Mobile health applications  have been widely used for various purposes for mitigating the COVID-19 pandemic, such as self-assessment, contact tracing, disseminating information, minimizing exposure, and reducing face-to-face health consultation. The objective of this study is to systematically review COVID-19 related mHealth apps and highlight gaps to inform the development of future mHealth initiatives in Indonesia.A systematic search strategy using a PRISMA flowchart was used to identify mHealth apps available in Google Play and Apple Play stores. We searched mHealth apps using certain specific terms related to COVID-19 outbreaks. The inclusion criteria were apps-based smartphone users related to COVID-19 using local language, free of cost, available in the Google Play and Apple Play Stores, and supported by the Indonesian government. We excluded games, apps on infectious diseases unrelated to COVID-19 specifically, and apps with non-Bahasa Indonesia (Indonesian language). The selected mHealth apps were assessed based on two measures: (1) the WHO guidelines on digital health intervention and (2) the four dimensions of the mHealth technology fit framework. In addition, user feedback from experienced and non-experienced users was conducted to evaluate four dimensions of the apps.A total of 339 mHealth apps were generated from the initial search, remaining seven selected apps that met inclusion criteria. The results highlighted that mHealth apps reviewed had still not been widely used by the general public. The applications were purposed to disseminate information, conduct a self-risk assessment, provide an online community forum, and telemedicine or teleconsultation regarding COVID-19. Data services, including data storage, aggregation, and data exchange, are available in most apps. The rarest function found was contact tracing and assisting health management and health workers, such as the availability of testing facilities, reporting test results, and prescribing medication. The main issues reported were the lack of data security and data privacy protection, integration and infrastructures, usability, and usefulness.Our study highlighted the necessity to improve mHealth apps' functions related to assisting health workers and the function of digital contact tracing. An effort to increase public awareness regarding the use of mHealth is also necessary to streamline the function of this innovation. Policymakers must consider usefulness, usability, integration, and infrastructure issues to improve their mHealth function. Digital technology innovations are known as an enabler of health systems against pandemics. During Ebola and Zika epidemics, mHealth apps have improved access to testing, public awareness, supporting health workers, and contact tracing , 2. mHeaA considerable amount of literature has been published to examine COVID-19 mHealth –15. MostRecent evaluation of mHealth apps concerning COVID-19 reported higher adoption of contact tracing systems is essential to lower the number of infections . TherefoPeduliLindungi”, while the Indonesian Social Security Administrator for Health (BPJS) launched their mHealth apps for COVID-19 screening called “Mobile JKN”  or local language in Indonesia; (2) apps had to be free of cost and had to be launched and updated during the COVID-19 outbreak for the management of COVID-19 in Indonesia; (3) apps that available in Google Play Store and Apple Play Store, and (4) apps had to be launched and supported by the governments of Indonesia. We excluded games, apps on infectious diseases unrelated to COVID-19 specifically, and apps with non-Bahasa Indonesia (Indonesian language). We searched for the mHealth apps using the term “COVID-19,” “corona virus,” “epidemic,” and “pandemic” within the app title and description.The mHealth apps reviewed were searched in the Google play store and Apple play store as Indonesians mainly use them. The search was conducted in the third week of August 2021 and updated on 7 November 2021. The inclusion and exclusion criteria were applied based on the PRISMA procedure to collect the data   and the reliability coefficient  for each dimension were 0.81 and 0.81 for the usefulness dimension, 0.83 and 0.84 for the usability dimension, 0.86 and 0.86 for the integration and infrastructure dimension, and 0.82 and 0.82 for the others dimension. In addition, to estimate the reliability of the entire survey, the Spearman-Brown correction was applied. Kappa values were 0.83 indicates the instrument was statistically reliable.In addition to the systematic review, we conduct user feedback to understand users' evaluation of four dimensions of the apps: usefulness dimension, usability dimension, integration and infrastructure dimension, and other additional dimensions , 26. Eacn > 30 as the minimum sample size for using a parametric statistical test , whole group 2 was users with no prior experience using those of the seven selected apps . All respondents were educated from high school or higher with IT and medicine background knowledge to ensure they were able to evaluate all of the app evaluation items. We used a non-probability sampling method based on convenience sampling to determine the number of samples in both groups . We follcal test , 29. ForThis study received ethical approval from the Ministry of Education and Culture, University of Brawijaya (Number 123/KEP/UB/2021). Informed consent was obtained from all subjects involved in the study. Written informed consent has been obtained from the patient(s) to publish this paper.We identified 339 potential COVID-19 apps in Indonesia. Of these, 337 apps used the Indonesian language. n = 16) and using non-Bahasa (n = 2). We also excluded seven apps not specifically related to COVID-19 (n = 6) and non-free apps (in-app purchase). The remaining seven apps were analyzed in this study. The reviewed apps (n = 7) in PeduliLindungi, 10 rumah aman, Mobile JKN, and SiLacak), and three apps (42.8%) developed by the local government . By November 2021, the PeduliLindungi app was downloaded by 50 million people out of the 273.5 million Indonesian population (18.3% of the Indonesian population), while Mobile JKN, which belongs to the BPJS was downloaded by 10 million people (3.65% of the population)  provided a self-risk assessment function that screened users with a set of questions related to their symptoms, occupations, travel history, and contact history. Six (85.7%) apps  also provided information through chatbots or helplines. Most apps (71.4%) were developed to supply information dissemination regarding preventative measures . Five apps (71.4%) offered online community forums for patients and family members and provided symptom trackers for the users . The function of enrolment to health service and teleconsultation or testing appointments were available in five (71.4%) apps . The reported COVID-19 test results and the prescription/medication management were only available in three (42.9%) apps . Only the PeduliLindungi app, which is sponsored by the Ministry of Information and Communication, offered specific facilities for the high-risk population, such as the availability of testing services and protective equipment. All apps still did not have facilities for client financial transactions. Most apps (85.7%) provided notifications for confirmed cases and deaths , and four apps (57.1%) provided hotspot identification . However, only the PeduliLindungi app allowed contact tracing. As for data service management, six apps (85.7%) had provided data storage, aggregation, and visualization . Five (71.4%) apps could record the location data or offer Bluetooth handshakes . Finally, the location mapping of health facilities was available in four (57.1%) apps . The detailed information on seven selected apps based on the WHO guidelines on digital health intervention is available at https://figshare.com/s/bde8b7c1082234dd012e.p-value = 0.91). Participants in both groups reported that 14.3% of apps work as advertised , 14.3% of apps do not become clinically effective for the target population, disease, or disability , and 14.3% of need more than 1 min to derive information they need .Users' feedback for seven selected apps was drawn from the questionnaire is presented in p-value = 1.00), 14.3% of apps can be used easily , 14.3% of apps support the local language, and materials relevant to local culture and ethnicity , 14.3% of apps take into account socioeconomic status and the user's age that support users with lack digital literacy . All apps do not have tools that support disabled users .In terms of usability dimension, participants reported that 28.6% of apps are pleasurable and enjoyable to use . Participants reported that 86% of the apps do not work within their user's workflow . All users stated that the apps' data were not encrypted on the device, on transmission, were not anonymized, and did not contain a robust privacy policy to protect users .With regard to integration and infrastructure dimension, all users reported that all apps contain personal health information and share data with other apps, networks, and medical record systems . Only 21.4% of the apps were able to gather history of patients and provide useful information , while 14.3%  gave a comprehensive output.Furthermore, 28.6% of the apps could not be used to educate or train patients, families, and/or support staff, did not provide information for clinicians and point of care, and did not provide a differential diagnosis  infrastructure, low internet connectivity, low prescription, user resistance, and mHealth illiteracy are the main barriers to mHealth adoption in Indonesia, which is also commonly found in other developing countries  provides information regarding testing services and equipment for a high-risk population. The user feedback also reported that all apps did not incorporate facilities for disabled people and local language.All apps still did not meet the WHO recommendation for digital health information for COVID-19 mitigation . Most apMost of the apps were not designed to assist health workers and health system managers. There is no function for health worker decision support, communication, activity planning, scheduling and training, hospital staff/human resources, monitoring, health commodity stock monitoring, and the movement system for health workers using electronic passes. Users also reported that they could not gather comprehensive output about patient history from the apps. These also confirm previous findings in a previous systematic review in East and South-East Asia . The revData and information privacy were the biggest issue in all apps. In the apps reviewed, when installing the apps and using the main features, users should input their data such as name, phone number, citizen registration number, email, Bluetooth interaction with other apps users, and real-time location. Data privacy concerns were also reported from user feedback. All users found that data encryption was not designed and anonymized, while the apps collect individuals' privacy preferences and personally identifiable information. The apps also did not include a robust privacy policy addressing personal and confidential information collected, the rationale for collecting information, sharing of information, and user control. These findings support evidence of previous mHealth related COVID-19 investigations in the country that data protection and security are a big concern as most of the apps have low-security protection technology , 38. TheIssues of synchronization were also found in all apps. While most apps provided data exchange, storage, and aggregation, the apps did not integrate with each other. Each app had been developed with its own function, design, and platform. There is no data integration between central government apps and local government apps. The local government-initiated apps were designed only for people in their jurisdiction and cannot be synched to central government apps. With the characteristics of a fragmented, decentralized health care system in which the government system consists of many tiers of government organization, the current mHealth apps can be detrimental for technology-assisted COVID-19 contact tracing as the technology was unable to monitor the movement of people across jurisdictions. Previous studies suggest that single national contact tracing, which is incorporated with specific contacts information and the local health system, is preferable in such a fragmented decentralized health system .Based on the research, there are several recommendations that mobile app developers can consider to improve their existing COVID-19 apps or create a high-quality COVID-19 mobile app in the future. First, the developers must implement the core data protection principles such as the General Data Protection Regulation (GDPR) to ensure that the app is secure and provide assurance to the users that all shared information is kept confidential. Second, creating an application integration network is essential to allow applications to communicate with each other so that work processes can be done more effectively and efficiently. For example, application integration between central and local governments would be very useful to maintain, manage, and keep the apps up to date while alleviating data duplication and redundancy across governments. A collaboration with local health authorities to develop a mHealth app can increase the reliability of the app, which will encourage more users to be engaged in its use. Third, improvement of user interface designs of existing apps is needed. For example, to increase the apps' uptake of the public, the apps should take into account socioeconomic status and the user's age, the local language, and ethnicity as well as those with disabilities. The apps should be made available without requiring any payment in both the Apple App Store and the Google Play Store to make them more accessible to the public. It is also crucial to categorize mobile apps into appropriate categories to enable users to find an app easily and thus improve its user uptake. Fourth, the findings suggested designing an app that can assist health workers and health system managers. For example, they would need to add functions for health worker decision support, contact tracing, notification of confirmed cases, monitoring status of beds and ventilators, priority checklists for facility management, and a telemedicine system. Adoption of mHealth and telemedicine in the current pandemic requires health workers to use videoconferencing, while the medical care system is still managing the outbreak . Hence, mHealth apps for COVID-19 in Indonesia are mainly designed for disseminating information, conducting a self-risk assessment, providing an online community forum, and telemedicine or teleconsultation regarding COVID-19. The least function found was contact tracing and assisting health management and health workers, such as availability of testing facilities, reporting test results, and prescribing medication. The main issues were data security and data privacy protection, integration and infrastructures, usability, and usefulness. This study suggests the necessity to improve the usefulness, usability, integration, and infrastructure of mHealth apps, especially data security and data privacy protection.The study was limited by the fact that COVID-19 mHealth apps selected were limited to free applications available in the Google Play Store and Apple Play Store. We were unable to review in-app purchases. Another limitation is that we did not include web-based applications. We did not perform a more robust search in publication indexes such as PubMed, Web of Science, and Scopus. New COVID-19 mobile apps may be launched that could not be included in this review. Moreover, our sample was based on convenience sampling which was characterized by insufficient power to identify differences in population subgroups. The potential bias of the sampling technique because under-representation of subgroups in the sample in comparison to the population of interest may occur . Future The original contributions presented in the study are included in the article/SS, TA, HD, HH, and AM prepared study design. RS, HH, and TA collected data and conduct data analyses. SS and AM wrote the main manuscript text. All authors reviewed the manuscript. All authors contributed to the article and approved the submitted version.This study was supported by LPDP and ISF under the International Collaboration Productive-Innovative Research Funding Scheme Number. PRJ-71/LPDP/2021 dan No. 01/DIPI/2021 dated April 14, 2021.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.


A thorough understanding of the original root and canal anatomy is a critical technical prerequisite for performing cleaning and shaping treatments. Therefore, this research aimed to characterize maxillary first premolar teeth' root morphology and canal architecture.One hundred forty-two extracted human adult maxillary first premolar teeth have been retrieved. The extracted teeth were thoroughly cleaned and irrigated to eliminate any remaining debris or blood. They were then preserved in formalin solution until they were eligible for screening. To begin, a visual examination was employed to ascertain the number of roots and their geometry in each sample. Then, utilizing digital radiography in two plains, mesiodistal and distomesial, to further determine those parameters. Finally, a sectioning technique had been used to have the samples cut mesiodistally into slices to validate the internal root canal architecture and identify the number of root canals and their varieties in accordance with Vertucci's categorization system. The canal layout, the pulp chamber, and the root canals were all highlighted (marked) using a fine tip marker in a permanent orange hue to make the canal features more accessible and accurate to visualize. All of the processes were conducted by two highly qualified dentists. The sample size was estimated statistically using the Sealed Envelope program, and the percentage of each configuration was derived in proportion to the overall sample size in order to establish the percentage of each type in each configuration.From the 142 teeth examined, 42 (29.57%) had one root, 97 (68.31%) had two roots, and only three premolars (2.12%) had three roots. Concerning canal configurations, 100 teeth (70.43%) had type (IV) canal configuration, followed by 37 teeth (26.05%) had types (V), three teeth (2.12%) had type (VIII), and one tooth (0.70%) for each of type (I) and type (II).The anatomical pattern of inspected maxillary first premolars are mainly two rooted and predominantly have a type (IV) canal morphology. The precise orientation about the anatomy of root canals may be a leading cause of treatment failure in endodontics . Hence, When one reviews the literature, it becomes apparent that there is a divergence of opinion concerning the root and canal morphology of the first maxillary premolar . AccuratClinically, before endodontic therapy is performed, it is crucial to identify the root-canal anatomy, the number of roots and canals of the tooth prevalent in a population to reduce errors, to achieve complete debridement and obturation of the canal space during endodontic treatment . HoweverThe Dentistry Ethics Committee approved the present study at the University of Sulaimani (NO.: 2020/433). The applied experimental methods have followed the CRIS guidelines described in the 2014 concept note . The samThe sample size is calculated using the aforementioned sample size and taking into account that z = 1.96 and the proportion of single root canals = 10% (ref), with a difference of 0.05 and a power of 80%.;Then each specimen was examined radiographically by a periapical radiographs.  which has been deployed to inspect the extracted teeth to make sure they had the following inclusion criteria; fully formed roots with mature apices, and there was no sign of resorption or abnormal defect (fractured or cracked root). At the same time, the exclusion criteria include the presence of any calcified root canals, previous root canal treatment, internal and external resorption, and not fully formed root apex . The invOne hundred forty-two left and right first maxillary premolars, which had been previously extracted because of caries, trauma, periodontal disease, or orthodontic reasons, were selected. The participants’ age ranged from 20 to 45 years old, while the gender of the individuals was not included in the records. However, all teeth were identified as maxillary first premolars at the extraction time by the operator.They were washed after extraction and stored in a 10% formalin solution until the collection was complete . Each toInclusion criteria include fully formed roots with mature apices, and there is no sign of resorption or abnormal defect (fractured or cracked root). At the same time, the exclusion criteria include the presence of any calcified root canals, previous root canal treatment, internal and external resorption, and not fully formed root apex.Class aSingle root, single tipped.Class bSingle root, the small double apex can be seen or felt.Class cSingle root, bifid apex .Class dTwo roots .Class eThree roots .Two experienced investigators visually inspected the root morphology and recorded the findings. The teeth were classified according to the forms and number of roots a follows :Class aSAfter visual inspection, the teeth were radiographed in mesiodistal and distomesial plains, and the direction of the beam was set at 40 degrees horizontal angulation to evaluate the root canal morphology using digital radiography  . ExposurThe long axis of the root is placed parallel and near the surface of the X-ray sensor , type HD, size 1.5. a standardized parallel technique Periapical radiographs were obtained for all the teeth using a film holder . A high-frequency oral X-ray machine was used with an exposure time of 0.367 s . Two endodontists evaluated all the teeth and their corresponding radiographs utilizing digital radiography, and they were equipped to expand the computerized photo on the computer and extract precise and accurate details. They examined each specimen several times until reaching a consensus concurrently.Type IA single main canal is present from the pulp chamber to the root apex.Type IITwo separate canals leave the pulp chamber and merge to one canal to the apex.Type IIIOne canal leaves the pulp chamber and divides into two smaller canals that later merge to exit one canal.Type IVTwo separate and completely distinct canals run from the pulp chamber to the root apex.Type VA single canal exiting the pulp chamber, which divides into two canals with separate apical foramina.Type VITwo separate canals join at the middle of the root to form one canal, which extends till the apex, just short of the apex, and again divides into two.Type VIIThe canal starts as a single until the middle third of the root, then divides into two separate canals that rejoin after some distance and then, near the apex, divides into two again.Type VIIIThe pulp chamber near the coronal portion divides into three separate canals extending till the apex.Examination of the root canal system of the teeth was based on Vertucci's classification of root canal morphology :Type IA According to Vertucci's classification, all teeth were examined using digital radiography. Then, the teeth specimens were sliced mesiodistally into slices to verify the internal root canal anatomy, using a low-speed diamond saw (200 rpm) with a loading of 50 g . Finally, for more accessible and more accurate visualization of the canal details, the canal configuration, the pulp chamber, and roots canals were highlighted (marked) with a fine tip marker permanent orange color .The actual data is being rearranged and transported to SPSS Statistics for Windows, version 24.0  software. The sample size was calculated with the Sealed Envelope software.From the 142 maxillary first premolars studied, 42 teeth (29.58%) had one root, while two teeth (1.41%) were single-tipped root apex and the rest; 40 teeth (28.17%) had double-tipped root apex  had type I configuration, and one tooth (0.70%) had type II configuration. Whereas in double-tipped root apex, 13 teeth (9.16%) had type IV configuration, and 27 teeth (19.01%) had type V configuration, as shown in  had type IV configuration, and only ten teeth (7.04%) had type V root canal configuration. While in double roots with separated two roots, all the 63 teeth (44.37%) had type IV root canal configuration as shown in  or double-tipped root apex (class b). The double-tipped root apex was more prevalent than the single-tipped root apex in the present study. On the contrary, a survey by Senan et al.  and Peir.  showed a. [. [On the other hand, the root patterns were also analyzed in this study. The result showed a higher incidence of separated two-roots than fused two-roots. Unfortunately, many studies did not mention the details of the two roots, whether they were fused or separate , 47, 48,. , Gupta e. [. , and Sen. [.  showed t. [. [In the present study, the lowest incidence of three-rooted maxillary first premolar was observed compared to single-rooted and two-rooted. This result agrees with Rwenyonyi et al. , Tian et. [. , and Pec. [. . In cont. [.  and Walk. [.  reported. [. .. [In the present study, the Vertucci classification was selected as a base for the exploration of root canal configurations since it is the most commonly used classification, and the maxillary first premolar is the tooth that was showing all the eight types of canal configurations, in addition, it was utilized in the current study for easy comparison with the results of other investigations. The type IV root-canal morphology was the most common type seen in the present study and the similar studies reviewed in the literature but with variations in the percentage and frequency-specific for different kinds of canal configurations –40, exce. , Liu et . , Senan e. , and Ash. , who fouDue to the number of tested teeth leading to the relatively small size included in the present study, the root and canal morphology patterns should be considered since they could not represent the larger population of Iraq. However, further studies are recommended to explore the tooth morphology in the Iraqi population using a more significant number of samples and more advanced techniques, such as dissecting light microscope, CBCT, and computed tomography, to study the root canal morphology. The sample size and conventional approach used to determine the precise root canal morphology are prevalent limitations of this research. Clinically, it is crucial to identify the root-canal anatomy prevalent in a population to reduce errors during endodontic treatment.The present study showed a high incidence of two-rooted with separate roots and predominantly have Type IV Vertucci's configuration. Nevertheless, the present study results further confirm the importance of a thorough knowledge of root canal morphology for each population and the need for a careful exploration and radiographic examination of these teeth before endodontic therapy.


Schools were closed after the onset of COVID-19, with non-face-to-face practices or distance education in nursing education replacing video learning or simulation classes in nursing education clinical practicum. This led to an increase in interest in virtual environment simulation education. While technology-based teaching methods might feel new and intriguing to learners, it is necessary to evaluate learner satisfaction with such an educational method beyond its novelty value. Therefore, this study examined the mediating effect of learning immersion on the relationships between instructional design and educational satisfaction, for virtual environment simulation.A descriptive cross-sectional research design was used. The study sample included students in the third or fourth year of the nursing curriculum in South Korea. The participants were 164 nursing students, who had an experience with virtual environment simulation practices during the past year, prior to September 2021. Data were collected using an online questionnaire. The questionnaire addressed the characteristics of nursing students, instructional design, learning immersion, and educational satisfaction. The collected data were analyzed using path analysis.The indirect effect of the path between instructional design and educational satisfaction, mediated through learning immersion in virtual environment simulation was found to be significant. Furthermore, the direct path was also statistically significant.Educational content, based on virtual environment simulation, should be implemented based on instructional design. It is necessary to recognize the importance of instructional design that can promote learning immersion in virtual environment simulation, as well as to prepare consistent standards for such design. Nursing education provides students with the knowledge and skills they will require as professional nurses , 2. SimuWith the recent developments in technology, research has been conducted on the effectiveness of virtual environment (VE) simulation education using technology as a strategy for future clinical practicum , 6. The VE simulation education has been used in surgical skill disciplines and anatomy classes in medical schools , 11. In A VE refers to an environment where two-dimensional (2D), or three-dimensional (3D) images were implemented with a computer, mobile device, or virtual reality/augmented reality/mixed reality device , and doeAccording to the Jeffries simulation framework, the five key components of simulation are participant, facilitator, educational practices, simulation design characteristics, and outcomes . The insWhile technology-based teaching methods might seem new and intriguing to learners, it is necessary to evaluate learner satisfaction with such an educational method beyond its novelty value. Learning outcomes are affected by educational satisfaction, which plays a significant role in determining behavior and intention , 32.Well-designed simulation education can increase learning immersion and learning outcomes , 33. In Immersion is a positive experience that an individual feels, by maximizing their concentration on the activity , and leaThis study examined the mediating effect of learning immersion on the relationships between instructional design, and educational satisfaction in VE simulation, using path analysis. The study hypotheses are as follows:H1: Instructional design in VE simulation has a direct effect on learning immersion.H2: Learning immersion in VE simulation has a direct effect on educational satisfaction.H3: Learning immersion in VE simulation has a mediating effect on the relationship between instructional design and educational satisfaction.This descriptive cross-sectional study examined the effect of instructional design in VE simulation, as perceived by nursing students on educational satisfaction through learning immersion.The participants were nursing students, who were experienced in VE simulation practices, during the past year, in a nursing college in South Korea. The inclusion criteria were as follows: (1) students in the third or fourth year of the nursing curriculum; (2) students who understood the purpose of this study; and (3) students who expressed their intention to participate voluntarily. The exclusion criterion is students who had experienced only nursing skills-based VE simulations without a scenario.To conduct a path analysis, the recommended adequate sample size is 20 times the number of measurement variables . Hence, The study received ethical approval from the Catholic University of Korea Research Ethics Committee (No. MC21QESI0092), and informed consent was obtained from all subjects. Data were collected for September 2021, using online questionnaires. Recruitment documents, containing the study title, objectives, method, participant criteria, and participation benefits and risks, were distributed across online nursing college communities in South Korea, informing the participants about the study. Based on this information, students could decide to participate in the study by clicking on the link to the online questionnaire. A total of 180 respondents were included in this study, 16 of whom had incomplete data, and the remaining 164 respondents were analyzed.The instructional design was measured using the Korean version  of the SLearning immersion was measured using the Learning Immersion in Simulation Scale, which was originally developed by Ko . There wEducational satisfaction was measured using the Educational Satisfaction Scale in Simulation for Nursing Students, by Kim and Heo . The scaCorrelations with the variables were processed using Pearson’s correlation coefficient, to test for multicollinearity. The correlation coefficient ranged from 0 to 1, with values of 0.80 or less , and theStructural relationships between variables were identified by analyzing indirect effects using the model. The sizes of the direct effect, indirect effect, and total effect were calculated by bootstrapping, to confirm the significance of the mediating effect. The collected data were analyzed using IBM SPSS for Windows, version 26.0  and AMOS, version 26.0 .The participants were 56 34.1%) junior and 108 (65.9%) senior nursing students. Of these, 19 (11.6%) were men and 145 (88.4%) were women. The average age of the participants was 23.03 years (SD = 2.71). The average experience frequency of VE simulation was 6.23 (SD = 4.63), with 97% of them having experienced it five times or less. The VE simulation product experienced the most was vSIM® for Nursing, with 153 participants (93.9%), and the discipline in which VE simulation was experienced the most was adult health nursing, with 144 participants (87.8%) ; the average score for learning immersion was 56.37 (SD = 8.49); and the average score for educational satisfaction was 57.26 (SD = 6.53).Correlations were calculated to determine whether there was multicollinearity between the variables. The correlations are presented in Table p < .001), and from learning immersion to educational satisfaction in VE simulation , were statistically significant. The direct path from instructional design to educational satisfaction in VE simulation , was also statistically significant , was significant. Further, 60.1% of the learning immersion in VE simulation was explained by instructional design, and 44.0% of the educational satisfaction in VE simulation was explained by instructional design and learning immersion.Covariate decomposition of the final model was performed to examine the direct, indirect, and total effects between each pair of variables Table . The indThis study investigated the effect of the instructional design of VE-based nursing education content, on educational satisfaction. The path model was constructed to reveal the direct and indirect effects in the relationship between variable pairs mediated by learning immersion. The results showed that instructional design in VE simulation affected educational satisfaction, and that learning immersion had a partial mediating effect on the relationship between instructional design and educational satisfaction in VE simulation.It was also noted, when nursing students recognized that the instructional design was well structured in the VE simulation, it induced higher learning immersion and increased educational satisfaction. The students perceived that instructional design was well-structured in VE simulations, which promoted self-learning satisfaction . The insThe finding that instructional design in VE simulation had a direct effect on educational satisfaction, as well as an indirect effect on learning immersion as a mediating variable, indicates the importance of instructional design in VE simulation education. However, although the positive results of a meta-analysis study of VE simulation in nursing education provide supportive evidence of the applicability thereof, most studies focus only on new technologies and do not provide design-specific details . Even ifIn the model, the mediating variable, namely the learning immersion in VE simulation, partially mediated the relationship between instructional design and educational satisfaction. Learning immersion is an important mediating variable in the relationship between learning presence and satisfaction , and an VE simulation education has been developing continuously together with the internet environment and improvements in computer science technology . TherefoThis study had several limitations. The cross-sectional design limited the interpretation of causality. Since the participants responded with a self-reporting questionnaire, biased perceptions and capabilities for desirable answers may have affected the validity of the results. The data used convenience sampling, which also limited data interpretation.VE simulation-based educational content should be implemented with high-quality instructional design. Instructors should consider this and implement factors that will promote the educational satisfaction of learners experiencing VE simulation.Such efforts to improve the quality of educational content based on VE simulation, provide useful information to nursing faculty who design and develop teaching methods for educational programs in a new environment and can also be used as a reference for further research related to educational content based on VE simulation.


Active cancer (AC) is a known risk factor for stroke and a common comorbidity among patients being considered for treatment with endovascular thrombectomy (EVT). This systematic review and meta-analysis aimed to evaluate the current evidence for the feasibility, efficacy, and safety of EVT for patients with AC.I2 statistics were used to evaluate the heterogeneity. Funnel plots were used to evaluate publication bias.MEDLINE, EMBASE, and the Cochrane Library were searched for relevant randomized controlled trials (RCTs) and observational studies which met the inclusion criteria for EVT in patients with AC. Studies were excluded due to the mismatch of data format, article type, and group design. The risk of bias was assessed through different scales according to the study design. A total of six studies and 3,657 patients were included. Compared to without active cancer (WC) patients, patients with AC had a significantly higher proportion of in-hospital mortality . The estimated rate of favorable outcome of six studies was lower in patients with AC than in patients with WC . For 90-day mortality of four studies, the AC group had a higher proportion when compared with the WC group . There was no difference between rate of six studies of successful recanalization  and four studies of symptomatic ICH  comparing AC and WC.Patients with AC are less likely to have a favorable outcome and have a higher risk of mortality after EVT. Further studies are warranted for this unique patient population. Cancer is a widely known risk factor of acute ischemic stroke (AIS), especially among patients with active cancer (AC) which was diagnosed within 6 months or during the admission period, requires chemotherapy or surgical treatment within 6 months, or was recurrent, metastatic, or inoperable . SeveralEndovascular thrombectomy (EVT) has revolutionized acute stroke care and is recommended as the first-line treatment for AIS due to large vessel occlusion (LVO) , 15. WheThis study was conducted according to the statement of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) .Studies for inclusion were identified by two independent reviewers (CS and ZS) from the three databases: MEDLINE, EMBASE, and the Cochrane Library. Eligible studies were restricted from database inception until 24 January 2022 in the English language. The terms “ischemic stroke”, “brain ischemia”, “cancer”, “neoplasm”, “embolectomy”, “mechanical thrombectomy”, and “endovascular thrombectomy” were applied in our search strategy for potentially relevant studies. The detailed search strategy is presented in the online The criteria for study design were specified according to the Population, Intervention, Comparison, Outcome (PICO) model.Inclusion criteria included adult patients age ≥ 18 years) with AIS due to LVO, including anterior or posterior circulation occlusions, undergoing EVT. These were divided into active cancer (AC) group and without active cancer (WC) group according to the presence of AC. Active cancer was defined as cancer that was diagnosed within 6 months or during the admission period, requires chemotherapy or surgical treatment within 6 months, or was recurrent, metastatic, or inoperable  of 0–2 or equal to pre-stroke score at 90 days.Symptomatic intracranial hemorrhage (SICH) was diagnosed if a new intracranial hemorrhage was associated with any of the following conditions: (1) NIHSS score increased >4 points than that immediately before worsening; (2) NIHSS score increased >2 points in one category; (3) deterioration of neurological status led to intubation, hemicraniectomy, external ventricular drain placement, or other major medical or surgical intervention, according to the second European Australasian Acute Stroke Study classification (ECASS II) .Secondary outcomes:Successful recanalization (MTICI 2b-3) determined by post-interventional DSA.Mortality at 90-day follow-up.In-hospital mortality.The comparator was patients of the WC group, who also received EVT without limitation of additional intravenous thrombolysis.We included RCTs and observational studies, including cohort studies and case-controlled studies. Other types of articles such as abstracts, conference reports, and case reports were excluded. Studies which did not report the above outcomes or extractable complications were also excluded.Two reviewers (ZF and ZS) independently searched the databases to include eligible studies. In the initial stage of screening, titles, keywords, and abstracts were reviewed, and irrelevant studies were excluded. Subsequently, full articles of all the remaining studies were obtained and carefully reviewed to assess eligibility, and reasons for inclusion or exclusion of studies were documented in detail. Conflicts in study selection between two reviewers were resolved by a third reviewer (HZ).The extraction of data from included studies was conducted by two independent reviewers (LD and HZ) using a standardized data extraction form. The extracted information of included studies was as follows: (1) characteristics of the study, such as publication time, country, and the number of patients; (2) demographic characteristics, such as age, gender, cancer type, medical history, laboratory results, site of occlusion by angiography, and intervention characteristics; (3) aforementioned outcomes such as sICH and favorable outcome. The resolution of disagreement regarding data extraction was achieved through the assistance of another reviewer (XB). For missing or ambiguous data in included studies, clarification of data through direct contact with the corresponding authors by e-mail was attempted.I2 statistic. If I2 is <20%, the heterogeneity was considered acceptable. The Mantel–Haenszel method for fixed-effects estimation was applied if heterogeneity was mild or moderate. For substantial heterogeneity of outcomes, we conducted meta-regression and sensitivity analyses to explore the potential source of heterogeneity.Two reviewers (QT and XW) independently assessed the risk of bias for each included study. The Cochrane Collaboration criteria were applied in the process of selection of RCTs . The Newp-value < 0.05 was considered statistically significant. The Stata statistical software  was used for data analysis and heterogeneity assessment.A meta-analysis on a specific result was performed only when there were at least two suitable studies for analysis. If there were insufficient suitable studies for meta-analysis, the results were described in the narrative. We adapted OR with 95% CIs for dichotomous data and the mean differences (MD) with 95% CIs for continuous data. The standard of We found 5,764 references, abstracts, and related clinical trials from the three electronic databases and clinical trial registries. Among the results, 24 full-text articles were retrieved after initial checks, and six studies were finally eligible for inclusion in the qualitative and quantitative analysis. The process of study selection and reasons for exclusion are summarized in p = 0.030; I2 = 66.6%). The estimated rate of favorable outcome of six studies and 3,657 patients was lower in patients with AC than in patients with WC . The outcome of four studies and 3,345 patients of 90-day mortality showed that the AC group had a higher proportion when compared with the WC group . There was no difference between rate of successful recanalization  in six studies and 3,657 patients and symptomatic ICH  in four studies and 3,140 patients between groups AC and WC.The Newcastle–Ottawa scale was used to assess the bias risk of observational studies, such as case-control studies, with the majority of included studies being low-risk. Funnel plots were used to explore the publication bias, with the results demonstrating no evident reporting bias. The outcomes of the above analyses are presented in p = 0.828; I2 = 0.0%) and rate of symptomatic ICH  in patients with AC were comparable with patients with WC. However, patients with AC had a significantly lower rate of favorable outcome . We also showed a tendency for a higher proportion of in-hospital mortality  and 90-day mortality  in patients with AC.This systematic review and meta-analysis summarized the safety and efficacy of EVT for AIS patients with AC. The successful recanalization proportion , given to many patients in our meta-analysis, may be associated with higher risks in patients with AC. However, we did not observe a difference in hemorrhage rates and other studies have reported that IVT using alteplase is safe and effective for patients with AC , 24. TheOur study has several limitations. First, we could not evaluate the effects of cancer-related factors, including the cancer staging, brain metastasis, treatment status, and life expectancy due to insufficient data. Second, selection bias is inevitable in our study selection process. Furthermore, several included studies had small sample sizes, and there were inconsistent outcome measures. All of the included studies are retrospective, and only one was multicenter. More data are needed to confirm our conclusion.AC is likely to influence patient outcomes after EVT and may hold a higher risk of mortality. While there were similar rates of reperfusion and hemorrhage, further high-quality studies are warranted to better understand long-term outcomes.The original contributions presented in the study are included in the article/LD contributed to the initial idea for this study. CS, QT, and XW developed and revised the search strategy. LD and HZ finished the study design. BY was consulted about the clinical issues. LD, ZF, and HZ contributed to the original draft. LD, ZF, HZ, CS, QT, AD, RR, ZS, XG, XW, and BY were responsible for the revision of the draft. All authors approved the final work before submission.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.


Early childhood caries (ECC) is a major oral problem affecting the health and wellbeing of children worldwide. Diet quality is a better predictor of ECC risk than single foods or specific nutrients. The purposes of this study were to assess the associations between ECC and diet quality among 2- to 5-year-old Chinese children.via a mobile APP. The Chinese diet balance index for preschool children (DBI_C) indicators score, high bound score (HBS), low bound score (LBS), and diet quality distance (DQD) score were calculated to assess the diet quality of study subjects. The associations of ECC with HBS, LBS, DQD score, and DBI_C indicators score were analyzed by Mann-Whitney U test and multivariable logistic regression analysis.A total of 150 eligible children were included in this study. The decayed, missing, or filled surface (dmfs) score was recorded for each child by dental examination. All participants were divided into three groups based on their age and dmfs score . Parents were invited to complete a questionnaire on the general characteristics and oral health behaviors of the participants. The information of 24-h dietary intake from each child was captured P > 0.05). In the meantime, the risk of ECC and S-ECC were significantly increased with the Grains score , and significantly decreased with the Food diversity score . Moreover, the risk of S-ECC also significantly decreased with the Vegetables score (OR = 0.137).In this study, 21, 31, and 98 children were diagnosed with caries-free, ECC, and S-ECC, respectively. Statistical analysis revealed that the risk of ECC and S-ECC were significantly increased with the DQD score , but both were not associated with HBS and LBS (Both ECC and S-ECC were associated with a high degree of dietary imbalance and grains intake as well as a low degree of food diversity among Chinese children aged 2–5 years. In addition, S-ECC was also associated with a low degree of vegetable intake. Early childhood caries (ECC), one of the most widespread chronic diseases, has posed a threat to children's health worldwide. It is defined by the American Academy of Pediatric Dentistry as a child under 71 months of age with one or more decayed (with or without cavitation lesions), missing (due to caries), or filled tooth surfaces (dmfs) in any primary tooth . The FouECC is a multifactorial disease, with common risk factors including cariogenic microorganisms, inappropriate feeding practices, frequent contact with fermentable carbohydrates, poor oral hygiene habits, and a series of social variables , 7. It hTraditional nutritional epidemiology investigates the association between chronic diseases and diets through a single (or few) food or specific nutrient. However, the effects of and interaction with other potentially contributory groups on ECC may be missed out . Diet quvia a mobile device and recorded as the primary sources of dietary intake, which follow the method for recording diet  are subject to inherent errors that could lead to inaccurate assessments, negatively impacting patients and research outcomes. Recently, along with the popularization of cameras and mobile phones, image-based methods integrating mobile device application technologies have been developed . All theing diet . Parentsing diet . TherefoThe present study was conducted to investigate the associations of ECC and S-ECC with diet quality among Chinese children aged 2–5 years. We hypothesized that the risk of ECC and S-ECC is not associated with diet quality among Chinese children aged 2–5 years.A cross-sectional, analytical study design was carried out. One hundred and fifty healthy children were chosen by a convenience sampling method from the Department of Pediatric Dentistry at the Dental Hospital, Hebei Medical University, China, and three urban kindergartens in Shijiazhuang, China.The eligibility criteria included children aged 2–5 who live with their parents/legal guardians, presence of primary dentition only.Exclusion criteria were as follows: (1) Children with energy intake below 450 kcal/d or above 2,800 kcal/d ; (2) Chi* 0.15 = 9%. Type I error = 5%. The confidence level was 95%. The required sample size calculated by PASS (Version 15) was 120. Assuming that the loss of follow-up was randomized, the loss of follow-up rate of 10% would require 134 cases. A total of 150 children were finally enrolled in the analysis.The determination of sample size with the following assumptions: ECC prevalence of 62.5% was generated from The Fourth National Oral Health Epidemiological Survey Report 2018 . A margiThis cross-sectional study was approved by the Ethics Committee of Dental Hospital, Hebei Medical University, China (No. [2018]028) and conducted in accordance with the principles of the Declaration of Helsinki. Parents/legal guardians of all eligible participants were informed about the research purpose, the health benefits, and potential hazards before the study commenced. They all provided written informed consent. All the data in this study were used for scientific research only. In addition, participants suffering from ECC or other oral diseases were offered the necessary advice and treatment.Dental examinations were carried out under field conditions by two trained and calibrated pediatric dentists. Duplicate clinical examinations were conducted to test the reliability of intra-examiner, with kappa values averaging 90 and 88% for the examiners themselves and between the two examiners, respectively. To ensure the accuracy of the examinations as much as possible, two caries diagnostic criteria have been employed: the International Caries Detection and Assessment System (ICDAS-II)  was usedFor early enamel caries, after food residues and debris were removed, the decayed (with or without cavitation lesions), missing (due to caries), or filled surface (dmfs) score of children was determined through the visual examination using the sterile dental mirror and the portable air compressor under sufficient illumination. For cavitated lesions, the dmfs score was determined using the sterile dental mirror under sufficient illumination after cleaning and drying the teeth. And if necessary, a community periodontal index (CPI) probe was carried out to clean debris from the pits or fissures without significant axial force or excessive pressure. The 150 children were divided into three groups depending on their age and total dmfs score: the caries-free group consisted of 21 children (dmfs = 0), the ECC group consisted of 31 children [based on the definition by the American Academy of Pediatric Dentistry  were acquired using a mobile phone APP , which consists of the Children's Household Nutrition Management Micro-platform and Children's Nutrition Supervision Micro-platform. Firstly, twenty parents/legal guardians were randomly selected to test whether they could use this APP proficiently and correctly. According to the active feedback from the parents/legal guardians, no further explanation is deemed necessary for the use of this software.The parents/legal guardians uploaded all the food consumed by children within 24 h (including snacks and beverages), in the form of images, onto the Children's Household Nutrition Management Micro-platform, in which they can also mark and supplement the information on food intake. The next day, the researchers acquired the details about food intake from the Children's Nutrition Supervision Micro-platform. All food items received were confirmed with the diet uploader by phone. We will request parents to make corrections or re-upload the food images if any errors are found at any time during the above period to ensure the accuracy and validity of the data obtained. In the meantime, if the parents uploaded diets as well as confirmed or corrected, we provided them with feedback on their child's dietary status as compensation. By calculating the score of each indicator in DBI_C, each child's dietary status was assessed and specific dietary recommendations were given.Each food item acquired in the 24-h diet was transposed into the corresponding DBI_C indicators, and the score of each indicator was calculated . The valAccording to the DBI_C score calculation method, the high bound score (HBS), low bound score (LBS), and diet quality distance (DQD) score were calculated, respectively. For these three indicators, a score closer to 0 means the dietary status is better. HBS is the absolute value of the sum of the positive score of DBI_C indicators, which reflects the degree of excessive dietary intake. Its score ranges from 0 to 36: 0 means no excessive intake; 1–7 means appropriate intake; 8–14, 15–22, and 23–36 means low, moderate, and high excessive intake, respectively. LBS is the absolute value of the sum of the negative score of DBI_C indicators, which reflects the degree of insufficient dietary intake. Its score ranges from 0 to 72: 0 means no insufficient intake; 1–14 means appropriate intake; 15–29, 30–43, and 44–72 means low, moderate, and high insufficient intake, respectively. DQD is the sum of the absolute value of the DBI_C indicators score, which comprehensively reflects the problem of dietary imbalance. Its score ranges from 0 to 84: 0 means that there is neither dietary insufficient nor excessive intake in the diet; 1–17 means appropriate, and 18–34, 35–50, and 51–84 means low, moderate, and high dietary imbalance, respectively.The statistical description was presented as means and standard deviation (SD) for continuous variables conforming to normality, the median and quartile range for those with skewness, furthermore frequencies and percentages (%) for categorical variables.t-test, Pearson χ2, Fisher exact test, and Mann-Whitney U-test) to evaluate associations of social demographics, infant feeding practices, and oral hygiene habits to ECC and S-ECC. Mann-Whitney U-test was utilized to compare the DBI_C indicators score, HBS, LBS, and DQD score between the study groups since the data distribution did not conform to normality and (or) heterogeneity of variance. All statistical tests were two-tailed with a statistical significance level of P ≤ 0.05.Univariate analysis was conducted using appropriate tests  were included in multivariable logistic regression models, that were constructed to assess the independent effect of these variables on ECC (Model 1) and S-ECC (Model 2). To understand whether potential confounders could affect OR, we adjusted for the following covariates: age and adult supervision of toothbrushing. HBS, DQD score, Grains score, Vegetables score, Food diversity score, and age were modeled as continuous variables. Adult supervision of toothbrushing was categorized as yes or no. The assumption of linearity between the continuous independent variables and the logit transformed values for the dependent variables were assessed by the Box-Tidwell test. Multicollinearity between independent variables was checked using the Variance Inflation Factor. The−2 log-likelihood ratio test was used to test the overall significance of the model. The goodness-of-fit of the models was assessed by the Hosmer-Lemeshow. The data were processed, analyzed, and plotted on SPSS (Version 26) and Graphpad Prism (Version 9).P = 0.010 and 0.021, respectively). A higher percentage of caries-free children (81%) were supervised to brush their teeth compared to children with ECC (45.2%) and S-ECC (56.1%) . These differences were significant between the caries-free and the ECC groups as well as between the caries-free and the S-ECC groups (P < 0.05).A total of 150 subjects aged 2–5 years meeting the study criteria were enrolled in our study and completed the program. Twenty-one of these individuals did not present with caries, 31 children were diagnosed with ECC, and 98 children were diagnosed with S-ECC. The general characteristics and oral health behaviors of study participants with the presence or absence of ECC and S-ECC are listed in P = 0.023 and 0.049, respectively) in addition to Vegetables score  and Food diversity score  that were lower than those without caries  and DQD score  than did the subjects without caries (P < 0.05).The mean scores of Grains and Salt among the studied children were both higher than 0 , while tt caries . Other tt caries . These dP = 0.043), Grains score (P = 0.026), and Food diversity score (P = 0.015), and not associated with HBS (P = 0.432) and Vegetables score (P = 0.247) (Model 1 in P = 0.012), Grains score (P = 0.004), Vegetables score (P = 0.001), and Food diversity score (P = 0.011), and not associated with HBS (P = 0.569)  were entered into the multivariable logistic regression analysis to assess their independent effects on ECC and S-ECC. Following adjustment for covariates , ECC was associated with DQD score , minerals , and lipids  , 44, and of milk . HoweverIn this study, children who did not present with caries had the highest Food diversity score than children diagnosed with ECC and S-ECC. Meanwhile, logistic regression models revealed that children with a higher degree of food diversity were less likely to suffer from caries. Food diversity has been confirmed to be positively related to dietary micronutrient intake , and it Image-based methods offer a more comprehensive range of viable options for dietary assessment, which is easier to incorporate into participants' daily lives. Furthermore, it can instantly record the diet consumed by an individual without relying on memory for input, which has the advantage of being fast, more efficient, and more precise compared to traditional methods. Several meaningful and valuable results were obtained, but some limitations should be noted. First and foremost, in this cross-sectional study, the findings only can reflect associations and cannot establish a causal relationship. Secondly, the limited sample size included in this study is due to time factors. Thirdly, DBI_C is a scale based on food group indicators and cannot assess the specific nutrient intake of children and thereby cannot analyze the association between ECC and nutrients. Finally, the image-based method relies on images to assess food intake. And the complex and diverse food cultures make the Chinese diet one of the most complex dietary systems worldwide. In the case of some unlisted food varieties, it cannot be identified or analyzed.Dietary imbalance is a serious health problem faced by this study sample. Both ECC and S-ECC were associated with a high degree of dietary imbalance and grains intake as well as a low degree of food diversity among Chinese children aged 2–5 years. Moreover, S-ECC was also associated with a low degree of vegetable intake. Nevertheless, large-scale prospective research is needed to validate these findings and to offer more information about the underlying causality and mechanism.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 Ethics Committee of Dental Hospital, Hebei Medical University, in Shijiazhuang, China . Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.HS conceived and designed the study. ZM, XL, ML, and CZ trained the data collectors. XW, ML, ZM, and CZ analyzed and reconciled the data. XW and FC drafted the first draft of the manuscript. HS reviewed and modified it to the final version. All authors contributed to manuscript revision, read, and approved the submitted version.This research was supported by the Hebei Provincial Department of Finance: Government-funded specialty competence Building and Professional leader Training  (Grant No: 0300000062), the Project funded by the Hebei Provincial Department of Finance: Study on the Correlation of Caries Activity and Dietary Nutrition among Younger Children (Grant No: 361029). The funders did not influence any stage of this study.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.


According to the General Strain Theory, stress can lead to a range of problem behaviors. In the current study, we focused on the association between perceived stress and mobile phone addiction. We hypothesized that this association is mediated by low self-control and that the first path of the mediation is moderated by security.N = 397; ages 16–21; 51.89% females) from a university in Hunan Province, China, were surveyed by cluster sampling method. The students completed the Smartphone Addiction Scale-Short Version (SAS-SV), the Depression Anxiety Stress Scale (DASS-21), the Self-Control Scale (SCS), and the Security Questionnaire (SQ) during regular class time. SPSS26.0 statistical software was used for descriptive statistics and Pearson correlation analyses, the SPSS macro PROCESS was used to test the mediating effects of self-control and the moderating role of security.College students (Mediation analysis showed that as expected, perceived stress was associated with lower self-control, which in turn was associated with a higher risk for mobile phone addiction. Also as expected, moderated mediation analysis indicated that the association between perceived stress and self-control was moderated by security. Specifically, the relationship between perceived stress and self-control was stronger for low security.This study provides useful insight into the understanding of how perceived stress increases the risk of mobile phone addiction. The results are consistent with the General Strain Theory and further indicate that concrete approaches are required for the prevention and intervention to reduce mobile phone addiction among college students. Many people in the world rely on mobile phones and their increasingly integrated functions. China is no exception. According to the 48th Report of the China Internet Network Information Center, as of June, the number of Internet users in China reached 1.011 billion; of this group, the proportion that accessed the Internet to use mobile phones had increased from 98.6% at the end of 2018 to 99.6% at present .Mobile phone addiction is a form of behavioral addiction in which the individual’s physical, psychological and social functions are significantly impaired due to excessive use of mobile phones . SubstanPrevious research has revealed that perceived stress is one of the crucial antecedents of mobile phone addiction –10. AccoHypothesis 1: Perceived stress is positively associated with mobile phone addiction.Self-control refers to the ability to resist inner desires and external temptations and adhere to expected goals . AccordiPerceived stress is thought to reduce self-control resources in two ways . One posLow self-control has been shown to have a positive association with mobile phone addiction , 25. AddHypothesis 2: Self-control mediates the relationship between perceived stress and mobile phone addiction.The mediation process by which perceived stress is associated with mobile phone addiction via low self-control may not be equally strong for all individuals. As a basic psychological need, security refers to having a sense of inner control in the face of stress, including the anticipation of possible future physical and psychological threats in the future, which is mainly expressed as a sense of certainty and control over the outside world .First, previous studies have shown that security moderates the association between perceived stress and problematic psychological development, such as loneliness, depression, and personality development , 29. SecHypothesis 3: Security buffers the association between perceived stress and mobile phone addiction; specifically, the relationship between perceived stress and mobile phone addiction will be stronger in individuals with low security than those with high security.In addition, compared to people with high security, those with low security may have more difficulty exerting self-control when coping with stress. That is, the mediating role of self-control in the association between perceived stress and mobile phone addiction should be stronger for people with low security. Gentzler et al. found that individuals with high security tend to enjoy their own positive experiences when faced with negative stimuli, whereas individuals with low security tend to repeatedly think about negative experiences , which iHypothesis 4: Security moderates the first path of the mediation process. Specifically, the relationship between perceived stress and self-control will be stronger for participants with low security.Thus, we developed and tested a moderated mediation model in which the association between perceived stress and mobile phone addiction is mediated by self-control and moderated by security .Mage = 18.30 years, SDage = 0.86), 206 were females (51.89%), and 191 (48.11%) were males. Among them, 273 were freshmen (68.8%) and 124 were sophomores (31.2%).Participants were recruited from one university in a large city in Central China. A total of 425 freshmen and sophomores were selected by cluster sampling. After getting rid of the invalid questionnaires  . The scaPsychology graduate students were trained as research assistants to distribute questionnaires in each class. They gave instructions and reminded the volunteers that participation was voluntary. It took about 20 min to complete the questionnaires and all participants were rewarded with an online shopping voucher which is worth five yuan after participation. All materials and procedures were reviewed and approved by the Ethics Committee of Hunan University of Chinese Medicine, and all participants and their legal guardians involved in the study provided written informed consent according to the ethical guidelines set forth in the Declaration of Helsinki.The statistical analyses were conducted in SPSS 26.0. First, descriptive statistics and Pearson correlation analyses were conducted. The second step was to test the mediation model and moderated mediation model using the SPSS macro PROCESS version 4.0 (Model 4 and Model 8) developed by Hayes . BecauseDescriptive statistics and correlations were computed for all variables and are reported in p < 0.01). p < 0.05) when self-control was included as a mediator. Perceived stress was significantly negatively associated with self-control . Self-control was significantly negatively associated with mobile phone addiction . Model 4 from the SPSS macro PROCESS was used to test for mediation. After controlling for gender and age, perceived stress was positively associated with mobile phone addiction  but not on mobile phone addiction . Thus, as expected, security moderated the first path of the mediating process (perceived stress → self-control). Contrary to our hypothesis, security did not moderate the direct process (perceived stress → mobile phone addiction).Model 8 from the SPSS macro PROCESS was used to test the proposed moderated mediation model with self-control as mediator and security as moderator, after controlling for gender and age. p < 0.001); for individuals with high security, the predictive effect was not significant . These analyses indicated that the predictive effect of perceived stress on self-control decreases with increased security.Simple slopes analysis was used to interpret the interaction effect. Security also moderated the overall indirect effect (perceived stress → self-control → mobile phone addiction) with the index of moderated mediation = –0.08, Boot SE = 0.03, and 95% Confidence Interval . For individuals with a high level of security, the indirect effect of perceived stress on mobile phone addiction through self-control was not significant, with effect = –0.42, Boot SE = 0.64 and 95% Confidence Interval . For individuals with low security, the indirect effect of perceived stress on mobile phone addiction through self-control was significant, with effect = –0.14, Boot SE = 0.10, and 95% Confidence Interval .2/df = 3.924, CFI = 0.939, TLI = 0.888, RMSEA = 0.086, SRMR = 0.041).To further verify the validity of the results, this study used a structural equation model to assess the mediating effect of self-control between perceived stress and mobile phone addiction. In addition to constructing the hypothesized model, other competitive models were constructed to test the superiority of the model. The general question in this study was whether college students who perceive high stress are also at higher risk of mobile phone addiction. We established this connection, consistent with other research , which fLow self-control mediated the relationship between perceived stress and mobile phone addiction, which verifies Hypothesis 2 of this study and supports the Strength Model of Self-Control. Both parts of this process (perceived stress → low self-control) and (low self-control → mobile phone addiction) can be conceptualized in terms of demands on psychological resources. With regard to the first path, stress may trigger negative emotion and negative cognition when they feel stressed . The regThe Dual Systems Model of Self-Control can help us conceptualize this mediated effect in terms of a lack of resources. According to this model, there are two main systems of individual executive function: the rational system and the impulse system. When resources are sufficient and the main activities can be carried out smoothly, the rational system occupies the dominant position and guides the individual to show self-control. In this state, the person can resist immediate satisfaction, think carefully, and make thoughtful decisions. However, because self-control starts to drain resources, the main activities cannot be carried out. The impulse system is then engaged to encourage intuitive, heuristic processing to meet the current ideas and needs . As a moIt is found for the first time that security moderates the first path of the mediation process (perceived stress → self-control), which verifies Hypothesis 4 of this study. Indeed, among college students with higher security, there was a weaker association between perceived stress and self-control; compared to students with lower security, those with high security still maintained self-control while enduring higher perceived stress. Individuals with low security are more afraid of losing control of the outside world and the recurrence of stress events. Therefore, they fall into the pain of negative emotions , and theBy contrast, students with high security may still trust the certainty of the external environment and their own control in the face of stress. These students are better able to handle perceived stress due to their belief that the external environment is controllable. Therefore, they are less likely to be immersed in negative emotions and maladaptive cognitions , self-cot = 16.51, p < 0.001, Cohen’s d = 0.92. In addition, according to the cut-off point of 32 for mobile phone addiction on the Short Version of the Smartphone Addiction Scale  was significantly higher than it was pre-pandemic 6.12 ± 5.54) , t to make up for the limitations of self-report data. Fourth, mobile phone addiction may have comorbidity with other psychological symptoms , and these variables may be controlled or explored as comorbidity in future studies. Last, the data were collected during the epidemic period, resulting in high levels of some variables. The results of this study mainly focus on the formation mechanism of mobile phone addiction among college students under the current normalization of epidemic prevention and control, so whether they can be extended to young adults in non-epidemic areas needs further validation in the future.Perceived stress positively predicted college students’ mobile phone addiction. Self-control mediated the relationship between perceived stress and mobile phone addiction. Moreover, security moderated the first path of the mediation processes. Compared with students who had lower security, those with higher security demonstrated a weaker association between perceived stress and self-control.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.All materials and procedures were reviewed and approved by the Ethics Committee of Hunan University of Chinese Medicine, and all participants and their legal guardians involved in the study provided written informed consent to participate according to the ethical guidelines set forth in the Declaration of Helsinki.BZ and SX conceived the idea for the study. BZ, SX, YP, YZ, CZ, YY, and AZ obtained the data. AZ, CZ, and YP performed the data analyses. AZ wrote the manuscript with the participation of other authors. All authors contributed to the article and approved the submitted version.


Participants completed a validated food frequency questionnaire, fasting (12 h overnight fast) biochemical analyses, and a physical examination including anthropometric measures. CAC and PAT were measured using electron beam-computed tomography. Logistic regression models were used to examine the associations of the Mediterranean-Style Dietary Pattern Score (MSDPS) with CAC (presence or absence), and linear regression models were applied to PAT analyses. In all of the adjusted models, no significant associations with CAC were found. For PAT, an increasing MSDPS was consistently associated with its lower volume in models adjusted for age, sex, diabetes status, total calories, and body mass index . The association between MSDPS and PAT was attenuated after adjusting for serum lipids and physical activity. In conclusion, the baseline data from the CACTI study show that a greater adherence to MSDPS is associated with a lower PAT volume and provide evidence that the Mediterranean dietary pattern is associated with lower cardiovascular risk markers.Several studies have identified improvements in the risks of cardiovascular disease in adults following a Mediterranean dietary pattern. However, data are scarce on its association with coronary artery calcification (CAC) and pericardial adiposity (PAT) in US adults with and without diabetes. To address this gap, we conducted a case-control study using baseline data from the Coronary Artery Calcification in Type 1 Diabetes (CACTI) study [ Cardiovascular disease (CVD) represents a collection of disorders associated with the heart and blood vessels and includes coronary artery calcification (CAC). The risks of these conditions can be increased by pericardial adiposity (PAT). CAC and PAT can serve as prognostic indicators for CVD ,2. CAC iIn individuals with diabetes, CVD is the leading cause of death, with heart disease and stroke being twice as likely for these individuals compared to those without diabetes . Adults While a healthy diet remains the cornerstone in CVD prevention and management, this strategy has manifold definitions. The American Diabetes Association recommends that adults with diabetes consume diets high in plant-based foods, lean proteins, and fiber . The CenSimilar to the recommendations from the ADA and CDC, the Mediterranean Diet (MedDiet) is characterized as the increased consumption of fruits, vegetables, and whole grains and reduced quantities of saturated and trans fats. However, the major distinction is that the MedDiet provides specific serving sizes for each major component and has been utilized in many different study populations. The MedDiet was first identified for its cardiovascular benefits by Ancel Keys . Since tThe MedDiet is characterized by a high habitual intake of vegetables, fruits, legumes, nuts, cereals (primarily whole grains), and olive oil and a low-to-moderate consumption of dairy, fish, meat, and wine ,32,33. HWhile several studies have assessed diet quality using the MedDiet adherence in relation to CVD risks, few studies have assessed the associations of a MedDiet with CAC and PAT outcomes in individuals with and without diabetes. A few observational studies have applied MedDiet scores to assess CAC and other coronary plaque measures in populations that included individuals with diabetes and reported an inverse association ,38. Addiclinicaltrials.gov .For this report, baseline data (2000–2002) from the CACTI study were used. The primary objective of the CACTI study was to examine the progression of subclinical atherosclerosis and its risks in individuals with a T1D diagnosis and in a group of non-diabetic controls, all of whom were free from CVD at enrollment in a case-control design . The hean = 11) [The participants completed a 126-item, validated semi-quantitative food frequency questionnaire  . The USDn = 11) . With thn = 11) ,45.To calculate a MedDiet score, the Mediterranean-Style Dietary Pattern Score (MSDPS) was applied. The MSDPS was developed by Rumawas et al. to assess conformity to the Mediterranean diet pyramid . In shorDemographics, medical history, physical activity level (Modifiable Activity Questionnaire), and medication use were collected from standardized questionnaires for all participants, as previously described . Height,To determine CAC, two measurements were collected using an ultrafast Imatron C-150XLP electron beam computed tomography (EBCT) scanner and averaged  . The preAnalyze Direct 11.0 volume analysis software was used to manually trace the heart using a spline edge detection feature, and boundaries included the chest wall, descending aorta, and bronchus. The PAT volume assessment started 3 mm above the left main coronary artery and was repeated for each 3 mm slice until 30 mm below the left main coronary artery . The PATThe main objective of the present study is to examine the associations of the MSDPS with CAC and PAT prevalence at the baseline of the CACTI cohort. To measure differences between the control group and the T1D group, an independent-samples t-test was conducted to analyze differences in risk factors, MSDPS, and individual components of the MSDPS. The Wilcoxon rank sum test was used to compare differences in continuous variables with skewed distributions. Baseline comparisons for sex, race (non-Hispanic white (NHW)), Hispanic origin, and CAC measurements as categorical variables between two groups were analyzed using chi-square tests.The logistic regression model examined the association of MSDPS with CAC (presence or absence). The application of the logistic regression model provides an odds ratio for the parameter estimate, which can give the change in odds of CAC for a one-point increase in the MSDPS. For the CAC outcome, the models were adjusted for appropriate confounding variables as listed: model 1 , model 2 ), and model 3 (model 2 + HDL + LDL+ systolic blood pressure).Linear regression models were applied to the PAT analyses. The application of the linear regression model provides a parameter estimate to indicate the volume change per one point increase in the MSDPS. For the PAT analyses, the PAT volume was log-transformed to meet equal variance and normality assumptions. The models applied to investigate the associations between MSDPS and PAT volume were adjusted as follows: model 1 , model 2 , model 3 (model 1 + BMI), and model 4 . In an exploratory analysis, race and Hispanic origin were added to Model 1 in CAC and PAT analyses, and lipid-lowering medications were adjusted in the final models for CAC and PAT analyses.Additionally, an interaction analysis was conducted between the MSDPS and diabetes status, and no significant interaction was found. Thus, the analyses were adjusted for diabetes status using the pooled sample. We also present the data stratified by diabetes status for comparisons. The statistical analyses were performed using SAS v9.4 . A two-sided alpha level of 0.05 was used to define statistical significance.3  decrease in PAT volume. Further adjustment for LDL, triglycerides, and physical activity, however, attenuated the association between the MSDPS and PAT volume in the pooled analysis. When stratified by diabetes status, the MSDPS and PAT volume revealed significant inverse associations in all of the adjusted models in the non-diabetic controls. No significant association was observed in the T1D group. These associations were not affected when further adjusted for race, Hispanic origin, and lipid-lowering medications.In 3 , −0.03 cm3 , and −0.03 cm3  lower PAT, respectively.In We observed an inverse association of increasing adherence to the Mediterranean-Style Dietary Pattern Score with pericardial adiposity in the models adjusted for age, sex, diabetes status, total calories, and BMI in pooled analyses; when LDL, triglycerides, and physical activity were added, this association was attenuated, indicating that the association was not independent of the roles of serum lipids and physical activity in cardiac adiposity. When stratified by the disease status, the association between adherence to the Mediterranean diet and PAT revealed significant inverse associations in non-diabetic controls only in all of the adjusted models. Adherence to the Mediterranean-Style Dietary Pattern Score was not significantly associated with the presence of CAC. When analyzing the individual scores of the MSDPS foods and associations with CAC and PAT, fruit, wine, and meat groups had a significant inverse correlation with PAT. The attenuation of the results in the model adjusted for lipids and physical activity is expected, since PAT has been significantly associated with LDL cholesterol, triglycerides, and physical activity ,50,51,52Longitudinal studies have reported that increased adherence to the MedDiet is associated with reduced pericardial fat in the Framingham Heart Study and in the Multi-Ethnic Study of Atherosclerosis ,54. HoweThe inverse association between the MedDiet and pericardial adiposity in the pooled analyses is likely due to its known effects in reducing fat accumulation ,56,57. TWhen the individual MSDPS components were analyzed for association with PAT, the significant findings for fruit and wine scores conform to the findings in the literature, which indicate reduced CVD risk ,62,63,64The inverse association with the meat score was unexpected. The meat score reflects the level of adherence versus the overall meat consumption. To receive maximum points (10 points) for meat consumption, individuals would have to consume only one serving per week. Individuals who consumed less than one serving or greater than one serving per week received a lower score. For example, individuals who ate 0.5 servings of meat per week and those who ate 1.5 servings per week received the same score (5 points). Therefore, this score indicates that a higher adherence to the recommended level of meat consumption is associated with a lower PAT volume. Similarly, wine consumption, including white and red wine, assigned maximum points for modest consumption, meaning that adherence to the recommended levels was associated with a lower PAT volume.When comparing our baseline MSDPS to the Framingham Offspring Cohort and the Atherosclerosis Risk in Communities (ARIC) cohort, the controls and T1D groups in our study showed similar scores of (mean ± SD) 25.4 ± 7.8 and 25.0 ± 7.8, respectively, compared to the score of 25.0 ± 8.21 for the Framingham cohort and the score of 20.0 ± 6.5 for the ARIC cohort ,73. Our Our insignificant findings for the association between MSDPS and the presence of CAC are contrary to previous reports, though not all of these studies examined CAC as a marker of atherosclerosis. A few longitudinal studies have shown that adherence to Mediterranean-style diets is associated with improved endothelial function and the limited progression of CAC ,77,78. TThere are also a few other reasons explaining the insignificant association between MSDPS and the presence of CAC in our study. First, our study participants were not habitually consuming a MedDiet pattern, as reflected by the overall low scores of adherence. Second, in early autopsy research, CAC manifestations have been found in individuals younger than 35 years of age ,80,81,82The strengths of our study include the large sample size and the inclusion of individuals with and without T1D. To our knowledge, this is the first study to assess the associations of MSDPS with CAC and PAT in adults with and without diabetes in the same cohort. The MSDPS has many strengths, including using the Mediterranean diet pyramid to construct its point system and point deductions for overconsumption . AdditioWhile this study has many strengths, it also has some limitations. The case-control study design may limit the generalizability to other populations and is not able to address causality. Secondly, the self-reporting of dietary components is subject to recall bias, as individuals may inflate or reduce the reporting of food groups that they perceive as healthy or unhealthy. Additionally, the FFQ used did not have olive oil as a separate category but included an option to specify other oils used for cooking; no olive oil use was documented, which likely affected our sample’s adherence scores. There is also the possibility of residual confounding, although we included all relevant covariates in our models. Finally, based on our previous publications of secondary aims using data from the primary study ,89,90,91In conclusion, the baseline data from the CACTI study show that a greater adherence to a MedDiet is associated with a lower volume of pericardial adipose tissue in non-diabetic controls only, but not with coronary artery calcification in patients with or without diabetes. Higher PAT volumes have been correlated with CAC development and, thus, coronary artery disease in adults. Therefore, our observed associations may be relevant in the early management of CAC. Overall, Mediterranean-style dietary recommendations must be included in the medical nutrition therapy for the prevention and management of CVD in US adults. Future research must examine these associations in multiple years of follow-up as well as in adults with other chronic diseases leading to vascular dysfunction.