximately 34,296 .Proteobacteria, Bacteroidetes, Firmicutes, Actinobacteria and Epsilonbacteraeota were the dominant phyla in the endometrial microbiota in both groups . At the h groups . In the bacteria . The abuEubacterium xylanophilum group was the highest. The AUC was 0.76. The AUCs of Candidatus Symbiobacter, Odoribacter, Blautia, Nocardioides, and Ileibacterium had a certain predictive value , the success rate of IVF is higher if only Lactobacillus is present in the vagina at different time points. Lactobacillus may play a certain role in pregnancy, embryo colonization and normal development during pregnancy , L. gasseri (CST II), L. Iners (CST III) and L. jenesii (CST V). CST IV is characterized by low levels or absence of Lactobacillus (lactobacilli in the vagina during pregnancy are dominated mainly by L. crispatus (CST I). In addition, the higher the abundance of L. crispatus is, the lower the abundance of other Lactobacillus species will be , but the abundance of L. iners in the embryo-arrest group was significantly lower than that in the normal pregnancy group ). The patients/participants provided their written informed consent to participate in this study.LW and ML contributed to the study design. LH, JC, HLiu, and YL completed all tests. LW, ML and WL analyzed the data and drafted this paper. HLi and ZL contributed to reagent management. All authors contributed to the article and approved the submitted version.The clinical case screening and data collection were supported by the Chengdu Science and Technology Bureau: technology innovation research and development project [2021-YF05-00648-SN] and Chengdu Medical Research Project [2022203].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.


Although some studies have reported that case management (CM), when is compared with standard care, reduces the loss of contact with health services, the debate continues about its superiority over other treatment models.To assess treatment adherence and reasons for treatment discontinuation, and the impact of the type of APs administration on it, for a group of patients with schizophrenia treated in a CMP or receiving standard treatment in mental health units (MHUs).An observational, longitudinal study (ten-year follow-up) was conducted on 688 patients with severe schizophrenia (CGI-S ≥ 5). All the causes of the end of treatment were recorded, together with the AP medication prescribed and kind of regimes.43.6% of the patients had discontinued treatment in MHUs and only 12.1% on the CMP (p < 0.0001). 27.6% of patients in MHUs were on long-acting injectables (LAIs), and 57.6 on the CMP (p < 0.001). Treatment discontinuation was closely linked to be on OAPs medication in both cases (p < 0.001).Our findings show how specific strategies as programs with an integrated treatment and case-managed approach, increase adherence. Moreover, treating with LAI APs clearly contributes to the achievement of these results. The widespread implementation of comprehensive community programs with case management, and the use of LAI-APs, should be an effective choice for people with schizophrenia and clinical severity and impairment, and at high risk of treatment discontinuation.None Declared


Related to psychological mechanisms, a low level of anxiety, seemed to be a significant predictor of all-cause mortality. We found no advantage for patients who had received psychosocial therapy in terms of survival. Conclusion: These first data confirmed our hypothesis about the association of psychological risk factors with the long-term outcome of CAD patients. Future studies will clarify whether the severity of disease, age or a particular type of coping or denial mechanism are associated with the presented outcome in low-anxious patients.Introduction: Behavioral and physiological risk factors worsen the prognosis of coronary heart disease (CHD). Anxiety is known to be a psychological predictor of CHD. In this study, we investigated whether this factor is associated with all-cause mortality in CHD patients in the long term. Methods: We studied 180 patients  with CHD from the Berlin Anxiety Trial (BAT) and the Stepwise Psychotherapy Intervention for Reducing Risk in Coronary Artery Disease (SPIRR-CAD) study. Their cardiac and psychological risk profile was represented by standardized procedures, including the Hospital Anxiety and Depression Scale (HADS) questionnaire. Mortality outcomes were assessed using a community-based registry. Results: Of 180 patients, we obtained information on all-cause mortality in 175 (96.7%) after a mean follow-up of 12.2 years (range 10.4–16.6 years). Of all participants, 54.4% had prior myocardial infarction, 95.3% had percutaneous transluminal coronary angioplasty and 22.2% had prior coronary artery bypass graft. Most of the patients (98.4%) had New York Heart Association class I and II, 25.6% had diabetes and 38.2% were smokers. Patients had a mean HADS anxiety score of 9.7 SD 4.1 at study entrance. We found the highest HADS anxiety quartile all-cause mortality in 14%, 30.2% in the middle quartiles and 58.7% in the lowest quartile (chi Symptoms of anxiety are frequent among patients with coronary heart disease (CHD) , with prHowever, evidence for anxiety as a prognostic risk factor is still conflicting and other studies have even found significant protective effects of anxiety on CHD ,15.Clinical and preclinical studies have gathered evidence that stress response alterations play a major role in the pathophysiology and therapy of anxiety disorders . ChangesAnxiety is dependent on the patient’s physical condition, various endocrinological and autonomic stress mechanisms, as well as neuropeptide levels and the type and timing of measurement. A certain level of anxiety can be interpreted as natural and necessary for patients living with heart disease, and in severe disease, repressive coping can influence the level of anxiety ,22.In a review, Celano et al.  stated tn = 180 patients who were included in one of three studies from 2004 to 2010. These were, the Berlin Anxiety trial (BAT), the Stepwise Psychotherapy Intervention for Reducing Risk in Coronary Artery Disease (SPIRR-CAD) trial (Centre Berlin) and the SPIRR-CAD pilot study. The flow chart  in the study sample was examined over a period of 1.5 years, and group therapy as an intervention was offered and the effects of symptom reduction were tested.The pilot study consecutively included The BAT was a randomized controlled trial, which included 62 patients with CHD and elevated levels of anxiety (>7 on the HADS), also recruited from Charité Berlin and the German Heart Centre Berlin, between May and December 2008. Inclusion criteria were a maximum age of 75 years, and a history of myocardial infarction (MI) or angiographically documented CHD. For the first time, this study investigated the effects of a psychotherapeutic intervention in anxious CAD patients over a course of six months .n = 570 patients aged 18 to 75, with recent coronary angiograms and a depression score of >7 on the HADS [The SPIRR-CAD trial was a large randomized controlled multicenter trial, comparing usual care in CAD patients to usual care, combined with a psychotherapeutic intervention. It included a total of the HADS . N = 61 More detailed descriptions of these studies can be found elsewhere ,25,26.Data on survival were collected using two sources of information. One source was the patient recording system of the Charité Berlin. The second source was the German civil register, where it is possible to obtain information on whether persons are deceased or still registered as alive.Data for statistical analyses were taken from the original trials, as mentioned above.The study presented here is based on data gathered during the above-mentioned studies and a subsequent follow-up for all-cause mortality. Working hypotheses of the main follow-up examination were that psychological factors, especially depression, as well as social factors and gender, play a role in the long-term prognosis of CAD patients .Due to our study aim, to demonstrate whether high anxiety is important for all-cause mortality in CHD patients 12 years after an acute coronary event, in this sub-study, we focused on the anxiety dimension.Operationalization of our study intent was directly dependent on the data presented in the three baseline trials, which all used a very similar cardiovascular and psychological data set. Measures of all three trials were examined with the intent not to lose too much information on the one hand, and to avoid a high missing rates on the other hand. The three basic trials all used the HADS questionnaire, so we decided to use this measure to assess psychological strain. As an additional measure of social distress, we used the information regarding whether the patients lived alone or with a partner.Anxiety was assessed by the German version of the Hospital Anxiety and Depression Scale (HADS) ,29. It iThe 14-item type D scale (DS-14) , with thStructured rating interviews for the assessment of Axis I mental disorders, according to DSM-IV, applied by using the SCID  in the STo expand our anxiety measurement, we used additionally:In the original studies, we measured HADS anxiety scores at baseline (T0) and 6 months (T2) later in the control and intervention groups. Patients in the intervention group had received 15 sessions of group-based psychotherapy and/or three individual supportive-expressive sessions of individual psychotherapy, respectively. An outcome criterion in the original studies was the reduction in anxiety scores (HADS score), which had decreased significantly in both the IG and CG groups ,26.t-tests or, in case of violation of requirements of t-tests and not normally distributed data, with the Mann–Whitney U test, respectively. Hypotheses were tested using chi-square tests between anxiety groups and survival rates. A stepwise logistic regression and the cox regression models of proportional hazards were used to control for the effects of disease severity and the effects of medical diseases other than anxiety severity in CHD. A predefined subset of variables was entered into the analyses. Age, history of MI, LVEF and smoking were used as predictors of survival besides anxiety in patients with CHD. In addition, we included physical activity and dietary habits in the model. Missing structure was tested via Little’s test. Analyses were done using SPSS version 27. All tests were two-tailed and statistical significance was defined as p < 0.05 for all analyses.Baseline characteristics were described and tested using cross tables for nominal data. Metric data were tested with The protocol of this study was approved by the Ethics Committee of the Charité, University Medicine Berlin (EA4/168/19).We studied 180 patients  with CHD from the three previous CHD studies in Berlin. After a mean follow-up of 12.2 years (range 10.4–16.6 years), we reached 175 (97.2%) of these patients and found that 116 (66.3%) were alive and 59 (33.7%) deceased.Patient characteristics at baseline are described in The anxiety groups did not differ in any of the demographic variables, but the patients without anxiety were sicker, had a higher NYHA class, were more likely to be smokers, had a lower BMI and a higher age compared to the patients with moderate and high anxiety.p = 0.001); non-anxious subjects being significantly older (m = 65 years) than moderate-anxious  and high-anxious patients ; in smoking status , having more smokers in the non-anxious group; and tNYHA class , with more patients with high NYHA in the non-anxious group.Comparing high anxious, moderate anxious and non-anxious patients regarding somatic and psychometric variables, we found significant differences in age  = 16.7; Mean HADS anxiety scores differed between the groups, along with mean HADS depression scores. The second evaluation of HADS anxiety, 6 months after baseline evaluation, showed that the treatment and control groups had lower values compared to the first evaluation, for both. Negative affectivity on the DS 14 was found to be 88.6% in the high-anxiety group and 86.2% in the moderate-anxiety group. In the anxiety-free group, 53.2% of patients were positive for negative affectivity and 36.2% for social inhibition. In half of the patients in the no-anxiety group we also found psychological problems, which could not be detected by the HADS anxiety scale. The comparison of anxiety disorders in both groups demonstrated a high proportion of anxiety disorders in the highest quartile (52.2%), followed by the medium quartiles (29.6%). In the no-anxiety group, we found no diagnoses of anxiety disorder . In summp < 0.01) were found in both groups in the HADS anxiety scale, but no significant differences between the groups were observed. Similar reductions were seen in the SPIRR-CAD trial, Berlin Center [At the 6-month follow-up in the anxiety trial , signifin Center . In the n Center , self-se2 20.8, p = 0.001), indicating that higher anxiety was associated with lower mortality.Until follow-up, 59 of the 175 patients with valid data had died: 14% in the highest HADS anxiety quartile, 30.2% in the two middle quartiles and 58.7% in the lowest quartile  of anxiety with BMI (r = 0.20), systolic blood pressure (r = −0.18) and age (r = −0.33), but not with family history of MI and other cardiovascular risk factors.p < 0.001) and baseline anxiety  had a significant influence on survival . LVEF (p= 0.059) and smoking (p = 0.079) became nearly significant in that model. When physical activity and dietary habits  were included in the model, again, age, anxiety and additionally LVEF  became significant, but physical activity , dietary habits and previous MI did not.In a logistic regression analysis, our results indicated that of the included parameters , only age  of the intervention patients and 68 (67.3%) of the controls survived. The change in HADS anxiety scores within 6 months of the original treatment trials in each group had no effect on survival.There is an ongoing discussion regarding whether anxiety or depression is an important risk factor for CHD prognosis. In this study we wanted to focus on anxiety, which is more in question as a cardiovascular risk factor than one for depression ,7,8.p = 0.04) and cardiac mortality  after two years. In contrast to these findings, we found a high survival in high- and moderate-anxious CHD patients after 12.2 years.The present study shows different disease severity, cardiovascular risk factors and age between high-, moderate- and no-anxiety CHD patients. Related to psychological mechanisms, a significant predictor of all-cause mortality was a low level of anxiety. In former treatment studies of these patients, a significant decrease of anxiety scores over time in treatment and control groups has been demonstrated without advantages for the psychosocial intervention ,26. We wWhen examining all-cause mortality, in 97.2% of our study sample, 12 years after MI/UAP, we received no information about cardiac death, recurrent MI, or PCI in the following period, especially in the first three years.(1)Between anxiety as risk of incident coronary heart disease, which has demonstrated convincing effects .(2)That after a cardiovascular event, anxiety as a trigger for new cardiovascular events in a short time perspective seems to be a risk ,9. An al(3)In a long-term perspective, several samples have shown that anxiety is not a risk factor, 5 years after exercise testing ,34 or 5 Looking at the literature of anxiety and CHD, we should differentiate:We think that the perception of anxiety is related to clinical, biological, and psychological factors that have an impact on the level of anxiety experienced by people with CHD . In addiThe measurement of anxiety symptoms could have an influence on our results: we applied the HADS-A as an anxiety measurement, which collects general anxiety symptoms. This was also used in a recent treatment study . Other aThe coping behavior and an avoiding coping style could interact and guide to low anxiety values . FrasureAnxiety could have positive influences on patients’ illness behavior. Patients with a nonphobic type of anxiety could see their doctors more frequently . ModeratWe have shown that B-type natriuretic peptides are correlated to LVEF and NYHA, and this may lead to anxiolytic effects ,21 in thAnxiety in CHD patients was associated with the cortisol-awakening response: a strong and significant increase in the cortisol-awakening response (AUCi) in CHD patients with anxiety contrasted with a low AUCi after the sleep period in CHD patients without anxiety ,27. In tIn the first pilot study, we included patients aged 30 to 84 years, and in the other studies, the age of patients was 75 and younger. Therefore, we got a higher variance, but age was negatively correlated with anxiety and could have influenced both, anxiety and survival.Treatment AspectsIt is important to note that intervention effects in positive treatment studies were based on stable or increasing anxiety scores in the control group, compared to the expected decrease in the intervention group. This effect could be observed only in the pilot study .We investigated the effects in a group of medically stable CHD patients, eliminating the previously observed effect of spontaneous remissions that might occur in patients in the first month after MI or CABG.We used an RCT design in two small, but homogenous, groups of CHD patients, which had focused on HADS anxiety  and HADSThe combined, here-presented study shows comparable reductions of anxiety in the intervention group, but anxiety scores in the control group decreased, as well ,26.In contrary to our expectations, the decrease of anxiety in these studies in the intervention, as well as in the control groups, was not associated with a higher survival rate. An effect of the psychosocial intervention on survival could not be demonstrated. This was also summarized by Blumenthal et al. , who fouLimitationOur results are somewhat surprising and contrast with some studies in the literature. There are several reasons for these results:The paradox result could be based on our study design and the relatively naïve study hypothesis, related to a simple two-factor association: anxiety and survival. Many factors could have intervened.We have presented a selected sample of CHD patients admitted to a university hospital and the German Heart Center Berlin of the city of Berlin, with 3.7 million inhabitants and the surrounding of Brandenburg.Patients were asked after an acute cardiovascular event if they are interested to join in a psychosocial treatment study. Hence, the motivation to join these studies was a first-selecting criteria. Several inclusion and exclusion criteria were additionally used to select this group of 180 CHD patients from three former treatment studies. As a result, a selection bias of our sample cannot be neglected.Twenty-seven patients in the pilot study met the anxiety criteria and 18 patients had low anxiety levels. In the BAT study, all patients met the anxiety criteria see , which cWe have used different instruments to demonstrate anxiety, but we have not differentiated between state and trait anxiety, and the special situation of patients confronted with a severe disease: we have not differentiated between “normal” and “pathological anxiety”, which also depends on physical symptoms and the status of a patient. Therefore, we have also accepted a reporting bias. In conclusion, this study shows the difficulty of measuring and improving psychological distress in patients with CHD. One possible explanation is that anxiety is a too-heterogenous concept and influenced by many physical and psychological factors. Additionally, a study with a less pre-selected sample of heart patients could be more informative.Interventions have shown not to be effective, and additional outcome criteria, such as active coping  or type It is not surprising that the short time effects of presented studies are in line with longtime survival of our examined CHD patients. We found no differences in survival between treated and control patients. Whether anxiety is only a predictor of the occurrence of coronary artery disease , or whetIn contrast to previous short-term follow-up studies, after major adverse coronary event (MACE), in our long-term follow-up study, high-anxious patients with CHD did not have a higher all-cause mortality than low-anxious patients. There seems to be a differential relationship between cardiovascular prognosis after MACE and anxiety: in a short-term perspective, it is associated with new cardiovascular events and mortality; in a chronic disease setting after 12 years, other chronic disease factors are more important. In addition, our study showed that elevated anxiety levels decreased over time in two studies, but there was no association with all-cause mortality and no statistically significant difference between IG and CG in all-cause mortality. Future research on anxiety after MACE and the association with recurrent MACE is needed for both short and long terms.


Objective: To evaluate the genetic causality between alcohol intake, smoking, coffee consumption, and arthritis. Methods: Mendelian randomization (MR) studies with alcohol, smoking, and coffee consumption behaviors as exposures, and osteoarthritis (OA) and rheumatoid arthritis (RA) as outcomes were retrieved from up to July 2023. Two researchers with relevant professional backgrounds independently assessed the quality and extracted data from the included studies. Meanwhile, we applied MR analyses of four lifestyle exposures and five arthritis outcomes (two for OA and three for RA) with gene-wide association study (GWAS) data that were different from the included studies, and the results were also included in the meta-analysis. Statistical analyses were performed using Stata 16.0 and R software version 4.3.1. Results: A total of 84 studies were assessed. Of these, 11 were selected for meta-analysis. As a whole, the included studies were considered to be at a low risk of bias and were of high quality. Results of the meta-analysis showed no significant genetic causality between alcohol intake and arthritis (odds ratio (OR): 1.02 (0.94–1.11)). Smoking and arthritis had a positive genetic causal association (OR: 1.44 (1.27–1.64)) with both OA (1.44 (1.22–1.71)) and RA (1.37 (1.26–1.50)). Coffee consumption and arthritis also had a positive genetic causal association (OR: 1.02 (1.01–1.03)). Results from the subgroup analysis showed a positive genetic causality between coffee consumption and both OA (OR: 1.02 (1.00–1.03)) and RA (OR: 1.56 (1.19–2.05)). Conclusion: There is positive genetic causality between smoking and coffee consumption and arthritis (OA and RA), while there is insufficient evidence for genetic causality between alcohol intake and arthritis. Arthritis is an inflammatory disease that occurs in the joints and causes structural damage and pain, with osteoarthritis (OA) and rheumatoid arthritis (RA) being the most common types of arthritis . OsteoarLifestyle provides great influences on arthritis onset and progression, and such is the case for OA and RA ,8. ObserMendelian randomization (MR) is an epidemiological study method that uses genetic variants associated with potential risk factors as instrumental variables (IVs) to explore the genetic causality between exposure and outcome . In MR, In the past few years, the potential causal relationships between arthritis and alcohol, smoking, and coffee consumption have been examined using MR methods ,25,26,27We obtained GWAS datasets from a study of 1.2 million people with alcoholic drinks per week and cigarette smoking initiation . Meanwhiwww.finngen.fi/en, accessed on 7 September 2023), and the three outcomes of seropositive rheumatoid arthritis, seronegative rheumatoid arthritis, and rheumatoid arthritis meeting the definition of M13  were selected.For outcomes, we obtained the GWAS dataset for OA from a genome-wide meta-analysis of up to 826,690 individuals  . The sump < 5 × 10−8 were selected and the SNPs with the linkage disequilibrium effect were removed . We then screened and excluded SNPs (p < 5 × 10−8) associated with confounders (body mass index was removed when OA was used as the outcome) using the PhenoScanner database . In addition, to further exclude possible associations between IVs and outcome, we excluded SNPs associated with outcome (p < 5 × 10−8). We also excluded palindromic variants that could not be oriented . F statistics were also computed, and the selected IVs all satisfied F > 10 to avoid possible bias caused by weak instrumental variables [To ensure that the IVs met the three basic assumptions of MR with sufficient validity, we used stringent conditions to screen single nucleotide polymorphisms (SNPs). First, SNPs significantly associated with exposure at the genome-wide level ariables .2 index and Cochran’s Q statistic were calculated using IVW analyses to assess heterogeneity. Potential horizontal pleiotropy between IVs was demonstrated by the intercept of the MR-Egger method [p < 0.05 and returns the corrected causal effects [The inverse-variance weighted (IVW) method was used for primary analysis, and the weighted model was used for secondary analyses. The IVW method assumes that all IVs are valid, and provides the most accurate estimates based on the calculation of Wald ratios . The weir method . MR-PRES effects .All statistical data analyses were performed using the TwoSampleMR package and the MendelR package in R software version 4.3.1.This study is based on the 2020 update of the (PRISMA-P) guidelines and is registered with PROSPERO (CRD42022375445). We searched the MEDLINE, EMBASE, and Cochrane Library databases using the following key words: alcohol, drinking, smoking, cigarette, coffee, Mendelian randomization, and osteoarthritis, rheumatoid arthritis, arthritis. The search period was from the time that each database was created to July 2023. The search process was not qualified otherwise.Any studies using the MR method to investigate causality between risk factors and osteoarthritis/rheumatoid arthritis or related phenotypes.Any studies on gender, age, cohort, and race.Any studies that include MR as part of their analysis.The inclusion criteria for the retrieved studies were as follows:Any case reports, narrative reviews, or other non-research-based studies.Any studies that did not include alcohol/smoking/coffee consumption in the exposures or OA/RA in the outcomes.Any studies of non-European origin cohorts.Any studies for which the complete English manuscript is not available.The exclusion criteria were as follows:Two trained researchers with relevant professional backgrounds independently read titles and abstracts of the literature. By reading the full text of all articles that met the inclusion criteria, researchers extracted information about specific methods and measures from the study design. We extracted data from the included literature and assessed the study quality based on the Guidelines for Strengthening the Reporting of Mendelian Randomization Studies (STROBE-MR) and its expansion statement, while referring to the Mendelian Randomization Reading Guide ,36,37.p value < 0.05 under a random-effects model was considered statistically significant. Inverse variance weighted (IVW) estimates were used as the primary analysis and the results of the weighted median method (WM) were used as a sensitivity analysis.Meta-analyses were performed using the “metan” command in Stata 16.0 to obtain pooled effect estimates. The primary outcome was the risk of diagnosis and development of arthritis, and subgroup analyses were performed for OA and RA. Since alcohol, smoking, and coffee consumption affect all parts of the body, OA and RA in different parts of the body or different subtypes are considered the same outcome to explore the overall impact on the disease. We used ORs and 95% confidence intervals to report pooled estimates of the causal effect between lifestyle and arthritis, and a two-sided p > 0.05), as well as no outliers in the MR-PRESSO method. Detailed results of the analyses and sensitivity analyses are available in the The results of the MR analyses of lifestyle on OA and RA are displayed in From the databases Medline, Embase, and the Cochrane Library, 23, 52, and 9 studies, were included, respectively. After reading the abstracts of the literature titles by the evaluators and excluding other apparently irrelevant studies, 14 studies were initially included. After reading the full text and excluding three studies that did not contain the index of interest, 11 studies were finally included. All 11 studies were in the English language and conducted by applying MR to alcohol intake, smoking, and coffee consumption as exposures, with OA and RA as the primary outcomes. The studies were published between 2018 and 2022. The included populations were of European origin, and the UK Biobank was the most used study cohort. Study characteristics of all the 11 included literature are shown in To examine the causal relationship between lifestyle and arthritis, a total of two studies related to alcohol intake ,18, fiveWe performed a meta-analysis using a random-effects model on the inverse variance weighted method estimates of the two included studies and our 10 MR analyses. The results showed that alcohol intake was positively associated with arthritis overall (OR: 1.02 (0.94–1.11)), but not statistically significant . SubgrouWe then performed a meta-analysis of the estimates obtained using the weighted median method as a sensitivity analysis to assess the robustness of the IVW analysis. The combined results of the weighted median method under a random-effects model were consistent with previous results, with insufficient evidence of genetic causality between alcohol intake and arthritis overall (OR: 1.09 (0.99–1.19)). Subgroup analyses also reported insufficient evidence to support a genetic causality between alcohol and OA or RA (ORs: OA: 1.08 (0.98–1.20), RA: 1.09 (0.91–1.30)) .We performed a meta-analysis of the estimates of genetic causal effects between smoking behavior and arthritis, with outcomes obtained by the inverse variance weighted method using a random-effects model. The results revealed a positive causal association between smoking behavior and arthritis (OR: 1.44 (1.27–1.64)) . A subgrAs a sensitivity analysis, a meta-analysis of the genetic causal effect estimates of smoking behavior for all arthritis outcomes obtained using the weighted median method was performed. The results of the random-effects model remained consistent with previous studies, reporting a positive genetic causality between smoking behavior and arthritis (OR: 1.42 (1.24–1.63)) . The subA meta-analysis was performed on the estimates of the genetic causal effects between coffee consumption and arthritis with outcomes obtained by the inverse variance weighted method using a random-effects model. The results revealed a positive causal association between coffee consumption and arthritis (OR: 1.02 (1.01–1.03)) . DividedAs a sensitivity analysis, a meta-analysis of the genetic causal effect estimates of coffee consumption for all arthritis outcomes obtained using the weighted median method was performed. The results of the random effects model remained consistent with the findings of previous studies, and suggested a positive genetic causality between coffee consumption and arthritis (OR: 1.01 (1.00–1.02)) . The subThis study assessed the genetic causality between lifestyle and arthritis by applying MR methods and a meta-analysis of past MR studies, leading to the following findings: there was a significant positive causal relationship between smoking behavior and coffee consumption and arthritis (OA and RA). The strength of the genetic causal relationship of smoking for OA and RA were roughly equivalent, and the genetic causal relationship between coffee consumption and RA was more significant than that between coffee consumption and OA. There is insufficient evidence of a genetic causal relationship between alcohol intake and arthritis. These findings are consistent with the vast majority of qualitative analyses of alcohol, smoking, and coffee consumption. Overall, the included studies and this meta-analysis were considered to be of high quality.For alcohol intake and arthritis, the results of our meta-analysis showed that overall, there was insufficient evidence of genetic causality between them. There are many studies with differing opinions about alcohol and OA. It has been reported that alcohol consumption is negatively associated with the prevalence of osteoarthritis of the knee in the Korean population . AnotherPrevious studies have also reported an association between alcohol intake and RA. A research study using data from the UK biobank showed a protective effect of alcohol on RA, with weekly or daily drinking associated with a reduced risk of RA compared with less than three drinks per month, and similar results were obtained in a cohort study of Swedish women ,43. In cAs one of the most common lifestyles, alcohol intake affects the primary skeletal–muscular system as well as other systems of the body, and this compounding effect may be the reason for its unclear relationship with arthritis. For example, alcohol is associated with obesity, and increased joint loading is a risk factor for OA . AlcoholThe results of our meta-analysis support a positive genetic causality between smoking behavior and arthritis, consistent with almost all the results included, and differing only from Lee’s study . PreviouSmoking has been recognized as a relatively clear risk factor for RA development . A prospCigarette smoke contains thousands of substances, including nicotine, polycyclic aromatic hydrocarbons, and nitric oxide, which can affect arthritis through various pathways. Chen et al. found that cigarette smoke extracts mediate cartilage destruction by increasing oxidative-stress-induced cell death . AnotherFor the results of a positive causal association between coffee consumption and arthritis, our meta-analysis was consistent with the results of several studies included in the systematic review ,25,26,27This is the first systematic review and meta-analysis of Mendelian Randomization studies on the causal relationship between arthritis and alcohol intake, smoking, and coffee consumption, to our knowledge. Owing to the increasing prevalence of MR studies, a pooled analysis of heterogeneous studies of the same outcome is necessary and meaningful.This study has a number of strengths. Compared to traditional epidemiological studies, using the MR method can explore causality at the genetic level and can largely avoid bias caused by confounders and reverse causality, with highly reliable results. MR is a GWAS-based method, and the strength of evidence for outcomes is related to the sample size of GWAS participants. Our study meta-analyzed studies that used different GWAS in exposure or outcome, expanding the study cohort and sample size. We assessed the study quality in various aspects by referring to the STROBE-MR guidelines and MR reading guidelines. The results showed that the quality of the included literature, from the study design to the discussion of the results, was high and the risk of bias was low. This guarantees the robustness of the data and the results of this study.For the meta-analysis, considering the heterogeneity across the literature, we applied a random-effects model for the analysis, and the results were still significant under conservative estimation. We estimated the results of the WM method as a sensitivity analysis in addition to the pooled IVW results to verify the robustness of the combined effects of the meta-analysis. The sensitivity analysis showed high agreement with the results of the main analysis, suggesting reliable results. Additionally, we performed a stratified analysis of two different types of arthritis, OA and RA, to assess the impact of a single lifestyle on specific outcomes.This study has some limitations. The GWAS dataset was selected from populations of European ancestry, which avoids the effects of population stratification, but also means that more caution should be exercised when applying the findings to other ethnic groups. The GWAS datasets used in some of the earlier published studies included in the systematic review may not be the most recent and comprehensive, which may have affected the accuracy of the results. The absence of GWAS data on different age groups and sexes rendered stratified analyses of the individual-level characteristics challenging. Some sex-specific phenotypic differences may not be distinguishable because of this. As an emerging epidemiological method, the small number of included studies makes it difficult to assess publication bias for individual exposure factors, which can affect the reliability of results.The influence of lifestyle as a part of the external environment on the development of arthritis is unquestionable . HoweverIn the future, GWAS cohorts with different regional populations, races, and behaviors will be further enriched, and MR studies will be available to determine additional genetic causal relationships between lifestyle habits as risk factors for diseases. Meanwhile, for the identified risk factors such as alcohol intake, smoking, and coffee consumption, exploring their mechanisms of action in the development of arthritis will be the next research direction.This study performed a meta-analysis of lifestyle and arthritis and showed positive genetic causality between smoking and coffee consumption with arthritis (OA and RA), while there was insufficient evidence of genetic causality between alcohol intake and arthritis. The results provide a basis for tertiary prevention in clinical practice and a potential direction for further arthritis-related research.


The purpose of this study was to evaluate the sensitivity of adhesive tape impression (ATI) cytology for the diagnosis of dermatophytosis in dogs and cats and to compare this test with the most commonly used diagnostic tests: microscopic examination of plucked hairs and fungal culture. Diagnosis of dermatophytosis can be challenging in some cases, especially in dogs with kerions, and at least two tests should be used for diagnosis since no single test can be identified as the “gold standard”. The present study supports this conclusion, as in comparison between the three diagnostic tests in dogs and cats with dermatophytosis no significant difference was found, apart from dogs with kerion. In this group of dogs, ATI cytology and fungal culture had the same sensitivity that was higher than hair plucks, and hair plucks were significantly less sensitive than fungal culture. Additionally, adhesive tape preparations can be superior to other diagnostic tests in cats. ATI cytology is easy to perform, inexpensive, noninvasive, minimally stressful for the animals, and can be a useful in-house diagnostic test for dermatophytosis. However, more studies with larger populations should be conducted to further evaluate the sensitivity of this diagnostic test in dermatophytosis.n = 19) or kerion (n = 11), and fifteen cats with alopecia were included in the study. Dermatophytosis was diagnosed with tape preparations in 82.2% (37/45) of cases, while with hair plucks in 66.7% (30/45) and fungal culture in 80% (36/45). In kerions, tape preparations and fungal culture had the same sensitivity  that was higher than that of hair plucks . The sensitivity was higher in cats than in dogs with alopecia for all tests, 80% versus (vs.) 73.7%, 86.7% vs. 68.4%, and 93.3% vs. 68.4% for cats and dogs for hair plucks, fungal culture, and tape preparations, respectively. No significant difference was found between the three tests, except for dogs with kerion. Hair plucks were less sensitive than fungal culture in kerions (p = 0.041), while in comparison with tape preparations they were marginally not significantly different (p = 0.078). ATI cytology is a useful diagnostic test in dermatophytosis, in dogs with kerion as well as cats.Rapid diagnosis of dermatophytosis is essential for early treatment induction and prevention of spreading to other animals and humans. No single diagnostic test is identified as the “gold standard”. The purpose of the study was to evaluate the sensitivity of adhesive tape impression (ATI) cytology in dermatophyte identification and to compare three diagnostic tests for dermatophytosis. Thirty dogs, with alopecia ( Microsporum canis (M. canis), Microsporum gypseum (M. gypseum) , and Trichophyton mentagrophytes (T. mentagrophytes) [M. canis is the most frequently isolated species, with a prevalence of >90% in cats and 70–80% in dogs [Dermatophytosis is a common superficial fungal skin disease that is zoonotic and affects multiple animal species, especially dogs and cats ,2. Dermaophytes) ,4,5. M.  in dogs .M. canis dermatophytosis [M. gypseum (new name N. gypsea) and T. mentagrophytes infections are usually negative with direct microscopy [Diagnosis of dermatophytosis is a combination of compatible history and clinical signs, along with the confirmation of an active infection with the fungi . The tesphytosis ,6. Depenphytosis . Fluoresphytosis . Skin scphytosis ,8. In onphytosis . Samplescroscopy . Fungal croscopy . Point-ocroscopy . Histopacroscopy . The usecroscopy . Howevercroscopy . In the croscopy .Adhesive tape preparations have been used for diagnosis and monitoring the response to therapy in veterinary dermatology ,13. TheiThe aim of the present study was to evaluate the sensitivity of ATI cytology to detect dermatophytes from lesional skin in dogs and cats and to compare the three tests  for the diagnosis of canine and feline dermatophytosis.® Crystal tape) onto the surface of the lesions and then placed onto a microscope slide over a few drops of blue Diff-Quick stain . Fungal culture was performed with a DTM , and hairs were obtained from the periphery and the center of the lesions with a sterilized forceps following drying of the area after disinfection with an alcohol-moistened gauze. Identification of the dermatophyte species was done with Roth’s flag. Thirty client-owned dogs and fifteen client-owned cats diagnosed with dermatophytosis were enrolled in the study. The samples were collected during the routine diagnostic procedure of skin disease, so additional consent from the animals’ owners was not required. Direct examination of plucked hairs and ATI cytology as well as fungal cultures (DTM) were performed in all animals. Briefly, hairs from the periphery and the center of the lesions were plucked with forceps and placed with a drop of mineral oil on a slide. For tape preparations, a clear acetate tape was firmly impressed three times (Scotchn = 15), dogs (n = 30), cats and dogs (n = 45), cats and dogs with alopecia (n = 34), dogs with alopecia (n = 19), and dogs with kerion (n = 11). The ability of each test to correctly identify animals with dermatophytosis was estimated using the sensitivity of the diagnostic test with the corresponding 95% Confidence Interval (C.I.). Subsequently, the sensitivities of the tests were compared using Mc Nemar’s statistical test on paired data, as the same animal individuals were used in the diagnostic tests. Furthermore, the percentage of agreement and the Cohen’s kappa statistic (κ) were used to compare the results of the diagnostic tests in pairs. Finally, the different effectiveness of each test within crucial groups of animals with same characteristics  was detected using a Chi-square test of independence or Fisher’s exact test depending on the frequencies of the contingency table. The statistical analysis was implemented using the R package version 3.2.2 [Six different datasets were used in the statistical analysis to evaluate the effectiveness of the three diagnostic methods  in different animal groups. The different datasets included animals positive to dermatophytosis sorted into cats  of the positive fungal cultures, while M. canis and T. mentagrophytes were isolated in one case .The results of the diagnostic tests of the 30 dogs are presented in Data regarding the signalment of the cats are reported in M. canis was isolated in 92.3% of the positive fungal cultures (12/13), while T. mentagrophytes was isolated in one case . The sensitivity of each diagnostic test with the corresponding 95% confidence interval (C.I.) within different animals’ groups is presented in The results of the diagnostic tests of the fifteen cats are presented in The three diagnostic tests were compared in pairs for their agreements of the offered results . The idep-values > 0.05) for all datasets except for the dogs with kerion. In that group, the sensitivity of hair plucks was significantly lower than that of fungal culture (DTM) , while the sensitivity of ATI cytology was marginally not significantly different from hair plucks’ sensitivity .The effectiveness of identifying the affected animals among tests was tested in terms of sensitivity (p = 0.044). On the other hand, the other two tests  showed similar effectiveness within the same groups of dogs . Each diagnostic test was tested for its sensitivity between dogs with kerion and dogs with alopecia. The effectiveness of hair plucks was found to be significantly lower in dogs with kerion than in dogs with alopecia . The result was marginal (p = 0.074) for the adhesive tape preparations.Dogs and cats with alopecia were further combined and tested to reveal possible differences in the tests’ efficiency within these groups of animals. Although the sensitivity was recorded higher in cats than dogs for all tests , and adhesive tape impression cytology, respectively), the statistical analysis showed no difference in the efficiency of the tests within these groups , T. mentagrophytes, and T. verrucosum as most common causes of kerion [and cats ,27,28,29et shops . Only on studies ,24,27,30erranean ,32, but f kerion ,9.In the present study, one test could be negative and others could be positive, and no test was 100% positive in the diagnosis of dermatophytosis. A large difference in test percentages was seen in dogs with kerion, and this group had the lowest percentage in one diagnostic test: the microscopic examination of plucked hairs. This agrees with a previous study of kerion cases with 34.8% sensitivity of hair plucks and 91% sensitivity of impression smear cytology . The higM. canis, so when they exhibit clinical signs of infection, the fungal load on lesional sites may be higher.In a WAVD clinical consensus paper on dermatophytosis in small animals, after a review of the literature, it is concluded that no single diagnostic test can be identified as the “gold standard” for the diagnosis of dermatophytosis . The preAdhesive tape impression cytology is a diagnostic test that is convenient and rapid to perform, inexpensive, noninvasive, safe, and quick to evaluate ,18. MoreRapid diagnosis of dermatophytosis is essential to prevent further transmission to owners and cohabitating animals. None of the diagnostics tests are identified as the “gold standard,” so a combination of at least two tests, direct microscopic examination of hair and scales and fungal culture, should be used for diagnosis. However, even though microscopic examination of plucked hairs can be useful in diagnosis, in this study it is found that it is less sensitive in dogs with kerions. On the contrary, in kerions, adhesive tape impression cytology is a valuable diagnostic test. Additionally, adhesive tape preparations can be superior to other diagnostic tests in cats. The adhesive tape impression cytology is easy to perform, inexpensive, noninvasive, and minimally stressful for the animals. It can be routinely used as an in-house diagnostic test for dermatophytosis, and from this study’s results, it is suggested in dogs with kerion and in cats. However, more studies with larger populations should be conducted to further evaluate the sensitivity of this diagnostic test in dermatophytosis.


Nurses’ clinical competence is one of the fundamental necessities for providing safe and effective care. Moral distress, as one type of occupational stressors, can affect various aspects of clinical competence, especially under conditions of complicated medical settings such as the coronavirus disease 2019 (COVID-19) epidemic. This study was conducted with the aim of determining the relationship between moral distress and clinical competence in nurses working in COVID-19 intensive care units (ICUs).The study was a cross-sectional study. A total of 194 nurses working in COVID-19 ICU affiliated to Shahid Sadoughi University of Medical Sciences, Yazd, central Iran, participated in the study. Data were collected using Demographic Information Questionnaire, Moral Distress Scale, and Clinical Competence Checklist. Data were analyzed with SPSS20 using descriptive and analytical statistics.2 = 0.179, P < 0.001) and 16% of the variance in utilization of clinical competence .The mean score of moral distress, clinical competence, and skills application were 1.79 ± 0/68, 65.16 ± 15.38, and 145.10 ± 38.20, respectively. Based on Pearson correlation coefficient, there was an inverse and significant relationship between the moral distress score and its dimensions with clinical competence and skills application (P < 0.001). Moral distress was a significant negative predictor that accounted for 17.9% of the variance in clinical competence (RConsidering the relationship between moral distress, clinical competence and skills application, to maintain the quality of nursing services, nursing managers can strengthen clinical competence and skills application by using strategies to deal with and reduce moral distress in nurses, especially in critical situations. Nurses are one of the main members of the healthcare system and play a prominent role in providing high quality services and improving the community health . ClinicaDuring the coronavirus disease 2019 (COVID-19) pandemic worldwide, healthcare staff faced challenges due to increased demands and changes in work commitments –11. ManyMoral distress is known as a complex phenomenon of human experience that arises from the feeling unwillingly involved in an unethical act, with little ability to behave differently or change the situation –24. In mStudies have identified that in addition to individual related factors such as clinical experience , age 4242, salarMaintaining the quality of healthcare services and nursing care is especially important in crises, and identifying the components and factors affecting clinical competence and its promotion has always been the focus of educational, health, and medical systems; also, moral distress is one of the common topics debated in nursing, especially in the COVID-19 pandemic, which can have different effects on the health and performance of nurses, patients, and healthcare organizations. Thus, this research was conducted with the aim of determining the relationship between moral distress and clinical competence of nurses working in COVID-19 intensive care units (ICUs).This cross-sectional study was conducted during September to November 2021.The research population consisted of nurses working in COVID-19 ICUs in six teaching hospitals affiliated to Shahid Sadoughi University of Medical Sciences in Yazd, central Iran. These hospitals were the major therapeutic and educational centers, and as general hospitals, offered a variety of specialized services to individuals. Most of the COVID-19 services in Yazd/Iran are provided by these hospitals, and these hospitals were COVID-19 admission centers. It should be noted that patients from southern cities of Iran refer to these hospitals for treatment.The sample size was calculated by the following formula to explore correlation between moral distress and clinical competence:Wherein N is the desired sample size, D-19 ICU , informeHaving approved the study proposal and having obtained code of ethics from Ethics Committee of the university, the electronic version of the questionnaires was sent to all the qualified nurses in cyber space and they were also informed through short message service short message service (SMS). Nurses were required to fill out the questionnaires in a comfortable and relaxed environment, preferably at home, and contact the researcher if they had any questions about the completion of the questionnaires.The data collection tool included three questionnaires: Demographic Information Questionnaire, Moral Distress Scale of ICU Nurses, and Clinical Competence Questionnaire.Demographic information questionnaire included personal and occupational characteristics such as age, gender, marital status, education level, and work experience in the nursing profession, work experience in COVID-19 ICU, employment status, and work shift.The second questionnaire was Moral Distress Scale of ICU Nurses, which was developed and psychometrically evaluated by Atashzadeh Shourideh et al. (2012). This tool contains 30 items in three dimensions of improper allocation of responsibilities and powers (10 items), errors (10 items), and violation of ethical principles (10 items). A 4-point Likert scale was used to score this tool in all items [not at all (0) to very much (4)]. The moral distress score was obtained from the average of sum of scores of the items. The face, content, construct, and convergent validity of this scale has been confirmed. The minimum validity index of the items of this scale was 0.85 and the scale content validity index/average (S-CVI/Ave) was equal to 0.94 . The relThe third questionnaire was the Clinical Competence Questionnaire, which was developed by Meretoja . The nurIn addition, nurses are asked to determine the frequency of using each skill by marking a 4-point Likert scale in such a way that zero means not using that skill and three means frequent use of that skill. Thus, the range of scores is from zero to 219. Since the number of items in each dimension is not the same, scores based on 100 were also calculated for a better interpretation of the data. The internal consistency coefficient of the seven domains was reported to range between 0.79 and 0.91 in the study by Meretoja et al. . This quThe data were collected, coded, and imported into SPSS 20. The frequency percentage, mean, and standard deviation were used to describe the demographics, moral distress, and clinical competence. In addition, the independent t-test and one-way analysis of variance (ANOVA) were used to identify the significance of the difference between the means of the groups, while the Pearson’s correlation coefficient was used to identify the level of correlation among the variables. A multiple regression analysis was conducted to predict factors that could affect the clinical competence of nurses. In all cases, P < 0.05 was considered to be statistically significant. Before performing the tests, the normal distribution of the data was checked using Kolmogorov-Smirnov (KS) test (P > 0.05).In the present study, 194 nurses completed the questionnaires. The average age of the participants was 32.48 ± 7.00 years. The participants had an average of 9.49 ± 6.47 years of nursing work experience and 7.70 ± 4.84 months of COVID-19 ICU work experience. As it is observed in Tables According to Table The average total score for clinical competence and skills application were 65.16 ± 15.38 and 145.10 ± 38.20, respectively. The highest average was related to the dimension of managerial abilities and the lowest average was related to the dimension of quality assurance  Table .There was a statistically significant relationship between clinical competence with gender (P = 0.003), type of work shift (P = 0.02), nursing work experience (P = 0.04), and COVID-19 ICU work experience (P < 0.001). This relationship between the skills application and gender (P = 0.002), type of work shift (P = 0.01), age (P = 0.03), and COVID-19 ICU work experience (P < 0.001) was also significant.Using regression analysis, changes in dependent variables  induced by independent variables  were predicted. Among the demographic characteristics, the mentioned significant or correlated factors were included in the regression analysis. The regression analysis demonstrated four  and five  predictors for the clinical competence and utilization of clinical competence, respectively Table .2 = 0.179, P < 0.001) and 16% of the variance in utilization of clinical competence .Based on the results presented in Table This study aimed at determining the relationship between moral distress and clinical competence of nurses working in COVID-19 ICUs.The results demonstrated that moral distress in nurses working in COVID-19 ICUs is at a moderate level which was consistent with previous literature , 55, 56,In this study, it was found that most moral distress was related to the dimension of errors. Silverman et al. (2021) pointed out that during Coronavirus pandemic, due to the increased number of COVID-19 patients, to provide sufficient personnel, the immediate implementation of the team model  can cause a lot of confusion for nurses and safety risks that would never happen in a regular ICU . OrganizMoral distress is an inevitable byproduct of patient care that cannot be completely eliminated from the workplace; yet, there are strategies for adequate workplace resources, improved work life, and managerial and organizational leadership that organizations can use. They can apply it to reduce the negative effects of moral distress , 32, 60.The findings further revealed that the clinical competence of the studied nurses and the application of nursing skills based on self-assessment were at a good and acceptable level. The clinical competence of Iranian nurses has been reported to be at the moderate to high levels , 61. ModIn the present study, the highest and lowest mean pertained to dimensions of the managerial abilities and the quality assurance, respectively. These findings are consistent with the results of the study by Kalantari et al. . Yet, inThe difference in results could be attributed to participants’ different work sectors, data collection tools, or current work conditions related to COVID-19. In the current study, treatment measures that included planning, decision-making, and implementation of care based on the clinical situation and consultation with other employees had the lowest level. Of course, the large number of patients, lack of manpower, and high workload during the COVID-19 period can be the reason; this should be noticed by the authorities in times of crisis.The findings of the study showed that there was an inverse and significant relationship between moral distress and its dimensions with clinical competence and skills application; this means that with increasing score of distress and its dimensions, the clinical competence of nurses and their skills application decrease. Moral distress was a significant negative predictor of clinical competence. Results from this study support those of previous studies that found an inverse relationship between job stress and clinical competence , 48, 50.Considering the relationship between moral distress and clinical competence, nursing managers can strengthen clinical competence and skills application by using strategies to deal with and reduce moral distress in nurses, especially in critical situations. To reduce moral distress, due attention ought to be paid to both individual and organizational factors . Some faThis study suffered from some limitations. One of the limitations was the use of a self-reporting tool, and there is a possibility of social desirability bias. There were confounding variables such as factors affecting nurses’ concentration that could not be controlled. A cross-sectional design was used in this research. For this reason, it makes causality impossible. Besides, since the present study was conducted on selected nurses of just one city, caution should be exercised in generalizing the results as this jeopardizes the external validity of the findings.The results of this study showed that there was an inverse and significant relationship between moral distress and each of its dimensions with the level of clinical competence and skills application. It is necessary for nursing managers to measure and control moral distress, especially in crises, to maintain the quality of nursing services in crises while maintaining the clinical competence of nursing.


Health professionals have been one of the groups most affected by the SARS-CoV-2 virus. Currently, there is little scientific evidence on the similarities and differences between COVID-19 infection and the development of long COVID in primary care (PC) workers. Therefore, it is necessary to analyse their clinical and epidemiological profiles in depth. This study was observational and descriptive, including PC professionals who were divided into three comparison groups based on the diagnostic test for acute SARS-CoV-2 infection. The responses were analysed using descriptive and bivariate analysis to examinate the relationship between independent variables and the presence or not of long COVID. Binary logistic regression analysis was also conducted, with each symptom as the dependent variable and each group as the independent variable. The results describe the sociodemographic characteristics of these population groups, revealing that women in the health sector are the most affected by long COVID and that being in this group is associated with its development. Furthermore, individuals with long COVID exhibited the highest number of symptoms and pathologies. Certain symptoms were found to be associated with long COVID development in this population, including an altered sense of smell, pneumonia, fever, and sore throat, among others. Similarly, altered senses of smell and taste, chest tightness, and joint pain, among others, were found to be associated with acute COVID-19 infection. Additionally, patients with pre-existing overweight or obesity were more likely to experience acute COVID-19 and develop long COVID. The data obtained can be crucial for improving the detection, diagnosis, and treatment of long COVID patients, ultimately leading to an enhancement in their quality of life. The symptomatology associated with COVID-19 is a topic of public health interest due to its rapid transmission and the emergence of new virus variants on all continents. The appearance of these new variants poses an even greater challenge to public health, representing a significant danger to the total control of the pandemic . While tCOVID-19 infection can manifest as asymptomatic or with mild, moderate or severe symptoms. The range of symptoms associated with the infection is quite broad and can affect various organs and systems . The cliThe absence of a standardized and globally agreed-upon definition makes it challenging to categorize the epidemiology of long COVID and develop potential treatments. To address this issue, the WHO has defined post-COVID condition as an illness that occurs in individuals with a history of probable or confirmed SARS-CoV-2 infection, typically occurring 3 months after the onset of symptoms and lasting for at least 2 months, with symptoms that cannot be explained by an alternative diagnosis .The Spanish Society of General Medicine conducted a survey describing the general characteristics of patients with persistent COVID-19 diagnosed during the first wave of the pandemic in the first year . The surMany aspects of persistent COVID are still poorly understood, and some studies suggest that this phenomenon may actually encompass multiple different syndromes ,17. SpecIt is worth mentioning that vaccination has proven to be an important preventive strategy for long COVID, as it is highly effective and efficient in preventing severe infection and hospitalizations due to COVID-19 ,21. AddiDue to the mechanism of virus transmission, healthcare professionals are particularly susceptible to infection and transmission. A study utilizing data from the UK Biobank  investigPreliminary results of the “Factors of COVID-19 Diffusion” project in Spain have demonstrated that the percentage of infected healthcare professionals was a relevant factor contributing to the spread of the pandemic during its upswing . Data frGiven that healthcare professionals have been one of the most affected groups, the aim of this study was to conduct a more comprehensive analysis of their clinical and epidemiological profiles. Additionally, it was important to describe the clinical and epidemiological profiles of patients with long COVID treated in PC and compare them with the profiles of patients with acute COVID-19 infection and those without COVID-19 infection. On the other hand, it was also considered important to study the symptoms that turned out to be associated with a higher prevalence of being infected with COVID-19 or developing long COVID when experiencing them.We conducted an observational, descriptive, multicentric study with three comparison groups, classified according to the results of the acute infection diagnostic test (ADT: antigen detection test and/or polymerase chain reaction (PCR)), by SARS-CoV-2, and the existence or not of long COVID-19 or post-COVID-19 syndrome, following the WHO definition .The groups were: (1) “Cases”: patients with acute infection by SARS-CoV-2 (positive ADT) and long COVID; (2) “Controls 1”: patients with acute infection by SARS-CoV-2 (positive ADT) and absence of criteria for long COVID; (3) “Controls 2”: individuals without acute infection by SARS-CoV-2, for whom an ADT had been requested for presenting an acute clinical picture due to the presence of COVID-19 or for being a close contact of a confirmed case of COVID-19.The study included PC professionals of the Spanish National Health System (NHS).Selection criteria were as follows: (1) being a health professional of the NHS; (2) meeting clinical or epidemiological criteria for suspected COVID-19 disease and/or long COVID ; andhttps://www.imim.es/ofertadeserveis/software-public/granmo/ (accessed on 13 February 2021)).The Office for National Statistics of the United Kingdom has estimated that one in 10 patients diagnosed with COVID-19 have symptoms beyond 12 weeks after diagnosis and, therefore, a long COVID prevalence of 10% was assumed . TherefoThe enrolment procedure was initiated to deepen the clinical-epidemiological analysis of patients with persistent COVID-19, which led to the initiation of the EPICOVID-AP21 investigation. The information from study participants was obtained through an online questionnaire created using the Google Forms tool. The questionnaire was sent to members of the Spanish Society of Family and Community Medicine and the Spanish Society of General Practitioners. Each participant received an invitation and a link to access the online questionnaire. Interested participants completed the questionnaire online before providing informed consent.The research project received authorization from the management of the Cordoba and Guadalquivir Health District and the Cordoba South Health Management Area. Additionally, it obtained approval from the Clinical Research Ethics Committee of the Reina Sofia Hospital in Cordoba . Informed consent was obtained from the patients participating in the study, ensuring voluntariness. Data processing was conducted in compliance with the European Data Protection Regulation and Organic Law 3/2018 on Personal Data Protection and guarantee of digital rights.The questionnaire data were stored in a survey created with Google Forms in Google Drive. These data were exported to an Excel spreadsheet and analysed with the statistical software SPSS version 17.0 . A descriptive and comparative analysis of the groups was conducted. Confidence intervals of 95% (95% CIs) were estimated for the main parameters of the study.t-test or ANOVA . If the data did not meet the assumption of normality, non-parametric tests such as the Kruskal–Wallis test were used. Bilateral contrasts were used, and a significance level of p ≤ 0.05 was applied.Bivariate analysis was performed to determine whether there was any relationship between groups  and to test the relationship between the independent variables and the presence or absence of persistent COVID-19 disease. For this analysis, the Chi-square test was used, as well as mean comparison test for independent samples such as Student’s p = 0.05).A binary logistic regression analysis was performed to test which variables were associated with the prevalence of having acute COVID-19 and long COVID. The dependent variables were: acute COVID-19 (yes vs. no) and long COVID (yes vs. no). The independent variables included in the regression model were: sociodemographic variables ). Odds ratio (OR) values and their respective 95% confidence intervals (95% CIs) were found for each variable. Statistical analysis was performed using the IBM Statistic SPSS 20 program with a significance level of 95% , and 25.1% lived in rural areas, with no significant differences between comparison groups.p = 0.007).Regarding COVID status, 73% of the participants did not have COVID-19 (negative ADT results), 16.8% had acute COVID infection, and 10.2% of the patients had the clinical picture of long COVID. The patients with long COVID had a mean duration of 35.23 ± 20.70 weeks . The mean age of the entire sample was 46 ± 11.37 years , with no statistically significant differences between the comparison groups . Signifip < 0.001).Of the patients in the study, 81.2% were symptomatic. The mean number of clinical signs or symptoms experienced by the patients was 4.44 ± 6.05 . Significant differences were observed by group, with an average number of symptoms in patients without COVID-19 of 2.64 ± 4 , in patients with acute COVID-19 infection of 6.38 ± 5.26 , and in those with long COVID of 14.60 ± 8.78  .p < 0.001), headache , muscle or joint pain  and dyspnoea  compared to those with acute COVID-19 or individuals without COVID-19.p < 0.001), altered taste , chest tightness , pneumonia (p < 0.001), loss of appetite (p < 0.001), joint pain (p = 0.035), abdominal pain (p = 0.005), or eye discomfort (p = 0.009).p = 0.004), pneumonia , fever , chills , sore throat , dizziness , nausea , or back pain .Similarly, significant findings were also obtained for patients who developed long COVID and presented with an altered sense of smell . The group of patients with long COVID  had a higher average number of pathologies compared to those with acute COVID-19  or without COVID-19 . p < 0.001), asthma , hyperlipemia , and anxiety syndrome  had a higher prevalence among patients with long COVID compared to those without.The average number of pathologies reported by the patients was 0.80 ± 1.04 , with significant differences observed among the groups . In patients with long COVID, significant results were obtained for overweight or obesity , asthma , anxiety , and coagulation disorders , indicating a higher prevalence of long COVID in patients with these conditions.The objective of this study was to conduct a more comprehensive analysis of the clinical and epidemiological profiles of primary care professionals in Spain. Additionally, it was considered important to describe them in greater detail and compare them with the profiles of patients with acute COVID-19 infection and those who did not have it. On the other hand, it was also considered important to study the symptoms that turned out to be associated with a higher prevalence of being infected with COVID-19 or developing long COVID when experiencing them.Our results indicated statistically significant differences in the presence of long COVID between men and women, with a higher prevalence among women. Women were also been shown to be more likely to develop the condition. The analysis of COVID-19 cases in healthcare workers reported to the Red Nacional de Vigilancia Epidemiológica (RENAVE) in 2020 confirmed a significantly higher prevalence of cases in women compared to men . FindingLikewise, statistically significant differences were observed in relation to the symptoms caused by COVID-19 infection. Symptoms were more pronounced in the group that had long COVID than in the sample that only had acute COVID-19, and even more pronounced than in those who were not infected. However, it is also noteworthy that the highest percentage of the population included in the study experienced symptoms resulting from COVID-19. For example, in the study by Carfi et al. , only 12Our results also demonstrated that certain symptoms can be associated with a higher prevalence of experiencing an acute COVID-19 infection or developing long COVID. Symptoms such as altered taste and smell, chest tightness, pneumonia, loss of appetite, joint pain, abdominal pain and/or eye discomfort were found to be associated with acute COVID-19. Similarly, in this population, there were symptoms associated with long COVID, including altered sense of smell, pneumonia, fever, chills, sore throat, dizziness, nausea, and/or back pain.Other authors also emphasize the importance of establishing an association between symptoms and COVID-19 to facilitate the diagnosis of the disease . SeveralThere was also a high prevalence of pathologies such as stroke, depression, coagulation disorders, renal failure and/or anaemia. Other studies also indicated an apparent association of COVID-19 with stroke, likely due to shared factors between them . SimilarOur results also presented statistically significant data on the patients who had asthma when infected with the COVID-19 virus and subsequently developed persistent COVID. However, no significant data were obtained for people with chronic obstructive pulmonary disease (COPD), despite the fact that people who have asthma and/or COPD are at an increased risk of COVID-19 infection and developing more severe symptoms. It appears that these diseases are quite rare as comorbidities with COVID ,65.However, before concluding, it is worth mentioning the importance of these results for early diagnosis. The obtained data describe both the sociodemographic and clinical profiles of the healthcare population in Spain and their relationships with infection and the development of long COVID. This comes at a time when, despite the availability of reliable methods such as RT-PCR and serological tests as diagnostic tests, access to these tests is limited in other regions with low socio-economic levels, mostly developing countries. In addition, it is important to highlight the major health-related issues regarding the lack of services and shortages of ICU beds that have been and continue to be experienced in many areas ,67.This study had a number of limitations. The type of survey used (self-administered) can introduce an information selection bias.In addition, the limited evidence on the clinical characteristics of COVID and long COVID in healthcare professionals made it difficult to compare with the results of our study. Similarly, the scarcity of studies analysing the associations of COVID-19 and long COVID symptoms made it difficult to compare our results, emphasizing the lack of studies examining associated symptoms of these conditions in healthcare professionals. Due to these biases, external validation of the study may be limited. However, it is important to consider that the results obtained in the study represent valuable data for the investigation of symptoms and/or complications associated with or derived from COVID-19 and long COVID in healthcare professionals. They hold great importance for future research on this disease, as well as for the design of studies and research protocols on persistent COVID. Additionally, a larger sample size of health professionals presenting COVID-19 and long COVID could address the differences between different professional categories.Some strengths of this study include the significant number of participants who collaborated and the importance of the results associated with COVID-19 infection and long COVID development, given the limited existence of studies examining these aspects. It is of great significance to obtain a population profile and contribute to early diagnosis, as well as establish early treatment and intervention measures to prevent symptom persistence and/or severity.In conclusion, our findings described the sociodemographic and clinical characteristics of healthcare workers of the SNH, who developed COVID-19, whether acute or long-term syndrome.Thus, this study provided relevant information on the differences in symptomatology between healthcare workers who were infected with COVID-19, those who developed long COVID and those who were not infected. This information can be significant for the early detection of symptoms and for the diagnosis of the disease.Regarding the previous pathologies of health workers, it is important to highlight the diseases that developed from the infection, such as nervous system disorders, and those previous pathologies that led to the development of long COVID. This will facilitate the implementation of multidisciplinary prevention and/or treatment programs aimed at improving the quality of life and well-being of this population group.The prevalence of long COVID was found to be higher in females, in addition to the greater probability of its development.The study revealed a high prevalence of fatigue in this population. However, there are other symptoms associated with long COVID, such as an altered sense of smell, pre-existing pneumonia and fever, sore throat, dizziness, nausea, and/or back pain.Certain symptoms associated with acute COVID-19 were also identified, such as an altered sense of taste and smell, chest tightness, and pneumonia.Finally, the highlights of this study include the following:Overweight or obese individuals are at a higher risk of contracting an acute COVID-19 infection or developing long COVID later on, as are those with asthma, anxiety, and coagulation disorders.


Instagram was the favorite social media where most of the participants spend more than 3 h. Of the participants, 97% used social media to keep informed and read the news. Almost half of the respondents search for orthodontics services on social media. Orthodontists were able to perceive differences in only two posts from the general perception (laypeople) regarding non- or low-scientific-evidence posts.Worldwide, social media is gaining popularity year after year. In Brazil, by 2027, there will be more than 188 million users of social media sites, against 165 million in 2022, therefore, the usage of general population and health care professionals, including orthodontists, is increasing. Differently from scientific journals that undergo a rigorous peer review process prior to publication, the same level of demand is not found on social media. Hence, this study aimed to assess whether orthodontists can recognize scientifically based and non-science-based posts and if their perceptions are different from general opinion (laypeople), dentistry students, and dentists (non-orthodontists). The posts were created using the search tool on Instagram with the hashtags #clearaligners #acceledent #selfligatingbraces and #propelorthodontics, four scientific based posts and four without or with low scientific evidence were selected and evaluated through a virtual questionnaire in the QUALTRICS platform by 385 people,  using a visual analogue scale (VAS). In addition, four questions were asked. ANOVA (Adjusted Bonferroni correction) and Pearson’s chi-squared, and Student T tests were applied to identify statistical differences. Significant difference was found only for posts with no scientific evidence between orthodontist’s group when comparing with laypeople ( Currently, social media has become the largest means of direct or indirect communication, with more than 3.5 billion daily users worldwide who spend an average of 3 h a day online . One of Online social media had an initial focus on large-scale, unidirectional dissemination of information using portals, websites, and personal pages. In addition to being a means to establish interpersonal relationships, online social networks have become interactive platforms that offer a large variety of additional services .Most patients using social media reported it helps in collecting information about orthodontic treatment . The maiConcerns were expressed that although articles submitted to scientific journals are often subject to a rigorous peer review process before publication, the same standards are not applied to social media posting. Although some studies report posts lacking scientific evidence on social media –11 it isHence, this study aims to assess whether orthodontists can recognize scientifically based and non-science-based posts and if their perceptions differ from general opinion (laypeople) as well as dentistry students and general dentists (non-orthodontists).This cross-sectional study was held in Brazil and approved by the Pontifícia Universidade Católica do Paraná ethics committee under number 2,235,302. All patients provided informed consent to participate in this research study at the moment they agreed to complete the online survey. The objective study population consisted of anyone over the age of 18, complete and respond all questions of questionnaire. Laypeople, dentistry students, general dentists, and orthodontists from Brazil were included.p the standard deviation of 0.5.A sample calculation was performed to define the number of individuals targeted to participate in the research. A sample number of 385 people was determined based on the Brazilian population, considered as an infinite population, a 95% confidence level, and a 5% error margin, in which Z = 1.96 corresponding to the abscissa of the standardized normal curve, for a 95% confidence level, e = margin of error considered 0.05 and To create the posts to be evaluated, the search tool on Instagram was used separately by three researchers with the hashtags #clearaligners, #acceledent, #selfligatingbraces, and #propelorthodontics, whose hashtags were based in a pilot study made preliminary by the same researches to help identify a strategic time for gathering posts as well as to come up with the relevant keywords. Every researcher selected 10 posts of public profiles of orthodontists, five scientific-evidence-supported posts (SESP) and five without or with low scientific evidence (WLSE). All profiles included for analysis were freely accessible to the general public on the internet and the posts were available by June 2022. Next, the posts were discussed regarding scientific evidence, and a consensus among the three researchers was found regarding which posts should be included.ramdomizer.org> between 0 and 1000. The username was “ortho.andrea”, proposing a neutral name to avoid any gender bias, with the same occurring with the name in the likes, which was called “Alisson Park”.Hence, four texts were used for scientific-evidence-supported posts and four without or with low scientific evidence—one SESP and WLSE for each hashtag. The chosen texts for each hashtag are presented in A self-administered questionnaire was developed by the authors according to , 13. Theramdomizer.org> and were visible one at a time. After each post, the question “On a scale of 0 to 10, how much does this post convey the credibility of a post with real content with a scientific basis? (0 none– 10 a lot)” was applied. The questionnaires ended when the participant answered all four questions of the first part and eight questions of the second part.The second part consisted of evaluating the posts created for the research. Eight images—four SESP and four WLSE—were evaluated through a visual analog scale. The posts were also randomized with the help of the website < th of 2022 until November 16th of 2022. Participants could access the questionnaire digitally using a computer, smartphone, or tablet. The questionnaire was available only in Portuguese and all Portuguese speakers who get the link could answer. The inclusion criteria were participants over 18 years old that completed all the questions in the questionnaire. Uncompleted surveys or that presented repeated number for all questions were excluded. Forty-nine participants were excluded and there were 385 participants included in the research.For data collection, the questionnaire link was distributed by the researches via social media  using the Qualtrics digital platform  and was made available from October 22For validation and reliability testing, the questionnaire was administered twice during the preliminary stage of data collection, with an interval of 20 days between the two administrations. For the first (test) and second (retest) administrations of the questionnaire, 30 subjects were included. The validation was based on previous studies –15. Thosp < 0.05) level of significance was chosen.The raw data was extracted from the Qualtrics software and using Microsoft Excel, the gathered data were collated and quantified in an electronic database . The quantified data was exported to the SPSS software version 25  in which was used for the statistical analysis. Cronbach’s alpha coefficient and paired Student`s T were used to measure internal consistency and confirm reliability. The mean and standard deviation of the numerical variables, as well as the total count and percentage of the qualitative variables, were calculated using descriptive statistics. To compare demographic data, paired student T test for sex and U-Mann-Whitney of ethnicity. To compare the dependent variables among groups, one-way ANOVA with Bonferroni correction due to multiple post-hoc tests and chi-square tests were used. A 5%  ; and #selfligatingbraces  no significant difference was found when comparing with ethnicity. For time spend on social media, no difference was found when comparing sex and ethnicity.The sample of this study was composed of 175 laypeople (45.45%) , 58 dentistry students (15.06%) , 102 dentists (Non-orthodontists) (26.49%) , and 50 orthodontists (12.98%)  , for thep = 0.673 for paired Student`s T test regarding reliability). The results showed that 365 (94.80%) participants use social media to read news and update themselves  and #propelorthodontics (p = 0.040) (p < 0.001) for the #selfligatingbraces, the group of orthodontists also showed a statistical difference for #propelorthodontics when compared with laypeople (p = 0.031) and dentists (p = 0.033). For the #clearaligners and #acceledent, no statistical difference was found (p > 0.05).Regarding posts on social media, for those with SESP, no statistical difference was seen when compared with the other groups for the Visual Analogue Scale (VAS). In the tests for the WLSE, statistical difference was perceived for the #selfligatingbraces (= 0.040) . In the Due to the growing number of social media users, mainly Instagram, and the search for information in these platforms, there has been a greater concern about the type of information that is transmitted by social media. Only two posts were identified in which orthodontists were able to perceive differences in relation to laypeople, in non-science-based posts. However, dental students and dentists (not orthodontists) did not show significant differences compared to laypeople.et al. [Social media, particularly Instagram, has developed into an essential tool for patients and healthcare professionals in recent years . The reset al. , in whicet al. , 17, 18.Users generate and share information using social media as a method of electronic communication to engage in social networking. It is possible to share information, thoughts, and other content in form of videos, images, and texts. Over 3.5 billion people use social media every day, and it has been estimated that people spend an average of 3h each day online . RegardiThe Instagram platform has been highly popular in recent years, and many businesses and professionals have started to use it for promotions . From thcarrieremotion, #invisalign, #damonbraces, #acceledent, #propelorthodontics, and #myobrace) 1730 posts were filtered to produce a sample of 300 Instagram posts. From those posts, less than 2% of the claims made were considered to be factually accurate [Regarding studies analyzing content in social media, a study using six hashtags  regarding non- or low-scientific-evidence posts. Dental students and dentists (non-orthodontists) did not show any statistical differences when compared to laypeople.Of the participants in the study, 97% used social media to keep informed and read the news on social media, and almost half searched for orthodontics services on social media. Instagram was the favorite social media platform.