A retrospective analysis of medical records of infertile patients using assisted reproductive technologies and melatonin was performed. 76 infertile women were examined. Group 1 included 33 patients who received 3 mg of melatonin two weeks before and during ovulation induction, and group 2 included 43 patients who did not take melatonin. The average age of patients in the groups did not differ. The data of gynecological and ultrasound examinations, structure and thickness of the endometrium, antral follicle count, hormone levels: anti-mullerian, follicle-stimulating, luteinizing, progesterone, estradiol, prolactin, thyrotropin, and thyroxine were evaluated. The primary infertility incidence was significantly higher in all examined patients. Patients in the first group tended to decrease ovarian reserve, recurrent loss, and unexplained infertility; in the second group, more endometriosis, tubal and male infertility factors were observed. The incidence of extragenital pathology in the examined patients did not differ as well as antral follicle count and the thickness of the endometrium. We also did not find any significant difference in the level of hormones in the blood of the examined women, except that patients taking melatonin had significantly higher levels of lutropin but lower levels of the anti-mullerian hormone in the blood. The incidence of infertile marriages, according to Ukrainian and international researchers, averages from 10 to 20% . Assistei.e., it is a biological “window” that reflects metabolic processes [The molecular mechanisms of melatonin are still largely unexplored. Through pituitary receptors, melatonin acts upon the secretion of pituitary hormones into the blood and, with their help – upon the reproductive system. The oocyte is surrounded by follicular fluid, rocesses . It is krocesses –12.The study of the anamnesis peculiarities, ovulatory reserve, and hormonal status in infertile patients undergoing assisted reproductive technologies with melatonin has not been sufficiently studied. It is known from very few literature sources  that theWe examined 76 infertile women. Group 1 included 33 patients who took 3 mg of Vita-melatonin produced by the Kyiv Vitamin Plant at the same time before bedtime, two weeks before and during ovulation induction. Group 2 included 43 patients who did not take melatonin. The study did not include women who worked night shifts. We studied outpatient records, as well as gynecological and ultrasound examination data and hormone levels in the blood. The ultrasound examination of the lesser pelvis organs was performed on the Mindray DC-80 X-Insight device with a transvaginal sensor. The structure and thickness of the endometrium were assessed, and the number of antral follicles (NAF) ranging in size from 2 to 10 mm in each ovary was counted. Serum levels of hormones were determined in all patients: anti-mullerian, follicle-stimulating, luteinizing, estradiol, prolactin, progesterone, thyroid-stimulating hormone, and thyroxine by immunofluorescence. For this purpose, standard kits of the DELFIA system and IFA method “STAT-GRAFIX” 20/09 were used. To process the obtained results, the method of variation statistics was used with the calculation of the arithmetic mean (M), the average error of the mean (m), and the probability (p). The reliability of parametric values was evaluated by the probability of Student's criterion.The mean age of women in Group 1 (who took melatonin) was 33.12±8.18 years, and in group 2 (who did not take melatonin) – 30.95±7.07 years (p>0.05), i. e. according to this parameter, they were equal.According to in vitro fertilization in the examined patients  higher than in group 2. At the same time, the AMG level in group 1 was lower than in group 2 (p<0.001).i.e., they were comparable.Summing up the discussion, it should be noted that the examined patients who took and did not take melatonin in preparation for ART did not differ in age, medical history, extragenital pathology, ultrasound examination data, and hormone levels in the blood, The presented literature data and the results of our study show that the use of melatonin in ART programs increases their effectiveness. Analysis of the medical records of examined patients showed that infertile patients who did not receive this preparation in such programs did not differ in age, the incidence of infertility, factors that led to infertility, concomitant extragenital pathology, ovarian reserve, and reproductive hormone levels. That is, in our study, they were equal.


Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is effective in improving motor function in patients with Parkinson's disease (PD). This study aimed to investigate mortality associated with bilateral STN DBS in patients with PD and to assess the factors associated with mortality and causes of death after DBS.We reviewed the medical records of 257 patients with PD who underwent bilateral STN DBS at the Movement Disorder Center at Seoul National University Hospital between March 2005 and November 2018. Patients were evaluated preoperatively, at 3, 6, and 12 months after surgery and annually thereafter. The cause and date of death were obtained from interviews with caregivers or from medical certificates at the last follow-up.Of the 257 patients with PD, 48 patients (18.7%) died, with a median time of death of 11.2 years after surgery. Pneumonia was the most common cause of death. Older age of disease onset, preoperative falling score while on medication, and higher preoperative total levodopa equivalent daily dose were associated with a higher risk of mortality in time-dependent Cox regression analysis.These results confirm the mortality outcome of STN DBS in patients with advanced PD. Parkinson's disease (PD) is one of the most common neurodegenerative diseases worldwide. Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is effective in improving motor function in patients with PD , 2. ThisWe conducted a retrospective longitudinal observational study of patients with DBS. We reviewed the medical records of patients with PD who underwent bilateral STN DBS at the movement disorder center (MDC) at the Seoul National University Hospital (SNUH) between March 2005 and May 2018. A PD diagnosis was made based on the United Kingdom Parkinson's Disease Society Brain Bank Criteria , and allPreoperative and postoperative assessments were performed according to the SNUH MDC protocol . The UniThe levodopa equivalent daily dose (LEDD)  and levoPostoperative evaluations were performed at 3, 6, and 12 months after STN DBS, and annually thereafter. Follow-up evaluations were carried out as inpatient procedures at the MDC, with video recordings and diary entries . The pri* preoperative falling on-medication score, T_COV_*preoperative depression). The other variables satisfied the proportional hazards assumption. SPSS ver. 20  and R version 4.1.2  were used for all statistical analyses, and a P-values of below 0.05 were considered statistically significant.A descriptive analysis was used to examine the DBS group. Demographic characteristics are presented as mean values ± standard deviations (SD) or numbers (%), when applicable. The Kaplan–Meier method was used for a survival analysis. Univariate and Cox regression analyses were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). We included sex, age at onset, disease duration at surgery, preoperative body mass index (BMI), depression, UPDRS-III score , axial score, falling score, and HY stage as covariates for Cox regression analysis. The proportional hazards assumption considers that HR for comparison groups is constant over the follow-up period, and the proportional hazards assumption was tested by the time-dependent Cox model, including an interaction term with time. HR varied over time in this model, which violated the proportional hazards assumption for two variables . Thus, we used time-dependent Cox regression analysis by including interaction terms with time (T_COV_P < 0.05)  died, with a median time of death of 11.2 years after surgery. The disease duration was 16.08 years from onset to death. The mean age at death was 67.7 years. For the survival group, the age and duration of PD at the time of the study were 62.2 ± 8.6 and 16.4 ± 5.4 years. Survival curves are shown in  < 0.05) .P = 0.028), higher preoperative total LEDD , and the interaction term with Time   were associated with a higher risk of mortality  of 257 died, with a median time of death of 11.2 years after surgery, and that pneumonia was the most common cause of death. The mortality rate in the present study was 18.7%. The present study was compared with previous studies that reported the mortality of patients with DBS in different countries and groups . The morPneumonia was the most common cause of death reported in the present study; many previous studies have also reported pneumonia as a common cause of death , 18–20. The suicide rate reported in the present study was higher than that in other studies; however, this is consistent with other studies' reports that suicidal behaviors can occur after STN DBS, especially during the first 3 years , 23. ThuOlder age of onset, the occurrence of preoperative falls on medication, and higher total preoperative LEDD were also associated with a higher risk of mortality in the present study. Older age at the time of surgery is a predictor of mortality in patients with DBS, which is in line with the results of previous studies , 9. In oThe present study additionally found that a higher total preoperative LEDD was associated with a higher risk of mortality. Furthermore, Fasano et al.  reportedThe present study had several strengths. Compared with other similar long-term studies, our study examined one of the largest cohorts, followed up at the same DBS center over a longer period of time. Patients were followed by the same neurosurgeons and neurologists. We were able to contact all patients by telephone or in-person, so none were lost to follow-up, leading to more valid conclusions. However, this study also had several limitations. First, this was a single-center study conducted in South Korea; thus, these results do not represent the entire Korean population. Second, whether DBS could affect the course of PD is a debatable issue, but we do not have control data. Third, we were not able to estimate total electrical energy delivered for DBS frequency due to the unavailability of impedance. Finally, there is no genetic and clinical information such as comorbidity burden and dementia conversion in patients with PD who underwent STN DBS surgery.In conclusion, this study highlighted the mortality outcomes of STN DBS in patients with PD; older age of PD onset, preoperative falling scores on-medication may be associated with a higher risk of mortality.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Institutional Review Board of Seoul National University Hospital (IRB No.1901-142-1005). Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.AhrK and BJ were involved in the conception and design of the work. H-JK, AryK, and YK recruited participants and collected the data. Data analysis and interpretation was primarily conducted by AhrK, with guidance and advice offered by AhwK, JO, HP, and SP. AhrK wrote the manuscript. BJ and SP commented on and reviewed the manuscript. All authors contributed to the article and approved the submitted version.


Red cell distribution width/albumin ratio (RAR) is thought to be associated with the prognosis of a variety of diseases, including diabetes and heart failure. To date, no studies have focused on the relationship between RAR and carotid plaque in patients with coronary heart disease (CHD).A total of 10,267 patients with CHD were divided according to RAR quartiles . Logistic regression was used to analyze the relationship between RAR and carotid plaques in CHD patients. The relationship between RAR and carotid plaques in according to sex, age and glucose regulation state groups were also assessed.Among the 10,267 participants, 75.43% had carotid plaques. After adjusting for confounding factors, RAR was found to be associated with carotid plaque formation . The risk of carotid plaque formation in the Q4 group was 1.24 times higher than that in the Q1 group. After multivariate adjustment, RAR was associated with the risk of carotid plaque in female . And the relationship between RAR and carotid plaques in patients younger than 60 years old  was stronger than that in those older than 60 years old . Under different glucose metabolism states, RAR had the highest correlation with the risk of carotid plaques in diabetes patients .RAR was significantly related to carotid plaques in patients with CHD. In addition, the correlation between RAR and the incidence of carotid plaque in patients with CHD was higher in women and middle-aged and elderly patients. In patients with CHD and diabetes, the correlation between RAR and carotid plaque was higher.The online version contains supplementary material available at 10.1186/s12933-023-01768-w. Coronary heart disease (CHD) is a common disease of the cardiovascular system. Its pathogenesis is caused by coronary artery atherosclerosis, which causes coronary artery stenosis or occlusion, hinders the blood and oxygen supply of myocardial tissue, and then causes the necrosis of myocardial tissue, leading to the occurrence of the disease. Coronary atherosclerosis is a risk factor for CHD. Carotid plaque is related to coronary atherosclerotic lesions, and carotid atherosclerotic plaques are similar to coronary atherosclerotic plaques in terms of pathogenesis and pathophysiological basis . StudiesRed cell distribution width (RDW) is a simple and readily available parameter that represents the heterogeneity of red cell volume and has traditionally been used in the differential diagnosis of anemia. In recent years, RDW has been found to be associated with a variety of disease processes and prognosis, such as CVD, venous thromboembolism, etc. . RDW hasNo studies have shown the relationship between RAR and carotid plaque in patients with CHD. In this study, we sought to explore the impact of RAR on carotid plaque and clarify the association between RAR and carotid plaque in the different glucose metabolic statuses of CHD patients.This large-scale, multi-center, retrospective, cross-sectional study included 107,301 CHD patients hospitalized in 6 hospitals in Tianjin from January 1, 2014 to September 30, 2020 [This study was approved by the ethics committee of Tianjin University of Traditional Chinese Medicine (TJUTCM-EC20190008) and registered with the Chinese Clinical Trial Registry (ChiCTR-1900024535) and ClinicalTrials.gov (NCT04026724).Trained medical staff collected data of age, sex, smoking and drinking status, medical history, and prior medication history by means of a standard structured questionnaire , 16. TheFasting venous blood samples were taken from all participants on the second day of hospitalization. RDW, ALB, fasting plasma glucose (FPG), glycated hemoglobin (HbA1c), total cholesterol (TC), triglyceride (TG), high-density lipoprotein-cholesterol (HDL-C), and low-density lipoprotein-cholesterol (LDL-C) levels were measured using an automatic haematology analyzer. Standard laboratory procedure for quality control were strictly followed . HyperliCarotid ultrasound examinations were performed by trained and certified physicians using an ultrasound diagnostic system. In B-mode imaging, the common carotid artery, internal carotid artery, and carotid artery bifurcation were scanned and imaged. Carotid artery color-Doppler was analyzed by professional physicians according to the results of Doppler ultrasound, and the number of carotid plaque and echo characteristics were recorded. The number of carotid plaque was divided into single (n = 1) or multiple (n ≥ 2). The echo properties of carotid plaque can be divided into hypoechoic, isoechoic, hyperechoic, and mixed types. Implement strict quality control procedures for image acquisition and analysis, and inter-laboratory quality evaluations by certified personnel.χ2 test and Kruskal–Wallis H test were used to compare the characteristics of the participants in the different groups. Odds ratios (ORs) and 95% confidence intervals (CIs) of carotid plaques were estimated for RAR using logistic regression. Four logistic regression models were constructed: Model a, unadjusted; Model b, adjusted for age, sex, SBP, DBP; Model c, adjusted for age, sex, SBP, DBP, TC, TG, smoking, drinking, use of antihypertensives, use of antilipidemic; and Model d was adjusted based on Model c with haematologic, rheumatical, diabetes, WBC, CRP, and Hb. The collinearity of the different models was tested before logistic regression. Missing values were imputed using the multiple imputation method. All statistical analyses were performed using SPSS 24.0 . P < 0.05 was considered statistically significant.The P < 0.001). Compared with the Q1 group, the number of patients with carotid plaques in the Q4 group was higher. They were more likely to be older, and had lower levels of TC, TG, HDL-C and LDL-C.The baseline characteristics of participants are shown in Table trend of RAR and carotid plaques was consistent with the results of RAR as a continuous variable (P < 0.01).As shown in Table As shown in Tables As shown in Table In addition, we also observed the relationship between age and sex of RAR and the risk of carotid plaque under different glucose metabolism states. RAR was associated with the risk of carotid plaque in female with DM status   patients, the lower RAR level, the higher the short-term and long-term survival rate of patients . Weng etWe also observed the relationship between RAR and carotid plaque by sex and age. RAR was associated with the risk of carotid plaque in female. And the relationship between RAR and carotid plaque was stronger in patients under 60 years of age than in those over 60 years of age. Similar results were found in a previous retrospective cohort study of the association of RAR in patients with AMI, the subgroup analysis showed that the effect of RAR was higher in female patients than in male patients . We thouMoreover, under different glucose metabolism states, RAR has the highest correlation with the risk of carotid plaque in diabetic blood glucose state. Studies have shown that RAR is strongly associated with all-cause mortality in diabetes , which mAt the same time, among the plaque echo property, RAR has the strongest relationship with mixture plaque. The hypoechoic plaque contains relatively more lipid components and more inflammatory substances, and the plaque are easy to rupture, with poor stability, while hyperechoic plaques have the opposite. RAR showed no obvious specificity between hyperechoic and isoechoic plaque properties.This study was a multicenter, retrospective clinical study. To our knowledge, this is the first study on the correlation between RAR and carotid plaque in patients with CHD. This study has a large number of participants, and we have established several confounding factor models and adjusted them, and the results are convincing. However, this study has several limitations. First of all, this is a multi-center study, and there may be deviations in the measurement methods of different research centers. However, the quality of external clinical laboratories in each center is evaluated by practitioners, which greatly improves the reliability. Furthermore, body mass index (BMI) is an important confounding factor in CHD and carotid plaques. Because much BMI data were missing from this study, it was not included in the model. Finally, this is a cross-sectional study. It is difficult to draw a causal conclusion without taking time as a factor. We plan to further explore this relationship in a prospective study in future.Our study demonstrated that RAR in patients with CHD was significantly related to carotid plaque. This association was more significant in women and patients aged < 60 years people. In addition, under different glucose metabolism states, RAR has a higher correlation with the risk of carotid plaque in DM patients. In conclusion, RAR, as a simple and practical parameter, provided reference value for the prevention and risk stratification of carotid plaque in patients with CHD.Additional file 1: Table S1. Additive interaction between RAR and diabetes for the risk of carotid plaques. Table S2. Relationship between the RAR and the risk of number of carotid plaque. Table S3. Relationship between the RAR and the risk of carotid plaque echo property.


Peromyscopsylla hesperomys and Orchopeas sexdentatus are regarded to be representative plague vectors in the United States. The incidence of plague is rising globally, possibly due to climate change and environmental damage. Environmental factors such as temperature and precipitation have a significant impact on the temporal and spatial distribution of plague vectors.Maximum entropy models (MaxEnt) were utilized to predict the distributions of these two fleas and their trends into the future. The main environmental factors influencing the distribution of these two fleas were analyzed. A risk assessment system was constructed to calculate the invasion risk values of the species.P. hesperomys and O. sexdentatus. They have the potential to survive in suitable areas of China in the future. The risk assessment system indicated that the risk level for the invasion of these two species into China was moderate.Temperature has a significant effect on the distribution of the potentially suitable areas for In order to achieve early detection, early interception, and early management, China should perfect its monitoring infrastructure and develop scientific prevention and control strategies to prevent the invasion of foreign flea vectors. Globally, flea-borne infectious diseases, for instance, plague, are creating a comeback and their incidence is on the rise, which may be related to global climate change and environmental damage . ClimateThe World Health Organization estimates that the number of excess deaths attributable to global climate change will reach 250,000 per year in 2030–2050. Moreover, global warming has vital implications for vector-borne infectious diseases: First, the temporal and geographic distribution of vector organisms is susceptible to climatic and environmental factors, and a tiny increase in temperature could cause obvious changes in the population size and distribution range of vector organisms. Second, climatic factors influence the reproduction of pathogenic microorganisms in vector organisms considerably . The occvia the formation of Yersinia pestis bacterial embolus, and the speed of this process is regulated by temperature  from 1950 to 2009 . In the Peromyscopsylla hesperomys (P. hesperomys) and Orchopeas sexdentatus (O. sexdentatus) were selected for the predicting suitable areas and the invasion risk assessment.In this research, Yersinia pestis , PubMed, Web of Science, Embase, and Google Scholar. Global Invasive Species Database (GISD), Invasive Species Compendium (ISC), European and Mediterranean Plant Protection Organization (EPPO), World Health Organization (WHO), and the U.S. Centers for Disease Control and Prevention (CDC) were used to screen for fleas with invasive risk and positive for plague a pestis . Two repP. hesperomys and O. sexdentatus were obtained from the Global Biodiversity Information Facility (GBIF) . The accuracy of the coordinate points was checked. When the species distribution data were too dense in a particular area, ENMTools software  is used to keep only one distribution point within the same raster to avoid result overfitting  by a spatial resolution of 5 arc-min, containing bioclimatic variables (Bio1–Bio19), monthly maximum temperature (Tmax1–Tmax12), monthly minimum temperature (Tmin1–Tmin12), monthly precipitation (Prec1–Prec12), and elevation (Ele). They were processed by the BCC-CSM2-MR (Medium-Resolution Beijing Climate Center Climate System Model version 2) under four different socio-economic models driven by CO2: shared socio-economic pathways (SSPs) 126, 245, 370, and 585  and future climate scenarios , were collected from WorldClim  to conduct Pearson's correlation analysis on environmental variables. If the absolute value of the correlation coefficient between two variables was >0.8, the variable with a smaller contribution was removed. If the absolute value of the correlation coefficient was < 0.8, both variables were retained. In the end, 10 variables were filtered as predictors of P. hesperomys, and 8 variables were filtered as predictors of O. sexdentatus , and the world map  is from the Natural Earth .The China map  is from the National Geomatics Center of China  was used to predict the suitable areas for P. hesperomys and O. sexdentatus under near-current and future climate scenario model. The training and testing data sets were randomly generated, with 75% of the distribution points for training and 25% for testing.MaxEnt software  curve was used to evaluate the performance of the prediction model. The area under the curve (AUC) value, which can judge the model accuracy, is defined as the area under the ROC curve. The judgment standard: AUC (0.5–0.7), low predictive; AUC (0.7–0.9), middle predictive; AUC (0.9–1), highly predictive.The regularization multiplier (RM) and feature combination (FC) affected the predictive performance and accuracy of the MaxEnt model . R softwArcGIS software (version 10.5) was purchased by the Department of Vector Biological and Control of the National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention (ICDC). Based on the natural break points, the probability of presence was classified into four categories: unsuitable area, low suitable, middle suitable, and high suitable, using ArcGIS's reclassification tool with complementary cloglog values .In this research, a multi-indicator invasion risk assessment system was designed by referring to the previous invasion risk assessment index system , 27. An P1), the possibility of colonization and spread (P2), and the damage consequences (P3). Each assessment factor is quantitatively or qualitatively described by specific elements.Based on the general process of foreign biological invasion , risk factors that affect biological invasion are divided into three categories, including the possibility of entry , moderate (0.25 < x ≤ 0.5), strong (0.5 < x ≤ 0.75), and extremely strong (0.75 < x ≤ 1). Scores of quantitative indicators are assigned values based on specific situations, and qualitative indicators are scored by experts based on their professional knowledge and research experience. The R-value is calculated by The calculated risk value ranged from 0 to 1, which was classified as extremely low risk (0.01–0.05), low risk (0.05–0.3), moderate risk (0.3–0.7), and high risk (0.7–1).The weight coefficients of the indicators were determined in accordance with the multiplication principle.The entry possibility calculated formula is as follows:Colonization and spread possibility calculated formulas are as follows:The damage consequences calculated formula is as follows:P. hesperomys under the near-current climate scenario were classified as unsuitable areas, low suitable areas, middle suitable areas, and high suitable areas. The suitable areas are mainly on the west coast of Canada, most of the states in the U.S. mainland and Alaska state, Mexico, and countries along the Andes Mountains. In addition, suitable areas are distributed in European including western Russia, North African countries , west and Central Asian countries , and east Asia countries . The total global area of the suitable areas is 25.11 × 106 km2 , Africa , and Asia . The total area of the global suitable areas is 9.11 × 106 km2 . The area potentially suitable for P. hesperomys under each climate scenario reveals an overall increasing trend in the future . The overall trend of the suitable area in China is decreasing   . TherefoP. hesperomys distribution zones in the southeastern U.S. is the same as that of southern China for a temperate climate with hot summers but without any dry seasons (Cfa). Its climate is characterized by a minimum monthly mean temperature in the range of 0 to 18°C and a maximum monthly mean temperature of 22°C or higher within 1 year and high humidity. The Cfa has shown a significant expanding trend during the past 40 years in China  and Tmin1 (minimum temperature in January), while the main environmental variables affecting the distribution of potentially suitable areas for O. sexdentatus were Bio3  and Bio2 . It also illustrated that high temperatures had a dramatic effect on the survival of vector fleas. Furthermore, a longer survival time of fleas was found at elevated humidity conditions. With rising humidity, the density of the host increases, and fleas may be more effective in transmitting Yersinia pestis  are needed to prevent the introduction of rodents and fleas. Second, use an early warning platform to master the dynamics of flea population. Flea surveillance has to be upped, especially in locations that are moderately or highly suitable for the two fleas. Third, environmental control: (1) hang sticky papers in the room to capture fleas, and (2) vacuum rooms infested with fleas, which can reduce 60% of eggs, 27% of larvae, and 95% of adults. Finally, chemical control: (1) clothing against fleas: spray 0.1% of dichlorvos on the bedding, and (2) to kill fleas on pigs, dogs, cats, and apply 1% permethrin or trichlorfon to the animal's body.Innovations: First, there is no study on the risk of vector fleas invading China at present. This research provides a systematic research method for the visual screening of the key invasive vector fleas and their invasion risks in China. Second, this study found many potentially suitable areas for fleas with the risk of invading China. Although they have not been intercepted and discovered in China at present, they may still colonize and localize under certain conditions. Finally, the suitable areas for vector fleas are gradually expanding to southern China with global warming and the dramatic increase of the Cfa climate in China.Constrained by historical climate data (1970–2000), there is a lack of the latest climate data to estimate current suitability zones, so there are limitations in this study. The MaxEnt model used in this study only considered the environmental adaptability of the species and only fitted selected environmental variables, such as temperature, precipitation, and elevation. A more accurate estimation of distribution in suitable areas requires additional variables such as topographic factors, soil moisture, interspecific relationships, vegetation cover type, population density, host density, land use, and economic indicators like GDP per capita. While this invasion risk assessment system involves a large number of related indicators, it still cannot fully and objectively represent the actual invasion risk of the species. Therefore, further optimization in the construction and screen of the indicator system is required.P. hesperomys and O. sexdentatus. Both species have large potential suitable areas in China, the temperature has a vital impact on the distribution of suitable areas, and the suitable areas of P. hesperomys are expanding into the southern part of China under global warming. The invasion risk assessment system was adopted, and both species were found to be of moderate invasion risk for China, which served as an early warning for biological invasion in China. China should develop scientific prevention and control strategies and strengthen surveillance of its related alarm systems to prevent the invasion of overseas flea vectors.From a worldwide perspective, our research offered scientific data about the distribution of the suitable areas of The original contributions presented in the study are included in the article/HH and QL: conception, design of the research, and critical revision of the manuscript for intellectual content. HL, YL, LD, CL, LZ, BW, DM, QM, and JW: literature review and acquisition of data. HL: analysis and interpretation of the data and writing of the manuscript. All authors read and approved the final draft.


The results demonstrate the unidimensionality of the scale and a high degree of internal consistency, along with satisfactory fit indices. Those people who identified as male and heterosexual showed greater modern homonegativity. We conclude that the Portuguese version of the MHS is valid and reliable for evaluating modern homonegativity in Portugal.The studies focused on analysing attitudes toward homosexuality show that the manifestation of homonegativity has evolved into more modern forms. We therefore propose using instruments that capture subtle aspects in discrimination against gay and lesbian people. The objective of this study is twofold. First, we aim to adapt and validate the Portuguese version of the Modern Homonegativity Scale. Second, we set out to analyse the modern homonegativity shown by Portuguese university students. The scale includes two parallel subscales (MHS-Gay Men and MHS-Lesbian Women), each with 12 items. Six hundred and forty-one Portuguese college students between 18 and 27 years of age participated in the study (M The treatment of people depends on the characteristics that each society takes as acceptable. In Europe, there are differences in the acceptance given to gay, lesbian and bisexual people. The study carried out by D’Amore et al.  comparesOver the last few years, different studies have been undertaken in Portugal to analyse attitudes toward gay and lesbian people. Most of these studies ,5 use HeOn the other hand, studies warn of the need to take subtle aspects into account in the discrimination against LGB people , which iOne consequence of the change in attitudes is the need to update the instruments used to measure them. Rye and Meany  carry ouThe aim of the scale is to measure attitudes toward behaviours and policies that are friendly to gay men and lesbians (LG-friendly policies). Morrison and Morrison  studied The MHS-G and MHS-L scales have been validated in the United States , and in Therefore, taking into account (a) the legal, social and political changes that have taken place in Portugal in the last few decades, tied with (b) the scant use of instruments that fulfil the recommendations in the Portuguese context, and (c) the conclusions in the validation of the MHS in Brazil, this study aims to adapt and validate the MHS scale for Portugal.Furthermore, the study of attitudes toward homosexuality has found considerable sociodemographic differences. Men tend to show more hostile attitudes toward LGB people than women ,25,26,27This investigation also seeks to analyse the modern homonegativity of Portuguese university students toward homosexuality with regard to personal , sociodemographic and ideological (religion) variables. Therefore, following the aims of this study and the results of previous investigations, we postulated the following hypotheses:Hypothesis 1:Men will show greater modern homonegativity than women toward gay and lesbian people.Hypothesis 2:The participating students who do not identify as heterosexual will show less modern homonegativity than those who do identify as heterosexual.Hypothesis 3:The participating students who profess a religion will show greater modern homonegativity than those who do not.age = 21.23; SD = 1.88). Seventy-three percent (n = 468) of participants self-identified as female, 82.2% (n = 526) as heterosexual, and 51.2% (n = 328) stated they had a religion, mostly Catholic (93.8%). Most participants studied social science programmes, followed by biology/health science programmes. In this study, we used non-probability convenience sampling. Six hundred and forty-one Portuguese college students between 18 and 27 years of age participated in this study , their sexual orientation , their religion (yes or no), and their field of study.Modern Homonegativity Scale. The Modern Homonegativity Scale (MHS) measures contemporary negative attitudes toward gay men and lesbian women and was originally developed in Canada by Morrison and Morrison . We usedAttitudes Toward Lesbians and Gay Men Scale. We used the Portuguese version of the Attitudes Toward Lesbians and Gay Men Scale (ATLG)  originalData collection was carried out online during the month of October 2021, through a website created for this purpose, which was disseminated through social networks targeting Portuguese college students. Using published email lists, we randomly contacted the coordinators of bachelor’s and master’s degrees at different Portuguese polytechnics and universities to make the request to their students to participate in this investigation. Anonymity, confidentiality, and informed consent were duly safeguarded. The information present in the Informed Consent was read and accepted by all participants and the data subsequently obtained were stored in encrypted databases, without reference to their IP’s. This study was approved by the Ethics Committee of the University of Granada (580/CEIH/2018).2/df (Ratio Chi-square and Degrees of Freedom), CFI (Comparative Fit Index), PCFI (Parsimony CFI), RMSEA (Root Mean Square Error of Approximation). In order to analyse the modern homonegativity, we used inferential analysis (Student’s t). The effect size was analysed with Cohen’s d test. It was considered a small effect when d = 0.20, medium when d = 0.50, and large if d = 0.80. The statistical software used was SPSS .Data analyses were conducted separately for the male and female subscales of the MHS. Descriptive statistics, correlational analyses, exploratory factor analysis, and reliability analysis  were calculated for all items of the MHS Scale using SPSS . The sensitivity of the items was assessed through Skewness (Sk) and Kurtosis (Ku) analysis. Absolute values of |Sk| and |Ku| higher than three and seven, respectively, were considered violations of the normality assumption. To conduct Confirmatory Factor Analysis (CFA), we used structural equation models using AMOS . The model’s fitness was evaluated through the following : χ2/df  = 3091.237, p < 0.001 for the gay men scale; and a KMO of 0.933 and a statistically significant Bartlett’s sphericity test χ2 (66) = 3539.731, p < 0.001 for the lesbian women scale, suggesting that the data matrix is appropriate for performing an exploratory factor analysis. The analysis of the eigenvalues and the respective scree plot suggests the retention of a single factor, which explains 47.565% of the variance for the gay men scale, and 51.068% of the variance for the lesbian women scale.Regarding the exploratory factor analysis process, the Kaiser-Meyer-Olkin (KMO) coefficient was calculated. We obtained a score of 0.935 and a statistically significant Bartlett sphericity test χThe factorial weight of each item can be seen in 2/df, CFI, RMSEA and PCFI presented a good fit to the data.Confirmatory factor analysis (CFA) was performed to determine the model goodness of fit with the variables and structure proposed by Morrison and Morrison . The varp < 0.01), positive and strong, indicating convergent validity.To assess the convergent validity of the gay men and lesbian women MHS scales, Pearson’s correlations were calculated between the scales ‘MHS-gay men’, ‘MHS- lesbian women’, and ‘Overall ATLG’ . All corWe also analysed modern homonegativity in relation to the gender, age, sexual orientation, and religion of the students.p < 0.001; Cohen’s d = 0.95] and lesbian women  than the female students . These differences showed a large effect size.Regarding gender, the male students  showed significantly greater modern homonegativity toward gay men  and lesbian women . The heterosexual participants revealed greater modern homonegativity toward both groups  than the rest .According to sexual orientation or choice , the results revealed statistically significant differences, with a medium effect size, in the showing of modern homonegativity toward gay men [t (218.89) = 8.03; Lastly, we analysed the differences in the showing of modern homonegativity between religious believers and non-believers. Those participants who professed a religion expressed greater modern homonegativity toward homosexual people than those who stated they had no religion. However, these differences were not significant.This study had two aims. First, we aimed to adapt and validate the Modern Homonegativity Scale  for use For the first aim, the Exploratory Factor Analysis produced results for the KMO and Bartlett’s sphericity that are similar to other validation studies of this instrument . This inThe results concur with what has been found in previous studies ,14,18,23Regarding the convergent validity, the results show that modern homonegativity has a strong and positive correlation with a traditional manifestation of attitudes toward gay men and lesbians (ATLG) ,34. ExamWith regard to the second objective, as expected (Hypothesis 1) the men show higher modern homonegativity toward gay men and lesbian women. These results are in agreement with other studies ,26,27,35Likewise, the results obtained in terms of sexual orientation also confirm our hypothesis (Hypothesis 2). Those people who identify as heterosexual reveal greater modern homonegativity toward gay and lesbian people . This faHowever, religion is not related to the expression of modern homonegativity toward gay men and lesbians. In contrast to what we anticipated (Hypothesis 3), there are no significant differences between those who professed a religion and those who did not. This finding contradicts other studies ,36 that The findings of this study aim to be an advance in the research of this field. In this regard, we have considered different implications in the university setting. It has been noted that the manifestation of homonegativity in higher education has evolved toward modern forms . This stIn addition, the acquisition of knowledge about LGBT matters is related to greater positive attitudes toward these students ,41. Yet In terms of this study’s limitations, we should point out both the size and distribution of the sample, and the online data collection. The study could be improved by increasing the number of male participants and of other, non-heterosexual orientations. This having been said, the use of offline and online questionnaires does not affect the quality of the results . AnotherIn general terms, the results suggest that the Portuguese version of the MHS is valid and reliable for evaluating modern homonegativity in Portugal. Following the findings of similar studies, we recommend the use of this instrument, since it examines the contemporary forms of homonegativity present in university students. In this regard, it has shown how certain personal and sociodemographic variables influence modern homonegativity. We need to continue studying the psychometric properties of this scale both to delve into the effect of the inverted items and the dimensionality of both scales, as the conception of homonegativity can alter with social change.


Cistanche salsa (C. A. Mey.) G. Beck, a holoparasitic desert medicine plant with multiple hosts, is regarded as a potential future desert economic plant. However, as a result of excessive exploitation and poaching, its wild resources have become scarce. Thus, before developing its desert economic value, this plant has to be protected, and the identification of its natural reserve is currently the top priority. However, in previous nature reserve prediction studies, the influence of host plants has been overlooked, particularly in holoparasitic plants with multiple hosts. In this study, we sought to identify the conservation areas of wild C. salsa by considering multiple host–plant interactions and climate change conditions using the MaxEnt model. Additionally, a Principal Component Analysis (PCA) was used to reduce the autocorrelation between environmental variables. The effects of the natural distribution of the host plants in terms of natural distribution from the perspective of niche similarities and extrapolation detection were considered by filtering the most influential hosts: Krascheninnikovia ceratoides (Linnaeus), Gueldenstaedt, and Nitraria sibirica Pall. Additionally, the change trends in these hosts based on climate change conditions combined with the change trends in C. salsa were used to identify a core protection area of 126483.5 km2. In this article, we corrected and tried to avoid some of the common mistakes found in species distribution models based on the findings of previous research and fully considered the effects of host plants for multiple-host holoparasitic plants to provide a new perspective on the prediction of holoparasitic plants and to provide scientific zoning for biodiversity conservation in desert ecosystems. This research will hopefully serve as a significant reference for decision-makers. Cistanche salsa (C. A. Mey.) G. Beck, a holoparasitic plant with multiple host plants living in expansive arid areas, has the potential to become one of the potential targets for desert economic development  and butyrylcholinesterase (BuChE) for Alzheimer’s disease  are widely used, with the Maximum Entropy (MaxEnt) algorithm being popular due to its user-friendliness . Using lIn addition to considering how these issues are related to the model settings, for holoparasitic plants, in particular, the effects of the host plants playing a fundamental role in its growth must be considered . Some reC. salsa and C. deserticola as non-parasitic plants, during distribution prediction and only investigate the role of the climate, soil, and other environmental factors  analyze the changes in the host plant caused by climate change; (2) predict C. salsa distribution according to the effects of the host plant; and (3) identify the natural reserve by changing the habitat of C. salsa and its hosts in different scenarios. Additionally, these results will also help other researchers and local government bodies to better understand how to protect multi-host parasitic plants.However, some studies still treat holoparasitic plants, such as  factors . To bett2) and is the location of two large deserts (the Taklimakan desert and the Gurbantunggut desert). Its unique climate and soil conditions mean that it may experience potential economic and research development  Moq., K. gracile Fenzel, K. cuspidatum (Ung.-Sternb.) Grub., Reaumuria soongarica  Maxim., Nitraria sibirica Pall., and Achnatherum splendens (Trin.) Nevski  Gueldenstaedt have been observed in fieldwork. As such, considering the history and current conditions, these host plants should all be regarded as host factors for future C. salsa prediction. In the present study, occurrence records (for host plants and parasitic plants) were obtained from online databases, including the Global Biodiversity Information Facility (GBIF), Chinese Virtual Herbarium National Plant Specimen Resource Center (CVH NPSRC), National Specimen Information Infrastructure (NSII), and fieldwork records. Additionally, after the occurrence data were obtained, the data were cleaned by removing the records without coordinates and duplicate data. These data were saved as the “.csv” files with the terms “longitude” and “latitude” in the header. However, these “.csv” files cannot be used in MaxEnt modeling directly, and there is a final step to be completed after preparing the environmental variables: that is, the resolution of occurrence records should be the same as that of variables. There were 465 occurrence records in total.Host plants of ) Nevski . HoweverThe current and future climate variables are all from the WorldClim 2.1 database (including 19 bioclimatic variables and elevation) and have a spatial resolution of 2.5 Arc-min. The spatial resolution of 30 Arc-s observed in the bioclimatic variables can be downloaded for both current and future scenarios but cannot be used in this study because the resolution of the variables is extremely accurate and the resolution of the occurrence records is not as accurate . AdditioEnvironmental variables (30 files) with the same resolution cannot be used in MaxEnt modeling directly. The use of highly correlated variables in building models without critically analyzing them will result in undesired effects : the nulThere are two fundamental steps in model building: (1) the preparation and processing of occurrence records and environmental variables; and (2) the optional strategy for the research object.For step one, the occurrence records are processed using data clean, and the variables also are processed by PCA. Before putting them together in the Maxent model “machine,” the spatial resolutions should be the same . To achiC. salsa is a holoparasite plant with multiple hosts, and it is not easy to input biotic factors when predicting the performance effects of the host, and this is often ignored by other researchers . As such, all of the processes within a specific climate condition can be included in three steps: (1) the records of the host plants and C. salsa and the environmental variables (PC1 to PC8) are processed; (2) the predicted distribution of the host plants is determined by factors PC1 to PC8 (these distributions are regarded as in-process factors for the next step); and (3) the predicted distribution of C. salsa is determined by the in-process factors (the distributions of its hosts).Additionally, for step two, earchers . Recentlearchers . AccordiThis approach is clear, but there is still a question of how to choose the optional model during training. Traditionally, the AUC (area under the curve) is a good choice for optional model selection . HoweverI” similarity statistic can all quantitatively evaluate this goal  the change in the habitat class of areas under future climate change conditions (We have primarily used two principles for the delineation and identification of conservation areas: (1) the classification of the fitness class of the distribution of wild resources of nditions .Habitat levels were classified using the Jenks natural breaks classification method, which looks for natural patterns in the data rather than artificial and rigid groupings . Jenks nUsing the current habitat as a criterion, habitat changes were classified into three broad categories based on the differences between the habitats in various climatic conditions and the current habitat: (1) areas with a constant habitat class over time; (2) areas with a decreased habitat class over time; and (3) areas with an increased habitat class over time.Based on the current habitat classes, a statistical approach was used to determine trends in the rate of change in the area for various habitat classes under various climatic scenarios. By utilizing trends rather than simply increasing or decreasing the sizes of areas to classify conservation areas, the natural patterns of habitat change can be better understood to benefit human activities.C. salsa is distributed around the Xinjiang region , and A. splendens (0.938), can be regarded as effective factors. These plants not only have the highest niche similarity but also have the most influential covariates (MIC) for niche extrapolation. The results of the extrapolation are summarized in C. salsa prediction, with a value of 73.77%. Additionally, for the MIC, N. sibirica, K. ceratoides, and K. cuspidatum occupy approximately 70% of all of the extrapolation results. Additionally, according to the habitat trends of the four host plants in different climatic situations, we can roughly divide them into two categories: (1) each major habitat  showed an increasing trend, including in the two host plants A. splendens and K. cuspidatum ratoides .A. splendens in HSH and MSH were found to be at 382.1% in SSP585 from 2,080 to 2,100 and 47.9% for SSP585 from 2,060 to 2,080. Additionally, the MRR of K. cuspidatum in HSH and MSH was 190.2% according to SSP585 from 2,080 to 2,100 and 29.6% in SSP585 from 2,040 to 2,060. For the host plants, in the decreasing category, the MSH of the host plant N. sibirica decreased, with a maximum reduction ratio of 26.1%. Additionally, the host plant K. ceratoides showed a very dangerous habitat change trend when the HSH of other host plants was increasing, and the HSH decreased in most cases, with a maximum decrease ratio of 17.7%. When identifying the natural reserves, the host plants with shrinking habitats should be focused, especially N. sibirica and K. ceratoides, in which habitat shrinkage was determined to be gradually increased. Therefore, according to the variations in the host plants in different climatic situations from the perspective of niche similarity and the influence of host plants from the perspective of MIC, and because of the variation in the parasitic plant C. salsa, the main strategy for identifying natural reserve is to focus on the main areas experiencing habitat shrinkage in both host and parasite distributions, including in the HSH of K. ceratoides, the MSH of N. sibirica and K. ceratoides, and the MSH and HSH of C. salsa under the current conditions. These areas are regarded as core protection zones  in the climate . This isC. salsa was reflected by the niche overlap value, especially when we chose the host factor as the limiting factor.Additionally, for the multiple host plants, analyzing the effects of the hosts in the prediction process is the most important factor in reserve identification. Two approaches can be applied in reserve identification to evaluate the effects of hosts: niche overlap and MIC. Niche overlap simply indicates that there is competition between two or more species sharing the source in the same area . AdditioAdditionally, the effects of host distribution on extrapolation evaluation indicate more quantitative information, and the ExDet metric can show the MIC , which can make the largest contribution to extrapolation in the target system . AdditioN. sibirica, K. ceratoides, and K. cuspidatum play a role in parasite distribution prediction, especially N. sibirica. The ExDet metric can be regarded as a tool for considering prior covariates, and in this study, the effects of N. sibirica and the other two host plants are fundamental in production model processing or data extrapolation (N. sibirica is mainly affected by PC2 and PC1, and these two components contain more than two environmental variables’ features, every environmental variable can be affected by climate changes. And especially in an arid land, water, especially groundwater, plays an important role in plant growth (Additionally, according to the MIC table , the hospolation . Additiot growth . As sucht growth . TherefoHowever, our study cannot effectively explain the factors causing different desert plants to have different climate change trends and cannot effectively explore how the deeper groundwater affects the arid plants’ distribution. In our future study, better explanatory variables will be discovered and introduced in addition to the hosts and environment in order for the results of the evaluation to be more accurate.A. splendens, K. cuspidatum, N. sibirica, and K. ceratoides are more important than other host plants from the perspective of niche similarity. Additionally, considering the MIC, K. ceratoides and N. sibirica are fundamental factors in core natural reserve identification. To identify natural reserves, especially under climate change conditions, multiple host parasitic plants require more attention to determine the effects of their host plants. For C. salsa, its host plants N. sibirica and K. ceratoides can provide good aid for planning and protecting areas. Under the same conditions of good similarity and MIC, the trends of the host habitat can likewise affect the future distribution of C. salsa, similar to the role of environmental variables in the prediction of non-parasitic plants. The MSH of N. sibirica and K. ceratoides and the HSH of K. ceratoides are combined with the MSH and HSH of C. salsa, which can better demonstrate the accuracy of identifying areas from the perspective of the host–parasite relationship. The core area for C. salsa was determined to have a final area of 126483.5 km2.A few host plants play fundamental roles in distribution prediction. The host plants The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.MS: investigation, data curation, methodology, formal analysis, and writing—original draft. JF: conceptualization, methodology, software, writing—review and editing, funding acquisition, investigation, project administration, resources, and supervision. JM and LW: validation and writing—review and editing the manuscript. All authors contributed to the article and approved the submitted version.


Visceral leishmaniasis (VL) is one of the most important neglected tropical diseases. Although VL was controlled in several regions of China during the last century, the mountain-type zoonotic visceral leishmaniasis (MT-ZVL) has reemerged in the hilly areas of China in recent decades. The purpose of this study was to construct an indicator framework for assessing the risk of the MT-ZVL in China, and to provide guidance for preventing disease.Based on a literature review and expert interview, a 3-level indicator framework was initially established in November 2021, and 28 experts were selected to perform two rounds of consultation using the Delphi method. The comprehensive weight of the tertiary indicators was determined by the Delphi and the entropy weight methods.Two rounds of Delphi consultation were conducted. Four primary indicators, 11 secondary indicators, and 35 tertiary indicators were identified. The Delphi-entropy weight method was performed to calculate the comprehensive weight of the tertiary indicators. The normalized weights of the primary indicators were 0.268, 0.261, 0.242, and 0.229, respectively, for biological factors, interventions, environmental factors, and social factors. The normalized weights of the top four secondary indicators were 0.122, 0.120, 0.098, and 0.096, respectively, for climatic features, geographical features, sandflies, and dogs. Among the tertiary indicators, the top four normalized comprehensive weights were the population density of sandflies (0.076), topography (0.057), the population density of dogs, including tethering (0.056), and use of bed nets or other protective measures (0.056).An indicator framework of transmission risk assessment for MT-ZVL was established using the Delphi-entropy weight method. The framework provides a practical tool to evaluate transmission risk in endemic areas.The online version contains supplementary material available at 10.1186/s40249-022-01045-0. Leishmania, which are transmitted by biting of sandflies from the genera Phlebotomus and Lutzomyia [L. donovani and L. infantum are the main Leishmania species in China. There are three epidemiological types of VL in China, namely anthroponotic visceral leishmaniasis (AVL), mountain-type zoonotic VL (MT-ZVL), and desert-type zoonotic VL (DT-ZVL), and the main transmitting sandflies for each type of VL are different [Phlebotomus chinensis (endophilic species) is the main vector in MT-ZVL endemic areas, including the central and eastern plains, and mountainous and Loess Plateau areas of China [Visceral leishmaniasis (VL), also known as kala-azar, is a serious disease caused by trypanosomatid protozoans of the genus utzomyia . If leftutzomyia , and is ifferent . Phlebotof China ., Ph. chinensis, and reservoirs, leading to the re-emergence of MT-ZVL in the hilly areas of China [Leishmania in endemic areas reached 51.9%, as detected by PCR [VL was once rampant in rural areas north of the Yangtze River, afflicting more than 600 counties and cities in 16 provincial-level administrative divisions (PLADs), with an estimated number of 530,000 patients in 1951 [of China . Since tof China , 9. The d by PCR . A totald by PCR .Several studies have been conducted to investigate the risk factors associated with the transmission of the disease based on patterned methods, and found that some meteorological, environmental, and socioeconomic factors could increase the transmission risk of VL –16. The Therefore, it is necessary to develop a comprehensive risk factor analysis tool for MT-ZVL transmission. The Delphi method is an anonymous questionnaire-based method that provides an objectivity and neutrality, as well as use of each expert's knowledge and experience. The method has a certain degree of subjectivity given that it is based on a set of integrated views, and practical and scientific support . The enthttp://www.sinomed.ac.cn/), China National Knowledge Infrastructure , China Science and Technology Journal Database  and Wanfang (https://www.wanfangdata.com.cn/) were comprehensively searched for published articles on the transmission risk of VL from 2010 to 2022. The search was carried out using the following keywords and terms: “visceral leishmaniasis”, “Kala-azar”, “Leishmania donovani”, “Leishmania infantum”, “canine visceral leishmaniasis”, “zoonotic visceral leishmaniasis”, “MT-ZVL”, “zoonoses”, “Phlebotomus”, “risk factors”, “transmission”, “epidemiology”, “control measures”, alone or in combination with “OR’’ and/or “AND’’ operators. As for grey literature, relevant global or national guidelines for VL were identified from the WHO or other resources.The questionnaire was designed using a systematic search approach, which was performed on literature of the risk factors for MT-ZVL. English and Chinese databases, including PubMed, Science Direct, Scopus, Google Scholar, Web of Science, Chinese Biomedical Literature Database  on the transmission risk of each indicator, using a 5-point Likert scale method  based on scientific information, necessity, and operability, and providing qualitative opinions and suggestions.Part I: The core part of the expert inquiry was the importance (Cs): whether the expert was familiar with the listed indicators and understood the meaning. The highest score was 1, and the higher the score, the greater the familiarity; judgment basis (Ca): Based on the expert's judgment, the degree of influence is divided into large, medium, and small. As shown in Table Part II: Basic information, including general information of experts ; familiarity (Cij), familiarity (Cs) and judgment basis (Ca) of each indicator of the framework. Experts also provided suggestions for modification and supplementation of the indicators.Two rounds of expert consultations were carried out, and the experts scored the importance (Cr), determined by the judgment basis coefficient (Ca) and familiarity coefficient (Cs) of the expert. The formula is Cr = (Ca + Cs)/2, and the larger Cr value indicates a higher degree of authority of the expert on the content of the consultation; (c) coordination coefficient , the W value and its significance test (χ2 test) reflects the degree of dispersion of the expert consultation. W is in the range of 0–1. The larger the W with a significant χ2 test value was, the better the coordination would be; (d) coefficient of variation (CV), where CV = standard deviation/mean value. The smaller the coefficient of variation, the more unanimous the opinion of experts.Indicator evaluation score: With the collected data, the assessment criteria were used to assess the indicator framework from those selected experts. An assessment criterion consisted of four parts: (a) positive coefficient: questionnaire response rate; (b) authority coefficient  The indicator proportion, jth indicator according to (3). According to the definition of information/entropy , \documewhere where  The entropy weight of each indicator, The entropy weight method is an objective method to determine each indicator’s weight based on the uncertainty contained within each indicator for the whole framework. The concept of entropy is well suited to measuring the relative strength of comparison criterion to represent the average intrinsic information involved in the decision. This method largely avoids the defects of the subjective assignment method on the weight calculation for each indicator, and a greater value indicates a greater incidence for the assessed indicator within the overall evaluation . The entDelphi, analytical hierarchy process (AHP), least square, and binomial coefficient methods were subjective weighting methods. Objective weighting methods mainly include the entropy weight method, principal component analysis method, variance and mean square deviation method, and multi-objective planning method. The Delphi method is highly subjective. Therefore, the combination of subjective and objective methods to jointly establish the weight, complement each other's strengths and weaknesses, respect expert opinions, reflect the objectivity of the data, and reduce the “polarization” effect of different evaluation methods, which can all improve the scientific information of the indicator.Considering the importance of the indicators and the degree of difference, the weight coefficients obtained from the above two methods were combined by multiplication to obtain the comprehensive weight, ument}Wc . If therW test on the weighted importance score at all levels of indicators. The test level was α = 0.05.Excel 2020 software  was used to input the expert consultation results. R1.2 software  was used to calculate the authority coefficient, weighted importance score, and CV of each indicator. SPSS 26.0 software  was used to perform Kendall’s The study conducting an indicator framework for the transmission risk of MT-ZVL applied a structured questionnaire to 28 experts during August, 2021. The questionnaire was distributed by a specially-assigned person and the experts were required to reply within one week. All experts were from the Centers for Disease Prevention and Control, and their basic details are provided in Table During the first round of this study, two experts refused to participate in the consultation; thus, 30 questionnaires were delivered with 28 valid questionnaires returned. The questionnaire recovery rate was 93.3% and half of the experts made recommendations. In the second round, 28 questionnaires were delivered with 28 valid questionnaires returned. Thus, the positive coefficient of experts was 100.0%, which highlighted that the experts were highly motivated. The authority coefficients of the experts in the two rounds were 0.82 and 0.83, respectively.W), χ2 test, and CV. The Kendall’s W value of the tertiary indicator in the first round was 0.277 , and CV ranged from 8% to 45%. In the second round, the W value was 0.187  and CV ranged from 14% to 34%. A high degree of recognition was demonstrated by the experts, and the outcome was satisfactory. The coordination coefficients for all levels are shown in Table The degree of dispersion of the expert consultation was expressed by the coordination coefficient , and the use of bed nets and other protective measures, thus, suggesting that the population density of sandflies was the most critical indicator for the risk assessment of MT-ZVL transmission. The rapid resurgence of the MT-ZVL epidemic was closely related to the increase in the population density of sandflies , which wAdditionally, topography was also considered an important indicator of MT-ZVL transmission risk. Historically, MT-ZVL was mainly distributed in hilly settings of Gansu, Sichuan, Shanxi, Shaanxi, western Henan, and northern Hebei, Qinghai, Ningxia, Liaoning, and the suburbs of Beijing . Such arPh. chinensis, has a small activity radius of usually no more than 300 m [Leishmania transmission and MT-ZVL risk, but the weight value of these indicators in this study were low, which may be due to the difficulty or low operability of detecting the infection rate in sandflies and asymptomatic dogs [The population density of dogs, including tethering, is an important indicator of the risk assessment of MT-ZVL transmission. Dogs are the main host reservoirs of MT-ZVL in China and increases in dog population densities create more favorable reservoirs and higher transmission risks. Previous study also shown that the elimination of dogs in endemic areas dramatically reduced the human VL cases, confirming the infected dogs were the major source of the human infection . In the an 300 m . Howeveran 300 m . Howeveran 300 m . Theorettic dogs .W at 0.187. Compared with the first round, the CV was smaller, suggesting that the degree of fluctuation of expert opinions was small, the degree of coordination was improved, and experts' opinions tended to be consistent. This study not only provides a reasonable, scientifically supported indicator framework for the evaluation of MT-ZVL risk but also found several key indicators by calculating the comprehensive weight. The conclusions of this research may help policymakers to develop guidelines for an effective evaluation method of MT-ZVL risk that can be further validated in different endemic areas. This study may also assist official organizations to identify potential risk factors to prevent the spread of the disease, as well as for the integration and rationalization of resources to ultimately improve the monitoring system in China. Limited by the research conditions, this indicator framework may have some deficiencies. It may be limited by the number of experts consulted, resulting in too few indicators or unbalanced weight coefficients. Due to different backgrounds and experiences of experts, and the meaning of second-round questionnaires are not well explained, so it is difficult to obtain a higher Kendall’s W score. Additionally, all experts were from China and further research on a broader national range will enrich the results presented in this study.The selection of experts was a crucial factor affecting the quality of the Delphi-entropy weight method . To imprThe re-emergence of MT-ZVL has become a serious public health concern. In this study, a risk assessment indicator framework of MT-ZVL was constructed using Delphi-entropy weight method for the first time in China, which consisted of four primary indicators, 11 secondary indicators, and 25 tertiary indicators. Among these indicators, the density of the sandflies, the topography, the population density of dogs and using of bed net were the most critical indicators. The results of this study indicated that the framework can be used to formulate strategies and develop targeted interventions for “vectors-reservoirs-humans” aimed at reducing risk for MT-ZVL control.Additional file 1: Table S1. The indicators for the two rounds of the Delphi consultation.Additional file 2: Table S2. First round of primary indicators of the risk assessment of MT-ZVL.


Physical activity (PA) has been associated with decreased incidence of diabetes. However, few studies have evaluated the influence of occupational and domestic PA on the risk of diabetes with a long-term follow-up. We aimed to examine the association between occupational and domestic PA and the risk of diabetes in a long-term prospective cohort of Chinese adults.A total of 10,343 adults who were followed up in the China Health and Nutrition Survey from 1997 to 2015 were included in our analysis. Occupational and domestical PA were collected with detailed seven-day data and were converted into metabolic equivalents values. Total PA included occupational, domestic, transportation, and leisure time PA. Diabetes cases were identified by self-reported doctor/health professional diagnosis of diabetes, fasting blood glucose ≥7.0 mmol/L, and glycosylated hemoglobin (HbA1c) ≥6.5%. Cox proportional hazards models were used to calculate hazard ratios (HR) and 95% confidence intervals (CI).P >0.05).During up to 18 years of follow-up (median 10 years), there were 575 diabetes cases documented. Occupational PA accounted for the majority of total PA (68%) in Chinese population, followed by domestic PA (25%). With adjustments for possible covariates, the highest quartiles of total PA  and occupational PA  were significantly associated with a lower risk of diabetes compared with lowest quartiles. The association between domestic PA and the risk of diabetes was insignificant (Higher levels of occupational PA were associated with a decreased risk of diabetes risk in the Chinese population. Domestic PA was not associated with the incidence of diabetes. The incidence of diabetes mellitus (DM) is increasing and has become a major healthcare burden worldwide, especially in China , 2. DM iExploring the relationship between different types of PA and the risk of DM has important public health implications. A meta-analysis based on prospective studies found that all types of PA help prevent diabetes . HoweverTherefore, this study aimed to explore the association between occupational and domestic PA and the risk of diabetes in the Chinese adult population using the China Health and Nutrition Survey (CHNS) database and to clarify which type of PA plays a major role. To our knowledge, this is the first large-scale, nationally representative, long-term follow-up to evaluate the relationship between occupational and domestic PA and the risk of DM risk in Chinese adults.https://www.cpc.unc.edu/projects/china). The survey used a multistage randomized cluster sampling method, with samples drawn from 15 provinces  in mainland China, covering most of the northern and southern regions. The CHNS conducted 10 rounds of surveys between 1989 and 2015, with 7 days of examination and data collection by researchers in the fields of nutrition, public health, economics, and sociology , stroke, or any type of tumor at baseline.All research procedures were conducted in accordance with the tenets of the Declaration of Helsinki (as revised in 2013) and were approved by the institutional review boards of the University of North Carolina at Chapel Hill, the National Institute for Nutrition and Health, and the Chinese Center for Disease Control and Prevention. Written informed consent was obtained from each participant.https://www.cpc.unc.edu/projects/china.Diabetes status was collected using a staff-administered questionnaire at each follow-up since 1997 and fasting blood samples in 2009. A total of 9,549 CHNS participants’ blood samples were collected. Diabetes cases were identified as those who self-reported a clinical diagnosis of diabetes, or receiving diabetes treatment, or with FBG ≥7.0 mmol/L 126 mg/dL), or with HbA1c ≥6.5%. The treatments for diabetes included in the questionnaires were special diet, weight control, oral medication, insulin injection, traditional Chinese medicine, and home remedies. Blood samples were collected from all participants after 12–14 hours of fasting and were stored in test tubes. All blood samples were analyzed at the central laboratory of the China-Japan Friendship Hospital. Fasting blood glucose was measured with glucose oxidase-peroxidase (GOD-PAP) using a kit manufactured by Landau, UK  was defined as the ratio of the working metabolic rate to the standard resting  metabolic rate. The time spent per week for different PAs was multiplied by a specific MET value based on the Compendium of Physical Activities to calculate the average MET hours/week to evaluate the intensity and duration of the activity . OccupatAnthropometrics were measured by trained investigators following the anthropometric standards recommended by the WHO . Three mThe standardized questionnaire was used by the investigators to collect demographic characteristics, health history, and health-related behaviors, including age, sex, marital status, smoking status (current/ever smoking or not), alcohol consumption (current/ever drinking or not), and educational attainment level . Dietary information was collected through a 3-day dietary review using food weighing methods to assess total energy intake.Continuous variables are expressed as mean ± standard deviation (M ± SD), and categorical data are presented as percentages or frequencies. Participants were divided into four groups according to quartiles of PA, and the lowest quartile was used as a reference. ANOVA tests were used to compare between-group differences for continuous data, whereas chi-squared tests were used to compare between-group differences for categorical data. Kaplan–Meier survival curves were used to assess the relationship between different types of PA and diabetes, and log-rank tests were used to examine significant differences among quartiles. Cox proportional hazards models were used to assess the association between PA and DM, and hazard ratios (HR) and 95% confidence intervals (CI) were calculated. Possible confounding factors were adjusted for in the regression models. Model 1 was adjusted for age and sex; Model 2 was adjusted for the variables in Model 1 plus marital status, education, household per capita income level, and urbanization index; Model 3 was adjusted for the variables in Model 2 plus smoking status, alcohol consumption, total energy intake, and blood pressure; and Model 4 was adjusted for the variables in Model 3 plus BMI. To explore the effect modifications, subgroup analyses were performed according to age (by the median age: <42 years or ≥42 years), sex, BMI , smoking status, and alcohol consumption. All statistical analyses were performed using SAS  and R version 4.0.2. A two-sided test of P<0.05 indicates a statistically significant difference.2(3.3) at baseline. During the 18 years follow-up (median 10.3 years), 575 incident cases of DM were documented, and the mean age of diagnosed DM was 56.1 years. The mean total PA, occupational PA, and domestic PA were 207.3 (127.7) MET·h/week, 149.1 (108.0) MET·h/week, and 44.6 (57.0) MET·h/week, respectively. The baseline characteristics of the participants are presented in A total of 32, 752 participants were eligible for enrollment in the study, and 10,343 participants were finally included based on the exclusion criteria Figure 1As total and occupational PA increased, BMI, SBP, and DBP decreased, total energy intake increased, and the proportion of young people, married, with low education level, and smoking also showed a tendency to increase. However, with an increase in domestic PA, the proportion of men, smokers, and alcohol drinkers declined significantly, and energy intake decreased. Men were more likely to have higher occupational PA, energy intake, BMI, and BP, whereas women were more likely to have higher domestic PA, almost twice as much as men were. PA was divided into quartiles, with the lowest quartile considered as the reference group. Kaplan–Meier estimates of DM incidence by quartiles showed that the highest quartile of total PA and occupational PA had the lowest risk of DM Figure 2Multivariate-adjusted Cox proportional hazard models were used to assess the association between PA and DM. In Models 1, 2, and 3, the highest quartiles of total PA and occupational PA were inversely associated with the risk of diabetes. Further adjustment for BMI in Model 4 attenuated this association, but the highest quartiles of total PA HR = 0.728  and occupational PA HR = 0.765  were still associated with a reduced risk of DM. However, no significant association was observed between domestic PA and the risk of DM after adjusting for various factors Table 2.Subgroup analyses were conducted to clarify whether the relationship between total, occupational, and domestic PA and the risk of DM was influenced by other potential factors Table 3,This large prospective study observed significant inverse associations between total and occupational PA and the risk of DM in the Chinese population. The protective effects of PA may mainly be derived from occupational PA. Age-specific differences were observed in the negative association between occupational PA and DM, with stronger correlations in middle-aged and older adults than in younger adults. However, no significant association was observed between domestic PA and the risks of DM.Previous studies conducted in different populations yielded findings consistent with this study that higher PA is associated with a decreased risk of DM –8. Some Similar to total PA, occupational PA was inversely associated with the risk of DM in current study. Several studies using data from the NHANS and the Malmö Diet and Cancer Study consistently showed that occupational PA was negatively associated with DM , 21. MorTo date, relatively few studies have evaluated the relationship between domestic PA and the risk of DM. A previous study in a Korean population combined work and housework PA (DWPA) showed that moderate- or high-intensity DWPA increased the DM risk, but the combination of different types of PA may have biased the results of study . A previIn addition, our study found that the inverse association between total and occupational PA and the risk of DM was more pronounced in the middle-aged and older populations over 42 years of age. However, the prevalence of DM increased more sharply after middle-age . We furtSeveral possible mechanisms may explain the relationship between PA and the risk of DM. PA could increase energy expenditure to prevent obesity, a major risk factor closely associated with diabetes , 39. MorThe present study has several strengths. First, our study systematically assessed the independent effects of occupational and domestic PA on the risk of DM, rather than focusing solely on total or leisure PA. Second, this is a prospective, large-scale study with a long follow-up period, and included data from nationally representative Chinese populations rather than restricted populations, such as the population limited to the older adults or those with diabetes, which improved the generalizability of our findings to the entire Chinese population. Third, METs were calculated to quantify PA levels in our study, which is more accurate. Nevertheless, this study has some limitations. First, PA information was obtained through a questionnaire, which may have led to recall bias. Second, the diagnosis of diabetes was mainly based on self-reports and blood samples were collected only in 2009. This may have led to an inaccurate incidence rate of DM and biased the Cox model results. Finally, although we adjusted covariates in the regression models, residual confounding from unmeasured or unknown factors remains possible.In conclusion, to the best of our knowledge, this is the first large-scale, nationally representative study with a long-term follow-up to systematically assess the independent association between occupational PA and domestic PA and the risk of DM in Chinese adults. Our findings showed that occupational PA was negatively associated with the risk of DM, whereas domestic PA was not associated with the risk of DM. Therefore, occupational PA may require more attention. Diabetes could be prevented by carrying out more other types of activities to increase the total amount of PA for people with low level of occupational activities. Individualized diabetes prevention and management strategies should be developed for different occupational groups, especially middle-aged and older people.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the institutional review boards of the University of North Carolina at Chapel Hill, the National Institute for Nutrition and Health, and the Chinese Center for Disease Control and Prevention. The patients/participants provided their written informed consent to participate in this study.The conception and design of the study: YL, HZ, LH, and JW. Acquisition of the data: JW, LH, ZL, and HZ. Analysis and interpretation of the data: JW, LH, HZ, and WL. Draft of the article: JW, LH and HZ. Critical revision for important intellectual content: JW, LH, NY, LX, FP, WL, HZ, and YL. Final approval of the version to be published: All authors. Funding acquisition: HZ and YL. Supervision: HZ and YL. Agreement to be accountable for all aspects of the work: All authors. All authors have approved the final article.