In intensive care unit (ICU), it is essential to predict the mortality of patients and mathematical models aid in improving the prognosis accuracy. Recently, recurrent neural network (RNN), especially long short-term memory (LSTM) network, showed advantages in sequential modeling and was promising for clinical prediction. However, ICU data are highly complex due to the diverse patterns of diseases; therefore, instead of single LSTM model, an ensemble algorithm of LSTM (eLSTM) is proposed, utilizing the superiority of the ensemble framework to handle the diversity of clinical data. The eLSTM algorithm was evaluated by the acknowledged database of ICU admissions Medical Information Mart for Intensive Care III (MIMIC-III). The investigation in total of 18415 cases shows that compared with clinical scoring systems SAPS II, SOFA, and APACHE II, random forests classification algorithm, and the single LSTM classifier, the eLSTM model achieved the superior performance with the largest value of area under the receiver operating characteristic curve (AUROC) of 0.8451 and the largest area under the precision-recall curve (AUPRC) of 0.4862. Furthermore, it offered an early prognosis of ICU patients. The results demonstrate that the eLSTM is capable of dynamically predicting the mortality of patients in complex clinical situations. Mortality prediction is essential for the clinical administration and treatment, especially in the intensive care unit (ICU) , 2. Vari2, fraction of inspired O2, Glascow coma scale, blood glucose, heart rate, pH, respiratory rate, blood oxygen saturation, body temperature, and urine output), the LSTM model was able to predict whether the patient suffered from 128 most common conditions, such as acute respiratory distress, congestive heart failure, and renal failure. Jo et al. used LSTM and latent topic model to extract information from textual clinical notes for assessing the severity of diseases , as expressed in equation  for survival and 1 (positive) for death. The ratio of negative and positive group size is denoted as γ:Given a training set with LSTM has the advantage of capturing temporal information and is popular to be adopted in time series modeling. Detailed structure of the LSTM block is illustrated in Xt. Then, the output of hidden layer, namely, the current hidden state ht, is computed as follows:ft, it, and ot are the forget, input, and output gates, respectively. ht−1 is the previous hidden state. Ct−1 and Ct are previous and current cell memories. The weight matrices wf, wi, wo, and wc and the bias vectors bf, bi, bo, and bc are model parameters. The symbol σ is the sigmoid function and tanh hyperbolic tangent function. The symbol · denotes matrix multiplication and ∗ elementwise product.The input of LSTM block is γ and negative ones weighted 1. The parameters within the net are updated over several iterations to reach the minimum loss value:A sigmoid layer is applied on the output of the LSTM block at final step for binary classification. The predicted score equation . The losThe eLSTM model is composed of multiple LSTM classifiers, and its architecture is illustrated in The procedure of eLSTM consists of two stages: base learner generation and integration.1, Subset2,…, Subsetp,…, SubsetP}.In the stage of base learner generation, the bootstrap sampling strategy  and randIn ensemble model rather than error control strategy, bias control is generally adopted to train multiple base classifiers benefiting the diversity of the model. Thus, appropriate number of training epochs for the classifiers is selected by experiments under a satisfied level of bias. The variance of the model due to the diversity of individual classifiers is controlled by the following ensemble operation , 46. ForF1, F2,…, FP} denote the set of P trained base classifiers. For the input V, the p-th LSTM classifier gives an individual predicted score Then, multiple LSTM classifiers learn from the subsets. Let {equation .Finally, in the integration stage, the scores of all LSTM classifiers are averaged as the overall output and calculated as follows:The procedure of the eLSTM algorithm is provided in Once the eLSTM model is accomplished, it is applied in this way: for an instance, each LSTM classifier uses partial values of the corresponding variable subset and makes a prediction; different LSTM classifiers utilize different sets of variables, producing multiple prediction scores; the final prediction is obtained by averaging all scores.For LSTM and eLSTM models, the full sequence of data is needed to predict the outcome. However, in practice, the patients' physiological parameters are collected day by day. To develop a dynamic procedure providing daily prediction, in this work, the values for coming days are padded by the latest available data to acquire complete sequences. Then, the LSTM algorithm and the eLSTM algorithm are employed on the complete dataset for predicting the outcome. Thus, the mortality assessment is updated daily with the replenished data approaching closer to the reliability. The process is illustrated in The proposed eLSTM algorithm is compared with three scoring systems , RF algorithm, and LSTM classifier. In the LSTM classifier, a sigmoid layer is applied on top of the LSTM block for binary classification. The LSTM block has one hidden layer with 64 hidden units, and a dropout of rate 0.5 is applied to the input layer. The weight parameters are initialized randomly using Glorot uniform initialization . The LSTThe experiment is repeated 50 times. For each experiment, 90% of the dataset is chosen as training data and the left 10% as test data. Before the training procedure, data are preprocessed by imputation and normalization. The missing values are filled by linear interpolation imputation method, assuming a linear development in time of the variable with missing data . Then, ax-axis and sensitivity as the y-axis for all potential thresholds, while the precision-recall plot applies recall and precision as the x-axis and y-axis. The area under ROC (AUROC) and the area under precision-recall curve (AUPRC) are calculated for comparison. Moreover, the bias between the predicted class labels and the true labels is comprehensively measured by sensitivity/recall, specificity, accuracy, precision, and F1 score. Sensitivity/recall calculates how many true-positive cases are correctly classified as positive, while precision counts the proportion of true-positive cases in the cases classified as positive. F1 score is the harmonic mean of recall and precision.To compare the performances of these models, several metrics are computed on predicted scores and true labels. The receiving operating characteristics (ROC) curve and the precision-recall curve are plotted to evaluate the performance of the classifiers. The ROC curve uses 1 − specificity as the The ROC curves and precision-recall curves of all models are shown in Figures p < 0.001). It can be seen the models of RF, LSTM, and eLSTM have much larger AUROC values  than scoring systems SAPS II, SOFA, and APACHE II . The proposed eLSTM model has the largest mean AUROC value of 0.8451, LSTM approach the second largest mean AUROC value of 0.8382, and the RF method the third largest of 0.8282. The eLSTM model outperforms other models in terms of AUPRC with the largest value of 0.4862 ± 0.0345. Also, the eLSTM algorithm has the largest sensitivity/recall of 0.7758 and the RF model and LSTM model have the medium value of 0.7197 and 0.7384, while the three scoring systems get the least value of 0.5418–0.6922. Post hoc analysis by Dunnett test shows the differences in AUROC, AUPRC, and sensitivity between eLSTM and other methods are significant (p < 0.05). Totally, the eLSTM model obtains the significant largest value of AUROC, AUPRC, and sensitivity. It is noticed that all methods have low precision and F1 score. It is mainly due to the imbalanced distribution of class label, that is, the number of negative instances is much larger than that of positive ones.Detailed statistical results of repeated experiments are given in p=0.011; eLSTM vs. RF: p=0.000). The charts also clearly reveal that while RF, LSTM, and the three scoring systems reach their highest performance on the last day, eLSTM achieves the corresponding levels at least 6 days earlier than the scoring systems and 2 and 1 days earlier than RF and LSTM, respectively. These facts demonstrate that eLSTM has stronger ability of dynamic prediction as well as early prognosis than the others.p=0.043; eLSTM vs. RF: p=0.000).The AUROC value of eLSTM goes up with the increase of the number of base LSTM classifiers . It has F = 45.932, p=0.000; AUPRC: F = 7.079, p=0.002). The AUROC values are similarly high for eLSTM with multiple sets of 16, 25, or 32 variables (p < 0.05), while there are no significant differences among the models with sets of 16, 25, and 32 variables. In this work, the size of variable subset was set as the median value of 25, which is in agreement with the recommendation of literature [ANOVA test indicates the size of variable subset in eLSTM models leads to significant difference in AUROC and as well as in AUPRC  in the entire MIMIC-III database , as thatIn this paper, we propose a new approach named eLSTM which can deal with the complex and heterogeneous ICU data for mortality prediction. The proposed eLSTM models obtain the prediction result by merging the results of multiple parallel LSTM classifiers. The base LSTM learners are trained on different subsets which are generated using bootstrapped samples and random feature subspace. Experimental results show that the proposed eLSTM algorithm effectively utilizes the ensemble framework in LSTM classifier and achieves excellent performance on the extracted MIMIC-III dataset. Also, it provides an early prognosis of ICU patients. The eLSTM model is promising to offer a universal quantitative tool for assessing risks of all patients in ICU and even for other complex clinical situations. In the future work, other approaches of aggregating component classifiers are worth investigating to optimize the structure as well as the algorithm.


The prevalence of endometriosis in the general population is estimated at 7-10%. There are various riskfactors for this disease, including early menarche age, prolonged menstruation or no history of pregnancy. It seemsthat sexual activity leading to orgasm during menstruation increases the retrograde menstruation, sending endometrialtissue to an abnormal sites and thus increasing the risk of endometriosis. The present study is aimed to determine theassociation between sexual activity during menstruation and endometriosis.This case-control study, conducted in the year 2017, recruited 555 women who were visitedat Alzahra Hospital in Tabriz, Northwest of Iran. The case group comprised 185 women of reproductive age withconfirmed endometriosis. The control group comprised 370 women of reproductive age without endometriosis visit-ing the hospital for other issues. Data was collected using a researcher-made questionnaire based on previous studies.Bivariate analysis was performed by the chi-squared test and multivariate analysis was done using conditional logisticregression to control confounding variables.The sexual activity of the two groups during menstruation was significantly different. The occurrence ofendometriosis in women who stated they had vaginal intercourse or non-coital sexual activities, leading to orgasmduring menstruation, was significantly higher compared to those who stated they did not.According to our findings, there is an association between sexual activities leading to orgasm duringmenstruation and endometriosis. Endometriosis is a benign gynecologic disease  definedEndometriosis has a complex and multifactorial etiology. The facAlthough no theory can cover all the manifestations ofthis disease, the retrograde menstruation is widely acceptedto describe the dissemination of endometrial tissue tothe peritoneal cavity through open fallopian tubes duringmenstruation , 5. PrevIt is hypothesized that sexual activity leading to orgasm during menstruation may increase retrograde menstruation, seeding endometrial tissue in other locations, and thus increasing the risk of endometriosis. So far, few studies have examined the relationship between sexual activity during menstruation and endometriosis -18. BaseThis case-control study, which was done in 2017, recruited women at reproductive age (20-50 years), with or without endometriosis. The participants in the case group were selected from women with endometriosis visiting Alzahra Hospital over the past two years, who had undergone laparoscopy and open surgery with a histological diagnosis of endometriosis. Participants in the control group were selected from the same age group of women visiting the same hospital for other reasons including vaginitis and an annual checkup. The absence of endometriosis in the control group was confirmed by a gynecologist colleague based on their signs and symptoms. The final selections were done based on our inclusion and exclusion criteria. The study inclusion criteria were: i. Age of 20-50 years, ii. Diagnosis of endometriosis by open surgery or laparoscopy and histologic diagnosis of endometriosis or the presence of endometrioma (case group), iii. Being married, iv. Being Iranian, v. Willingness to participate, vi. Absence of endometriosis (control group), vii. No history of tubectomy (control group), and viii. No history of infertility (control group). The study exclusion criteria were: i. Being menopausal (amenorrhea for over a year), ii. Being suspected of endometriosis or endometrioma (control group), iii. Having endometriosis in the surgical site or involvement of remote organs, e.g. lungs or brain, iv. Having breast, ovarian, or endometrial cancer, v. Having polycystic ovarian syndrome (PCOS), vi. Having any other life-threatening disease, and vii. Suffering from chronic pelvic pain. In this study, the sample size was determined according to the results of a pilot study on 150 participants and considering an odds ratio  to be about 1.8, was determined as n1=185 (case group), n2=370 (control group), and n=555  (with the case-to-control ratio of 1:2). The present study was confirmed by the Ethics Council of Tabriz University of Medical Sciences (ethics code: 5/D1003687). Afterward, data collection was started in Alzahra Hospital, Tabriz, which is a referral Gynecology and Midwifery Hospital in Northwest of Iran. We reviewed pathological results in the medical files that were available at Alzahra Hospital and registered women patients with endometriosis, as confirmed by histological diagnosis through laparoscopy or open surgery, for our study. The addresses and phone numbers of all considering patients, who had been identified over the past two years, were extracted from their records. They were contacted by telephone, the research objectives and methods were briefly explained to them, the study inclusion and exclusion criteria were checked, and finally they were invited to participate in the study. For those who were willing to take part, questionnaires were filled in through the interview. For the patients’ comfort, the interviewer and the patients were of the same gender. After sampling was done in the case group, the members of the control group were selected through purposive sampling from those visiting the gynecology clinic of the same center for other issues, such as vaginitis or an annual visit, and did not have endometriosis, as diagnosed based on symptoms by a gynecologist colleague. Research objectives and methods were first explained to them. For those who were willing to participate, inclusion and exclusion criteria were checked, and in case they met the criteria, they were recruited and questionnaires were completed by the researcher through interviews. Informed consent forms were obtained from all participants, and those in both case and control groups were matched for age ± 2 years. Data were collected by the researchers through interviews and using researcher-made questionnaires based on previous studies, highlighting sociodemographic and sexual activity characteristics. The sociodemographic characteristics questionnaire included questions on age; the level of education, employment, the level of income, smoking, alcohol use, the history of any diseases, allergies, and endometriosis in first-degree relatives . The sexual activity and reproductive and menstruation characteristics questionnaire included questions on vaginal or non-coital sexual activity  and anal intercourse, leading to orgasm during menstruation, cycle length, cycle intervals, number of pregnancies, menarche age, age at first pregnancy, oral contraceptive pill (OCP) user, intrauterine device (IUD) user, dysmenorrhea, dyspareunia, and recurrent vaginitis. Content and face validity were used to confirm the validity of the questionnaires, they were given to 10 faculty members and corrections were applied based on their opinions. Data were analyzed in SPSS 21 software. Sociodemographic and sexual activity characteristics during menstruation were described using descriptive statistics including frequency (percentage). Sociodemographic characteristics were compared between the two groups using chi-squared test, chi-squared test for trend, independent samples t test, and Fisher’s exact test. To determine the relationship between sexual activity during menstruation and endometriosis, chi-squared test was performed in the bivariate analysis. Conditional logistic regression was employed in the multivariate analysis to control confounding variables . Because no woman in the control group reported a history of this disease in her first-degree relatives, the family history was not included in the multivariate regression as a confounding factor. In this analysis, the odds ratio and confidence interval was set at 95%, and P<0.05 was considered significant. In this study, 185 women with endometriosis and 370 women without endometriosis were analyzed. The participants’ mean age was 35.21 years (SD: 7.09) in the case group and 35.28 years (SD: 7.03) in the control group. The two groups significantly were differed regarding the level of education; the percentage of participants with academic degrees in the case group was twice as high as those in the control group (P<0.001). Moreover, 32 (17.3%) women of the case group and 10 (2.7%) women of the control group were employed, again indicating a significant difference between the two groups (P<0.001). However, the two groups were similar regarding the sufficiency of monthly income (P=0.698). The two groups were compared in a history of diseases such as diabetes, hypothyroidism, hypertension, cardiovascular diseases, cerebrovascular diseases, seizures and asthma, and did not show any significant differences (P=0.860). The two groups were also similar regarding an autoimmune disease history, e.g. rheumatoid arthritis, multiple sclerosis, and lupus erythematosus (P=0.669). There were 38 (20.5%) women in the case group and 47 (12.7%) women in the control group with a history of allergies, indicating a significant difference between the two groups (P=0.016). Nevertheless, both groups were similar regarding the type of allergies  (P=0.946). In the case group 13 (7%) women reported a history of endometriosis in their mothers and sisters, and 7 (3.8%) women reported this in their aunts, while no woman in the control group reported a history of this disease in her first-degree relatives, demonstrating a significant difference between the groups (P<0.001). Only one woman in the control group had a history of smoking, and no one in either group had a history of alcohol use . Regarding vaginal intercourse during menstruation, the two groups were compared using multivariate logistic regression, while controlling the effects of possible confounding variables, such as the level of education, income, occupation, cycle length, cycle interval, number of pregnancies, menarche age, age at first pregnancy, OCP user, IUD user, dysmenorrhea, dyspareunia and recurrent vaginitis. The results showed that the risk of endometriosis approximately was five times higher in those women who stated they had vaginal intercourse during menstruation compared to those who stated they did not . Furthermore, 6 (20%) participants in the case group and 1 (3.6%) participant in the control group reported that they always had vaginal intercourse during menstruation, demonstrating a significant difference between the groups (P<0.001). Both groups were similar with regard to the days of vaginal intercourse  (P=0.111). Moreover, the risk of endometriosis was approximately three times higher in those women who stated they had non-coital sexual activity during menstruation compared to those who stated they did not . In addition, 9 (23.7%) participants in the case group and 6 (14.6%) participants in the control group reported that they always had non-coital sexual activity during menstruation, indicating no significant difference between the two groups based on a chi-squared test (P=0.141). Moreover, 2 (1.1%) participants in the case group and 15 (4.1%) participants in the control group stated that they have anal intercourse during menstruation, but there was no significant difference between the two groups  , a complete conclusion is not possible.In this study, an attempt was made to select women with and without endometriosis based on precise medical diagnosis. Furthermore, the most important and relevant factors with endometriosis were examined while controlling confounding variables. In this study, validity was only confirmed through face and content validity qualitatively and the quantitative indices such as content validity index (CVI) and content validity ratio (CVR) weren’t calculated. Also, considering the criterion for the definite diagnosis of endometriosis is histologic diagnosis through laparoscopy or laparotomy, one of the other shortcoming of this study is that the control group wasn’t selected based on histologic diagnosis. Thus, future studies should be conducted on selected case and control participants from women, in whom the presence or absence of endometriosis is confirmed by laparoscopy or laparotomy. Based on the results of the present study, vaginal intercourse or non-coital sexual activity leading to orgasm during menstruation increases the risk of endometriosis in women during reproductive age. This study has raised interesting issues and requires further investigation to better understand the mechanism of occurrence of endometriosis in such cases.


Background. The incidence of hypertriglyceridemia-induced acute pancreatitis (HIAP) is increasing worldwide, and now it is the third leading cause of acute pancreatitis in the United States. But, there are only 5% of patients with severe hypertriglyceridemia (>1000 mg/dl) which might generate acute pancreatitis. In order to explore which part of the patients is easy to develop into pancreatitis, a case-control study was performed by us to consider which patient population tend to develop acute pancreatitis in patients with severe hypertriglyceridemia. To perform a retrospective case-control study, we identified severe hypertriglyceridemia patients without AP (HNAP) and with HIAP with a fasting triglyceride level of >1000 mg/dl from The First Affiliated Hospital of Nanjing Medical University during January 1, 2014, to December 31, 2016. Baseline patient characteristics, comorbidities, and risk factors were recorded and evaluated by the univariate and multivariate logistic regression analysis for HIAP and HNAP patients. A total of 124 patients with severe hypertriglyceridemia were included in this study; of which, 62 patients were in the HIAP group and 62 were in the HNAP group. Univariate logistic regression analysis showed that there was no gender difference in both groups; however, there were more younger patients in the HIAP group than in the HNAP group ( Acute pancreatitis (AP) is a potentially life-threatening acute inflammatory disease of the pancreas. It is characterized by a systemic inflammatory response, with a growing number of hospitalizations each year, and it is associated with a mortality ranging from 3 to 30% in the world , 2. In aIt is reported that hypertriglyceridemia affects approximately one-quarter of the United States (US) population . It is rThe First Affiliated Hospital of Nanjing Medical University is an integrated healthcare delivery system in Eastern China. Data available for this study included demographic data, diagnoses, medication dispensing, and laboratory results. The hospital has an electronic health medical record system and a paper-based medical records library, which allow access to more detailed information and was included in this study.HNAP and HIAP patients with a fasting triglyceride level of >1000 mg/dl were retrospectively analyzed in The First Affiliated Hospital of Nanjing Medical University from January 1, 2014, to December 31, 2016. Among these patients, those with biliary pancreatitis, alcoholic pancreatitis, idiopathic causes, traumatic pancreatitis, and other undefined recorded causes were excluded from our study. The diagnosis of HIAP was made if the patients had AP with the serum total triglyceride (TG) level of >11.3 mmol/L (1000 mg/dl). The AP diagnosis was performed based on the following features: typical upper abdominal pain , laboratory tests (amylase and lipase), and evidence of pancreatitis upon abdominal imaging [The information on demographic data, history of diabetes, blood pressure, history of alcohol and cigarettes, and biochemical data was carefully collected. Data regarding deaths, length of hospital stay, and intensive care unit (ICU) admission were recorded and analyzed.All the patients whose data were collected for this study's purpose provided written informed consent for the acquisition, analysis, and publishing of the anonymized data collected during their hospital admission.P < 0.05 was considered statistically significant, and all statistical analyses were performed by using SPSS17.0 software package. Continuous variables are expressed as mean ± SE, and comparisons between groups were performed by using the t-test. Categorical variables were compared between groups by using the Pearson χ2 test.P=0.001) and higher fasting glycemia (P < 0.001) than the HNAP group. Although there is no statistical difference, a high percentage of smoking history and drinking history was also observed in the HIAP group.The baseline characteristics of hypertriglyceridemia patients with or without AP are summarized in P < 0.001) and lower HDL-c  were significantly associated with HIAP occurrence. In addition, the presence of pancreatitis was associated with higher hepatic biochemical indexes, such as GGT, LDH, AST, ALT, and alkaline phosphatase. Furthermore, a history of diabetes was more common in patients with HIAP , and higher fasting glycemia  was associated with the presence of pancreatitis.To investigate the risk factors contributing HIAP occurrence, we examined the potential variables and analyzed them by univariate analysis, as shown in A binomial logistic regression was performed to ascertain the effects of independent variables on the likelihood that patients had acute pancreatitis with severe hypertriglyceridemia.P value <0.05 and higher clinical relevance in univariate analysis into multivariate analysis (P=0.012) and lower age  were associated with an increased likelihood of developing HIAP.Introducing the variables with analysis , the resn = 22) and those without (n = 40) was performed. ICU admission was more frequent in the HIAP patients with diabetes than those without, and obviously, the difference was statistically significant  (P=0.06) (Comparison between HIAP patients with diabetes (P=0.018) . Similar(P=0.06) .In the present study, univariate and multivariate analyses identified that a history of diabetes and younger age were independent risk factors for acute pancreatitis in patients with severe hypertriglyceridemia. Moreover, we found that diabetes can influence the management of patients with HIAP, increase ICU admission rate, and prolong hospital length of stay. To our knowledge, this is the first case-control study to examine the risk factors in people with severe hypertriglyceridemia in China.The mechanism by which HTG leads to acute pancreatitis has not been clarified so far; however, several pathogenetic theories have been proposed. Bhatia et al. , 16 propHTG has also been shown to exacerbate other experimental models of acute pancreatitis . DiabeteThere are some special features of HTG-AP different from AP of other etiologies that are frequently discussed. Some older studies proposed that HTG may play a critical role in the development of respiratory failure and other severe complications associated with acute pancreatitis , 23. A FTo date, the exact pathophysiological mechanism of HTG-induced AP still remains unclear and is a topic of controversial discussion. However, further research efforts in this area will be needed to spread more light into the risk factor of hypertriglyceridemia-induced acute pancreatitis.This study has several limitations. First, our study used a retrospective design, which did not make dynamic analysis of patients' data. Second, there is no information regarding additional factors that may have contributed to pancreatic-related events such as GLP-1 receptor agonists and DPP-4 inhibitors , 29. TheIn conclusion, we demonstrated that diabetes and younger are vital and independent risk factors for acute pancreatitis in patients with severe hypertriglyceridemia. Moreover, the status of diabetes can aggravate the development of HIAP. These findings suggest that severe hypertriglyceridemia in young diabetic patients require more intensive pharmacologic therapeutic strategies, and HIAP patients who have diabetes should have more aggressive management. Further major clinical studies and animal experiments are needed to establish the influence of diabetes towards severity and mortality in HIAP.


Dietary questionnaires currently available which can assess the habitual diet are timely, costly, or not adapted well to the modern diet; thus, there is a need for a shorter food frequency e-Questionnaire (FFeQ) adapted to Western diets, in order to properly estimate energy and macronutrient intakes or rank individuals according to food and nutrient intakes.The aim of this study was to evaluate the relative validity and reproducibility of a 30-minute and 44-item FFeQ in a sample of adults obtained from the general population.A sample of French adults was recruited through social media and an advertising campaign. A total of 223 volunteers completed the FFeQ twice at one-year intervals and were included in the reproducibility study. During that interval, 92 participants completed three-to-six 24-hour recalls and were included in the validity study. Nutrient and dietary intakes were computed for all validity and reproducibility participants. The level of agreement between the two methods was evaluated for nutrient and food group intakes using classification into quintiles of daily intake, correlation coefficients and Bland-Altman plots.For relative validity, correlation coefficients ranged from 0.09 to 0.88  and 0.02 to 0.68  for food group and nutrient intakes, respectively. The median proportion of subjects classified into the same or adjacent quintile was 73% and 66% for food and nutrient intakes, respectively. Bland-Altman plots showed good agreement across the range of intakes. Regarding reproducibility, intraclass correlation coefficients ranged from 0.33 to 0.72 (median: 0.60) and 0.55 to 0.73 (median: 0.64), for food and nutrient intakes, respectively.The FFeQ showed acceptable validity and reproducibility in a sample of adults based on their food and nutrient intakes. The FFeQ is a promising and low-cost tool that can be used in large-scale online epidemiological studies or clinical routines and could be integrated into evidence-based smartphone apps for assessing diet components. A healthy lifestyle, characterized by an adequate, balanced diet combined with regular physical activity, is one of the determinants for good health . ModeratAmong the many available tools that evaluate individual dietary intakes, the food frequency questionnaire (FFQ) has been frequently used in nutritional epidemiology studies since the 1980s -6. DespiAs previously described , a consoExisting FFQs of 50 items or less have not been proven suitable to quickly and accurately assess the diet in several French population subgroups: i) the FFQ by Vercambre et al  was deveWeb-based dietary assessments provide a lot of advantages ,20: theyBefore using a newly developed or modified FFQ, it must first be validated to be considered an acceptable method of dietary assessment . The aimFrench National Institute of Health and Medical Research) network and through the Inserm’s Twitter and Facebook accounts. In total, 441 adults volunteered , provided their informed consents, and were invited to complete the FFeQ. They were asked to complete the FFeQ twice, at a one-year interval, in February-April 2016 and again in February-April 2017. In total, 319 participants completed the FFeQ once (the 122 participants who failed to complete the first questionnaire were more likely to be women and live in the South and East of France and overseas). Two hundred twenty-nine participants completed it twice (participants who completed both questionnaires were more likely to be women and live in the South of France). Participants who under- or over- reported energy intake in one of the FFeQs, ie, were in the top and bottom 1% of the energy intake-to-energy requirement ratio distribution, were excluded as previously described ) and nutrients (correlation coefficients median and range: 0.40 [0.05-0.68]), and our results were comparable to those from other studies ,46,48-52For validation studies, it has been suggested that correlation coefficients should be ≥ 0.3, preferably over 0.4, and optimally in the range of 0.5-0.7 ,45,53. IFor food groups, the lowest correlation coefficients were found for foods that are not consumed regularly such as “variety meats,” “whole-grain pasta, rice and wheat,” “legumes,” and “sunflower oil and groundnut oil”. Such findings on rarely consumed foods have been previously reported -34. Low Because of social desirability ,54, foodIn our study, unadjusted correlation coefficients for macronutrients ranged from 0.47 to 0.57. Similar results were previously obtained for online FFQs . One of the lowest coefficients was observed for sodium (deattenuated energy adjusted correlation coefficient of 0.07). As reported in the pilot study , even tAfter adjustment for energy some correlation coefficients were increased, and others were decreased. According to Willett et al , energy Despite some differences in estimations in both foods and nutrients by the questionnaire, agreement in classification was comparable to what other studies have shown  or slighOur study showed acceptable reproducibility for most foods  and nutrients . Our findings were comparable to prior reported correlation coefficients for reproducibility ,49,61. AAs previously reported in the literature, a slight decrease in food and nutrient intakes was observed between FFeQ1 and FFeQ2 ,32,64,65According to a review, correlation coefficients of 0.5 to 0.7 between two administrations are commonly reported . In our Agreement in classification was very good (median of 80% and 79% for food and nutrient intakes respectively). For all nutrient intakes 74% to 94% of participants were classified in the same or adjacent quintile.The current work has some limitations. People involved in the current study were volunteers. Volunteers may be more health-conscious, pay more attention to their diets than the average population, and therefore provide more accurate responses to questionnaires. However, subjects participating in observational epidemiological or clinical studies that are likely to use this tool in the future are also volunteers.Our work has several strengths. The tool we developed was easy to complete and not time consuming. The implementation of photographs helped the participants estimate the amounts of food consumed and it has previously been shown that the use of photographs improves the ability to report the true quantity of dietary intakes .In addition, a total of 92 participants were included in our study. It is higher than the reported number in recent studies ,69,70.Here, we present relative validity results for the online FFQ in a sample of French adults. A paper version of the FFQ has previously been validated in a sample of patients with chronic kidney disease  and furtFor most food groups and nutrients, the FFeQ showed acceptable relative validity and reproducibility in a sample of French adults. It appears to be valid to rank individuals based on their food and nutrient intakes and can now be used in large-scale epidemiological studies as well as in clinical routine to easily and quickly assess the habitual diet. Developing an evidence-based smartphone application from the FFeQ is the next step. This type of tool may further be used to monitor patients’ nutrient intakes and provide them with instantaneous feedback and nutritional recommendations about their diets.


Brazil is experiencing among the world’s fastest demographic aging worldwide. This demographic transition is occurring in a context of few resources and great social inequalities. The Brazilian Longitudinal Study of Aging (ELSI-Brazil) is a nationally representative study of 9,412 people aged 50 years or older, residing in 70 municipalities across the 5 Brazilian regions. ELSI-Brazil allows investigations of the aging process, its health, psychosocial and economic determinants, and societal consequences. The baseline examination (2015–2016) included detailed household and individual interviews and physical measurements . Blood tests and sample storage were performed in a subsample of study participants. Subsequent waves are planned for every 3 years. The study adopts a conceptual framework common to other large-scale longitudinal studies of aging in the world, such as the Health and Retirement Study, allowing cross-national comparisons. The goal of ELSI-Brazil is not only to build an understanding of aging in a large, Western, middle-income country in a rapid demographic transition but also to provide scientific data to support and study policy changes that may affect older adults. We describe the methodology of the study and some descriptive results of the baseline survey. Brazil, the world’s fifth most populous nation, with more than 200 million inhabitants, is experiencing among the fastest demographic aging worldwide, a trend that will accelerate during the 21st century . PromotiThe rapid aging of the population in low- and middle-income countries is occurring in a context of few resources and great social inequalities , 8. The Brazil has one of the world’s highest levels of socioeconomic inequality (Gini coefficient = 0.53 in 2013) . Life exThe Brazilian Longitudinal Study of Aging (ELSI-Brazil) is the first large-scale longitudinal study of older adults in Brazil. ELSI-Brazil was designed to provide a national data resource on the aging process and health, psychosocial and economic determinants, and societal consequences. The goal of the study is not only to build an understanding of aging in a large, Western, middle-income country in rapid demographic transition but also to provide scientific data to support and study policy changes that may affect older adults. Here we describe the objectives and main aspects of the study.ELSI-Brazil is a nationally representative, population-based cohort study of people aged 50 years or older. The baseline survey was conducted between 2015 and 2016.The sample was designed to be representative of the noninstitutionalized population within the eligible age range. Due to the lack of a centralized and reliable household registry, Brazil’s national household surveys use the Brazilian Institute of Geography and Statistics ) geographic operational base  for straWe used an inverse sampling design to avoid an increase in the sample size to compensate for nonresponses , 22. TheSample weights were derived to account for differential probability of selection and differential nonresponse. Correct use of weights is essential to population inference because the sample is not self-weighting by design. Because ELSI-Brazil has a complex sample design, analyses should account for geographical stratification and clustering in the estimation of standard errors. The mean natural and calibrated weights were: 3,501.6 (standard deviation (SD), 1,695.4) and 4,551.5  for the first stratum; 3,568.8  and 4,844.9  for the second; 4,341.5  and 5,706.3  for the third; and 2,627.5  and 3,573.0  for the fourth.Baseline measurements included: 1) household interview; 2) individual interview; 3) physical measurements; 4) blood tests; and 5) samples storage for future analysis. In households with more than 1 resident, the household interview was done with the adult chosen by the other residents as the one who would best provide the required information. All residents aged 50 or older were eligible for individual interview and physical measurements, and a subsample of 4,500 persons  was selected for blood collection. A proxy was required to answer the individual interview when needed, and this was annotated properly.https://academic.oup.com/aje).The household interview included measures of house characteristics and accessibility, as well as detailed information on housing assets, consumption, and income of each resident. Housing assets included house property; payment of mortgage; rental payment; house market value; other house, flat, land, or farm property and their market value; appliances in the household; vehicle property and market value; and domestic employees in the household. Consumption included money spent on eating out, utilities , condominium fees, fuel and maintenance or repair of vehicles, telephone bills, entertainment, property and vehicle tax bill, purchase of motor vehicles, education/school, private health plan, and other expenses. For those aged 50 years or older, individual income information included employment, private and state pension, and other benefits. For residents aged 17–49 years, income from all sources was considered. The measures obtained in the household interview are summarized in http://elsi.cpqrr.fiocruz.br/).Individual interviews included a broad range of topics related to an individual’s demographic characteristics, neighborhood, discrimination, living and health conditions in early life (childhood questionnaire), work and retirement, family transfers, health behaviors, women’s health, physical and mental health, oral health, functioning and helpers, psychosocial measures, and use of medications and of health services. Health measures included the broad geriatric syndromes of frailty, continence, gait, balance and falls , and hisA comprehensive set of physical measurements and blood tests was carried out. Interviewers administered physical tests at the respondent’s home. The anthropometric parameters included weight, height, and waist and hip circumferences, and were obtained in duplicate. Resting blood pressure was measured 3 times in the seated position after 5 minutes of rest; the average of the second and third measures must be used in the analysis. Other physical measures included grip strength, timed walk, and balance tests. A trained laboratory technician obtained nonfasting venous blood samples in a separate visit to the participant’s household. All biological specimens were sent to the central laboratory (see below). The following tests were performed: total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, urea, creatinine, ferritin, thyroid stimulating hormone (TSH), glycated hemoglobin, vitamin D, and hemogram. Serum and plasma aliquots are stored in liquid nitrogen at the Oswaldo Cruz Foundation, Belo Horizonte, Brazil. DNA extraction and genome assays on those aliquots are planned. Further details are described in the Subsequent waves are planned for every 3 years. Household interview, individual interview, and physical measurements will be repeated at each wave. Sample refreshment is planned every 6 years, at which laboratory tests and aliquots storage shall be repeated. In addition, as an attempt to reduce attrition rates, the following precautions have been taken: 1) during the baseline interview, telephone numbers and addresses of the participant’s network  were recorded; 2) between the interviews, telephone calls to monitor changes of addresses and vital status will be performed; 3) linkage to the National Mortality System will be performed. In order to track those participants who were not located through the above-mentioned procedures, a census tract visit (participant’s household and neighboring households if necessary) is planned for subsequent waves.http://elsi.cpqrr.fiocruz.br/). Interviews were recorded, when authorized by the respondent, and a sample of the recordings was reviewed by trained supervisors. Baseline blood collection and laboratory assays were performed by a private contractor. This laboratory is accredited by the Ministry of Health (Brazil), and by the College of American Pathologists (United States) and the Clinical Laboratory Accreditation Program (United States) (available by request). The blood samples were collected at the participant’s home. After preparation, samples were shipped  to the laboratory situated in São Paulo, Brazil. Best practices were followed to ensure quality and viability of the samples, including packing in dry ice and temperature monitoring along the transportation route .A series of small pilot studies and a further larger pilot study were performed to identify and correct potential problems in the data collection instruments and procedures. Central training and certification of interviewers were performed according to the study protocol. The standardized study procedures are detailed in the ELSI-Brazil operations manual  and Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil. The study’s steering committee includes researchers from these institutions and other consultants in Brazil and other countries. This committee developed the operation manuals and was responsible for training and certifying staff. The research center has developed data entry and management systems, as well as a system for transmission of interviews in real time.ELSI-Brazil was approved by the ethics board of FIOCRUZ, Minas Gerais (Certificado de Apresentação para Apreciação Ética: 34649814.3.0000.5091). Genotyping of the cohort population was approved by Brazil’s national research ethics committee (Certificado de Apresentação para Apreciação Ética: 63725117.9.0000.5091). Participants signed separate informed consent forms for the interviews, physical measurements, and the laboratory assays, authorized sample storages, and access to administrative records.http://www.ibge.gov.br/home/estatistica/populacao/pns/2013/.We used data from the recent Brazilian National Health Survey ), conducted in 2013 , to compAs shown in Table As shown in Table Reported limitations in performing most activities of daily living were similar between the 2 populations . Limitation in dressing was higher in ELSI-Brazil compared with PNS Table .Table 3There was a graded association between limitations in activities of daily living tasks and educational level Table . For allhttps://g2aging.org/). The research also includes new topics to capture Brazil-specific interests.ELSI-Brazil provides nationally representative data that enable inferences to be made about the Brazilian population aged 50 years or older. The study adopts a conceptual framework and approach common to other large-scale longitudinal studies of aging in the world, such as the Health and Retirement Study , the EngRecent economic crises and proposed reforms in social security may have unknown implications for the welfare of older Brazilians. ELSI-Brazil represents a unique opportunity to investigate the impact of such reforms. The topics covered include an array of successful aging measures and their determinants , and events and transitions . The study includes a wide range of socioeconomic measures and adopts new techniques for assessing income and wealth that have been previously shown to improve data quality –31. ChanDisability is a major concern in the context of population aging . The extELSI-Brazil is funded by the Brazilian Ministry of Health, and naturally, there is a great interest in information that can be useful for health planning and evaluation. The Madrid International Plan of Action on Aging called for the elimination of social and economic inequalities in access to health care and the development of health and long-term care to meet the needs of older people . To meetBrazil offers a rare opportunity to explore ethnoracial disparities on health and related outcomes in admixed populations. The Brazilian population originated from African, European, and Native American ancestral roots . The absThe dengue virus was reintroduced into Brazil in 1986, and by 1995 it had spread throughout the country . ChikungIn summary, ELSI-Brazil allows innovative investigations of the aging process, its determinants, and societal consequences. The study is part of an international effort –31 with Web MaterialClick here for additional data file.


Valuation of life (VOL) represents a construct capturing individuals’ active attachment to their life. The majority of studies on VOL were conducted in North America and Europe where personal autonomy and independence are highly valued, leaving open the question about the relevance of this construct in interdependence-oriented cultures. Using a framework of cross-cultural and life-span theories, the present study compared levels and predictors of VOL between the young-old and old-old individuals from Germany and Japan.Two hundred fifty-seven Germans and 248 Japanese, matched by age, gender, education, and IADL, answered a 5-item VOL scale and shared information on sociodemographic, social, and health resources.Germans’ VOL levels were higher than in Japanese participants. Both culture- and age-moderated predictions of VOL: education was significant only in the young-old Japanese, and close social partners mattered in the old-old, not in the young-old. Health determined VOL irrespective of culture and age.The findings suggest that cultural values and aging processes should be considered to better understand how individuals value their life and to help older adults to feel that his/her life is meaningful and worth living. Translational Significance: This study highlights the role of cultural values and aging processes in how individuals perceive their life as meaningful and worth living. We show that social status matters more among older individuals in an Eastern culture compared with those in a Western culture, and that close social partners are more important in very late life. Professional care providers and family members will benefit from these findings to improve older adults’ positive appraisals of their life.Given worldwide increase in life expectancy and exponential growth of the very old population, investigation of individuals’ perceptions of the value of their life when faced with age-associated multimorbidity and frailty is of high actuality. Culture is historically transmitted meanings  that are instantiated by practices , and individuals perceive or make sense of their life through their internalized cultural values . AccordiWhile the cross-cultural theory implies that aging is under the influence of cultural values, a life-span theory proposes age-related changes which may emerge similarly across cultures. According to the socioemotional selectivity theory , seekingThe main purpose of the study was to examine cultural and age-related variations in mean levels and predictors of VOL in old and very old adults from Western and Eastern countries. We compared data from Germany and Japan. Germany represents a country characterized by an individualist-independent culture, while Japan represents a country characterized by a collectivist-interdependent culture . BesidesThe present study addressed three hypotheses. First, given the cross-cultural theory of self-construals , we hypoSecond, we hypothesized that sociodemographic and social resources would be more important predictors for VOL in Japan than in Germany, as social status and relational harmony matter more in an interdependence-oriented culture. Further, we expected that the role of health resources for experiencing VOL would be more important to the Germans relative to the Japanese.Third, we hypothesized that prediction patterns would also differ according to age group, as individuals in different life phases are confronted with different age-related challenges, which may be similar across cultures. In line with the socioemotional selectivity theory , social This study is based on data collected in two independent studies in Germany and Japan. The German sample is a subsample of a population-based study conducted by The Japanese sample was also based on a population-based study performed by F = 18.22, p < .001, partial η2 = .04].To compare the two studies, we created a sample containing 310 pairs of German and Japanese participants matched by age, gender, education, and instrumental activities of daily living (IADL). A one-to-one matching algorithm was applied to find the closest match. Given the differences in sampling frames , we defined young-old, old-old, and oldest-old as individuals aged 65–74 years, 75–84 years, and 85 years and older, respectively. For subsequent regression analyses, we required a minimum of 103 individuals to detect medium effect sizes  with α = .05 and 1 − β = .80. We thus excluded the oldest-old individuals because the sample size was too small  for age-group specific regression analysis. After excluding participants with missing data for the key measures, the final sample included 257 German and 248 Japanese individuals. t = 4.67, p < .001; t = 3.06, p = .002; and t(217.68) = 4.40, p < .001, respectively].Whereas all the original German sample was included in the matched data set, only a subsample from the Japanese study was used due to the matching procedure. After excluding the oldest-old participants, the matched Japanese sample was younger, and had lower educational status and IADL compared with their unmatched counterparts , the overall fit indices of both models were equally acceptable and thus results indicated measurement equivalence across the two countries. Cronbach’s alpha coefficients were good .Testing the measurement equivalence of VOL across the countries, although fit indices of the configural invariance model were significantly better than those of the metric invariance model [χThe statistical analysis consisted of four steps. First, we performed chi-square tests separately for the young-old and old-old to compare the distributions of the categorical variables between the two countries and conducted 2 (country: Germany vs Japan) × 2 (age group: young-old vs old-old) ANOVAs to examine country and age differences in mean values for the continuous variables. Second, we examined correlations between variables for each country. Third, multiple hierarchical regression analyses including all predictors concurrently were performed for each country and age group. Fourth, based on Both German and Japanese samples were quite similar, and differed only with respect to a few variables, including social and health variables : a chi-sRegarding mean scores of VOL, we found a significant main effect of country and a two-way interaction between country and age group. Overall, German participants showed higher levels of VOL relative to Japanese participants. Follow-up analysis for the significant interaction effect showed that there was no age difference among the Japanese participants, whereas there was a tendency for old-old Germans to have lower VOL levels compared with the young-old Germans.r = .27, p < .001 and r = .19, p < .01, respectively), subjective health  and IADL . In terms of differences, VOL was significantly correlated with age  and education  in the German sample, and with number of children  in the Japanese sample.Comparing potential VOL predictors between the two countries, zero-order correlation patterns showed both similarities and differences . In termr = −.69 and Japan: r = −.83, ps < .001), we included only the variable “living alone” in the subsequent regression analyses, to prevent multicollinearity.Since correlations indicated a substantial overlap between living with a spouse and living alone in both countries . In both countries, parallel predictive patterns occurred, with number of children and subjective health being significant predictors with similar beta values . Differences in predictive patterns were also observed. In particular, education was a significant predictor in the Japanese sample  but not in the German sample. In contrast, social contact and IADL were significant predictors in the German sample  but not in the Japanese sample. Furthermore, despite being significant predictors in both samples, health variables explained a much higher proportion of unique variance in the German (22%) than in the Japanese sample (8%).Considering the country-specific total samples, the proportion of the variance in VOL explained in the German sample was twice as large as the variance explained in the Japanese sample . Social contact, subjective health, and IADL were significant VOL predictors in both countries . In both countries, the unique variance explained by social and health predictors were similar . One difference occurred in that education was a significant predictor in the Japanese , but not the German young-old group.Next, we concentrated on the younger participants. In both German and Japanese young-olds, the proportions of overall variance explained by the models were comparable (Germany: R2 = .41), relative to the Japanese (R2 = .17) old-old group. Substantial differences were also observed for the unique variance explained by the health variables, being more than three times larger in the Germans (27%) than in the Japanese (8%). In both countries, number of children was a significant VOL predictor, and showed comparable beta values . The predictive values of subjective health ; Japan: β = .26, p < .05) and IADL  differed between the two countries, but follow-up analyses did not confirm any significant differences in the regression coefficients (see below).When addressing the old-old group, regression models were significant in both countries, but the variance explained in VOL was much larger in the German (p < .05), validating our prior finding that education was positively associated with VOL only in the young-old Japanese (p < .01), supporting the finding that number of children was positively related in the old-old, but not in the young-old. Lastly, in terms of health predictors, no significant interaction was detected, and only the main effects of subjective health and IADL were significant , indicating that subjective health and IADL had similar effects on VOL regardless of culture and age. After including all the predictors, the interaction between country and age was not significant, but culture was still significantly associated with VOL (p < .001), which indicated that, whereas the predictors explained age differences in levels of VOL found in Germany, they did not fully explain country differences in levels of VOL.To confirm whether the regression coefficients differed significantly among the four groups , we conducted follow-up regression analyses, including the following three-way and two-way interaction terms simultaneously: predictor × country × age group, predictor × country, predictor × age group, and country × age group. For sociodemographic predictors, the interaction between education and country was significant  on the basis of the Japanese study. In addition, potential predictors explained only a much smaller amount of variance in VOL in the old-old Japanese (17%) compared with their German counterparts (41%). Since VOL was developed based on independent values such as personal autonomy, the construct could miss social aspects which are more important among the older Japanese cohorts who might more deeply internalize interdependent values. Future studies should further explore cultural meanings of well-being to understand the variation and commonality of VOL across cultures.Old and very old individuals from Germany, an independence-oriented culture, were found to perceive their life as more valuable relative to their counterparts from Japan, an interdependence-oriented culture, which may be related to the nature of the VOL construct deeply rooted in independent values such as personal autonomy. Findings further indicate both cultural and age-related variations in predictive patterns for VOL: whereas the importance of social status can vary depending on cultures, aging processes may universally influence how people value their life. However, the cultural differences were rather modest, and intersections between culture and aging were not found. Despite these results, this study suggests that cultural values deserve much more attention in studying aging processes and that professional care providers and family members will benefit from these findings to help older adults to feel that his/her life is meaningful and worth living. Clearly, more research and theory development are needed to better understand how individuals make sense of their life with advancing age across various cultures.Innovation in Aging online.Supplementary data are available at Supplementary Table 1Click here for additional data file.This work was supported by the program for promoting the enhancement of research universities from Osaka University. The German study was funded by the city council of Darmstadt, Germany , and the Japanese study was supported by Japan Society for the Promotion of Science KAKENSHI (JP21330152).None reported.


Various outcome measures are used for the assessment of balance and mobility in patients with stroke. The purpose of the present study was to examine test-retest reliability, construct validity, and responsiveness of the Timed Up and Go Test (TUG), Berg Balance Scale (BBS), and Dynamic Gait Index (DGI) for measuring balance in patients with chronic stroke.Fifty-six patients  with chronic stroke participated in this study. A senior physical therapist assessed the test-retest reliability and validity of three scales, including the DGI, TUG, and BBS over two testing sessions. In addition, the third assessment of each scale was taken at the time of discharge to determine the responsiveness of the three outcome measures.2,1] = 0.98), DGI  and BBS  were excellent. The standard error of measurement (SEM) of the TUG, DGI, and BBS were 1.16, 0.71, and 0.98, respectively. The minimal detectable change (MDC) of the TUG, DGI, and BBS were 3.2, 1.9, and 2.7, respectively. There was a significant correlation found between the DGI and BBS , TUG and BBS , and the TUG and DGI , respectively.The reliability of the TUG (intraclass correlation coefficient [ICCThe test-retest reliability of the TUG, BBS, and DGI was excellent. The DGI demonstrated slightly better responsiveness than TUG and BBS. However, the small sample size of this study limits the validity of the results. Stroke is the common cerebrovascular disease with a high mortality rate and persistent disability in adults worldwide . The preVarious outcome measures are used for the assessment of balance and mobility in patients with stroke , 11–17. Previous studies suggested that impairments in the multiple tasks balance function indicates negative outcomes for instance, increased risk of fall –23 and rTherefore, the present study aimed to compare the single-task outcome measure such as TUG test with the multiple-task outcome measures, including the BBS and DGI for measuring balance and mobility in patients with chronic stroke.Fifty-six patients with chronic stroke from the outpatient physiotherapy department were participated in the study. The inclusion criteria were as follows: first episode of stroke (more than 3 months of duration since onset), able to follow simple instructions, absence of comorbidities , and able to walk at least 10 m (assessed by the examiner to confirm the eligibility), with or without an assistive gait device. The institutional ethics committee, Rehabilitation Research Chair, King Saud University, Riyadh, Saudi Arabia, approved this study. An informed consent form was signed by each participant.A senior physical therapist administered the BBS, DGI, and TUG tests. The BBS was developed to evaluate the balance performance and determine the fall risk in the elderly . The BBSThe DGI was designed to evaluate the dynamic balance during walking . It has The TUG test is designed to measure functional mobility . The tesThe BBS, DGI, and TUG tests were administered by a single rater in two testing sessions over a period of 1 week, to assess the test-retest reliability. In addition, the third assessment of each scale was taken at the time of discharge to determine the responsiveness of the three outcome measures. The duration of the entire testing procedure was 45–60 min.2,1. The agreement between two readings of each scale was assessed using the Bland-Altman plot method [p-value of ≤0.05 was set for the statistical level of significance. All statistical analyses were done using the statistical package for the social sciences for Windows version 22 .Descriptive data, including mean and standard deviation (SD) values for each score distribution, were presented for each scale. Test-retest reliability of the TUG, total DGI scores, and BBS scores were analyzed using the ICCt method . The meat method . The stat method . The mint method . In addit method . A p-valTable Table Balance and mobility are the most important functional limitations in patients with chronic stroke . A varieIn the present study, the SEM value of TUG test was slightly higher than the total DGI scores 1.16 vs. 0.71) and the total BBS scores (1.16 vs. .98). Similarly, a previous study reported lower SEM (0.97) for the total DGI scores in patients with chronic stroke  reported vs. 0.71In the present study, a good positive correlation was found between the DGI and BBS, and a moderate negative correlation was found between the TUG and BBS. Jonsdottir and Cattaneo  reportedThe TUG, DGI, and BBS displayed a moderate degree of responsiveness from baseline to discharge, indicating they can adequately detect patients’ recovery following an intervention. However, DGI showed a better responsiveness compared to the TUG and BBS. A previous study reported an acceptable level of responsiveness of BBS at various stages of recovery in patients with stroke . AnotherGeneralization of the present results should be limited to the individuals with chronic stroke who could walk at least 10 m with or without a walking aid. Since it is not possible to score 4 points using a walking aid in DGI assessment, it becomes a 3-points scale for those participants who used such aids. This could results a better reliability of this scale. In addition, the degree of plantar flexor tone was not measured, which could affect the present results. Furthermore, lack of data about the premedical stroke history, exact stroke location and size may affect the scale interpretation. Since fewer female patients participated in this study, gender influence was not considered. However, this could have some impact on the overall responsiveness of each scale. It is recommended to examine the treatment effect on the DGI, TUG, BBS scores, muscle strength, the degree of spasticity, and gait parameters in prospective studies in patients with chronic stroke. Additionally, the small sample size limits the validity of the results. Therefore, future parametric studies are needed with larger sample size to confirm this finding and to compare these scales to one another.The test-retest reliability of the TUG, BBS, and DGI was excellent. The DGI demonstrated better responsiveness than TUG and BBS. The results of the present study support the use of these scales for measuring balance and mobility in patients with chronic stroke.


The present study examined whether and how career adaptability predicts employee well-being (EWB) based on career construction theory. A three-wave questionnaire design was used to collect the data, and 338 employees participated in the study. The results suggest that career adaptability has a significant effect on work engagement, which, in turn, predicts EWB. In addition to developing a mediation model, we tested the effect of guanxi as a moderator on the former part of the model. Thus, a moderated-mediation model was constructed in this research. In addition to the finding of the mediating role of work engagement, the discussion of guanxi represents a more important novel aspect that draws attention to contextual factors that may shape how employees respond to career adaptability. The results revealed that the indirect effect of career adaptability on EWB through work engagement when guanxi is low is stronger than that when guanxi is high. Furthermore, we discuss the limitations of this study and the implications for future research on career adaptability and EWB. Currently, the career and job landscape is characterized by ongoing uncertainty and increasing instability and flexibility . FurtherScholars often use the concepts of psychological well-being (PWB) and subjective well-being (SWB) to represent employees’ overall well-being . HoweverIn addition, adaptability is developed through the interaction between people’s inner and outer worlds. These worlds are closely related to specific roles and situations. Adaptability has been shown to have boundary conditions set by the culture environment. Prior research has primarily focused on the outcomes of career adaptability but overlooked important contextual factors. In the common workplace in China, guanxi suggests that interpersonal connections represent a stronger driver of typical relationships than rules and regulations in the Chinese culture . This stTherefore, this study contextualizes well-being in workplaces in which employees simultaneously manage work pressure and cultural-specific relationships. The aims of this study are as follows. First, we examine career adaptability as an antecedent of well-being based on CCT , 2005. CThe study makes several contributions to the literature on career adaptability and well-being. First, this study focuses specifically on well-being to address the weaknesses of previous research. In China, academic research on EWB typically focuses on non-professionals  and stilThe central goal of CCT is to obtain an understanding of how people use their work for self-improvement and to achieve satisfaction and happiness from social interaction , 2005. TCareer construction theory regards adaptability as core psychosocial resources or transactional competencies necessary for achieving adaptation goals. This theory indicates that higher levels of adaptation are expected among those who are willing (adaptive) and able (adaptability) to perform behaviors in constantly changing work environments . As an iCareer adaptability is a psychosocial construct that denotes an individual’s resources for coping with current and anticipated tasks, transitions, and traumas in their occupational roles that alter their social integration to either a large or small degree . When inHypothesis 1: Career adaptability is positively related to EWB.Adaptation is a consequence of adapting, which is defined as performing adaptive behaviors that address changing conditions . Career Work engagement, which is defined as “the positive, fulfilling and work-related state of mind that is characterized by vigor, dedication, and absorption” , refers Hypothesis 2: Work engagement mediates the relationship between career adaptability and EWB.According to the CCT, the effect of career adaptability has boundary conditions . Since tTraditional Western-based theories of supervisor-subordinate relationships tend to use the concept of leader-member exchange (LMX). This concept focuses on social exchanges in the work domain, while omitting potential exchanges that occur in the private domain. In contrast to LMX, guanxi in China mainly covers non-work exchanges within the vertical dyad, and the benefits of being involved in such exchanges can be social and economic in nature. The social exchanges embedded in guanxi are bound by personal favors, obligations, and trust . EmployeThe level of guanxi represents the strength of the environment. Situation strength theory states that an individual’s perception of a situation could modulate the effect of their individual characteristics on their behavior or cognitive expression . SituatiFurthermore, previous research has shown that such a “relationship” refers to the beneficial rewards that employees receive from their superiors , suggestHypothesis 3: Guanxi negatively moderates the relationship between career adaptability and work engagement, and thus, the positive effect is stronger when guanxi is at a low level.Hypothesis 4: The indirect effect of career adaptability on EWB via work engagement is moderated by guanxi, and thus, the indirect effect is stronger when guanxi is at a low level.Thus, we examined moderated-mediation models of the relationship among these variables as shown in This research was conducted through a survey using anonymous questionnaires. The eligible participants were full-time employees working in China at four state-owned enterprises to ensure the representativeness of the samples. After obtaining approval from the four companies, we mailed the questionnaires and e-mailed the guidelines to each company. In the guidelines, we informed the participants that their responses would remain anonymous. Based on assistance from the human resource management department of each enterprise, the questionnaires were distributed to individuals who voluntarily agreed to participate. In addition, data were collected from the employees at three time points over 2 months to minimize potential common-method biases . This stSD = 9.66), had at least a bachelor’s degree (53.8%), had 7.75 years (SD = 7.84) of organizational tenure, and had 4.98 years (SD = 5.77) of position tenure. Most participants were male (72.2%) because the participants were mostly employed at heavy industrial companies that had more male employees. The analyzes were performed using the Statistical Package for Social Sciences version 24.0  and the AMOS statistical package version 22.0 . After 4 weeks, we conducted the second wave of the survey. Internal media were used again to connect with the employees that participated during the first wave of the survey and collect information regarding work engagement and guanxi. Overall, 379 employees completed the second survey. The final wave was conducted after 1 month, and we collected information regarding EWB. Finally, after removing all incomplete, mismatched, and missing cases, 338 matched responses were available from all time points for the analyzes. In this final sample, the participants were 38.28 years old  consisting of 12 items developed and validated by The short form of the Utrecht Work Engagement Scale (UWES-9) developed and validated by The EWB scale developed and validated by Guanxi was assessed by a four-item scale developed by Because demographic backgrounds may have potential confounding effects , we usedp < 0.001; comparative fit index (CFI) = 0.901; incremental fit index (IFI) = 0.901; root mean square error of approximation (RMSEA) = 0.068; and root mean square residual (RMR) = 0.047. The results of the CFA showed that the proposed model fit the data as the normalized chi-square (chi-square/degrees of freedom) of the CFA model was lower than the recommended value of 3.0, and the values of the CFI and IFI were higher than 0.90. The RMSEA was lower than 0.08, and the RMR was lower than 0.05.We began by conducting a confirmatory factor analysis (CFA) with AMOS 22.0 to estimate the model. In the CFA analysis, the goodness of fit of our model was evaluated with a variety of fit metrics as follows: χ2/df = 2.549, The convergent validity of a model can be validated by the criteria that all average variance extracted (AVE) exceed 0.50 . Furtherr = 0.483, p < 0.01) and work engagement , which was positively correlated with EWB . Guanxi was significantly and positively related to work engagement  and EWB . In addition, several control variables were positively related to the main research variables, including a correlation between gender and guanxi  and a correlation between gender and career adaptability .The SPSS-PROCESS was used to test the hypotheses as proposed by B = 0.69, t = 12.70, p < 0.001) was a significant direct predictor of work engagement. Second, after controlling for the effects of career adaptability, work engagement had a significant effect on EWB , and career adaptability had a reduced relationship with EWB . Therefore, work engagement partially mediated career adaptability and EWB. Furthermore, by using the bootstrapping method for further calculation, we found that career adaptability had a significant indirect effect of 0.34  and a significant direct effect of 0.19  on EWB through the mediation of work engagement; these results did not include 0. These results support Hypotheses 1 and 2  was significant, supporting H3 (see Table To examine the moderation and moderated-mediation models, we used the procedure developed by B = 0.64, SE = 0.06, t = 10.48, p < 0.001. When guanxi was high, the effect was diminished, B = 0.35, SE = 0.06, t = 5.54, p < 0.001.To clearly illustrate the interaction effects, the interaction was plotted at one standard deviation below and above the mean of guanxi. As shown in Further tests of the moderated-mediation effects of guanxi using the PROCESS bootstrapping approach proposed by Using a sample of Chinese employees, this research tested whether and how career adaptability predicts work engagement and EWB. This research highlighted three main points. First, career adaptability plays a significant role in predicting work engagement and EWB. Second, work engagement plays a mediating role between career adaptability and EWB. Finally, guanxi plays a moderating role in this model. Specifically, the mediation model of career adaptability on EWB through work engagement was supported when employees experienced a low level of guanxi.The results of the current study are consistent with previous research, and this study makes several contributions to the literature. First, based on CCT, we found that career adaptability is positively related to engagement adapting and well-being adaptation. In addition, the findings supplement previous studies e.g.,  showing Second, the findings were interpreted according to Chinese social and cultural values, which supplemented the boundary condition of career adaptability research. Because of the guanxi orientation in Chinese values, Chinese employees particularly value the gain and loss of relationships . In contWe can draw some practical implications from our research results. The first set of practices concerns investment in employees. As career adaptability is gaining increasing attention in the workplace, it is necessary for supervisors to provide multiple career paths to employees, especially in China. Enhancing competence through training and providing a sense of an attractive career future contribute to the feelings of security and well-being . To achiThe second set of practices concerns the provision of engaging work. Previous analyzes of the antecedents of well-being highlighted the importance of opportunities for control, skill use, and variety at work. The third set of HR practices focuses on the creation of a positive social and physical environment. The moderating role of guanxi indicates that caution should be taken in cases in which employees exert effort to become obsequious instead of focusing on their work. Managers should address supervisor-subordinate guanxi to balance organizational incentives and employee expectations regarding employment. In cases in which adaptive employees reduce their work engagement, employers should adjust the resource availability according to their foreseeable personal contribution.This study has several limitations. First, although we investigated the variables at intervals, career adaptability, and EWB are not static, and more stringent measures should be used to consider their dynamic relationship. In future research, longitudinal designs or experiments should be designed to better establish causality.Second, we hope that researchers from other cultures can replicate our research. Then, we could consider multiple cultural factors in interpreting our results in the future. Our sample from China limits the universality of our conclusions. We believe that the relationship between superiors and subordinates in the workplace may help explain whether the pursuit of well-being interferes with the effect of guanxi.Third, control over the baseline measures of the mediator and dependent variable is lacking because of the limitations of the investigation. In future research, we aim to further improve our research design and supplement the control variables to explore the real influence of the relationship in the model. In addition, future studies could continue to focus on the influence of gender and other control variables on the research model.All procedures performed in studies involving human participants were performed in accordance with the ethical standards of the institutional and/or national research committee and the 1964 Helsinki Declaration and its later amendments or comparable ethical standards with written informed consent from all subjects. This research was approved by the Human Research Ethics Committee at School of Labor Economics, Capital University of Economics, and Business.XY and YQ designed the research and collected the data for the study. YF and YM analyzed the data and drafted the manuscript. All authors critically reviewed and approved the final version of this manuscript.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.


Coal resources play a strategic role in the long-term development of China. Large-scale mining has a considerable impact on the landscape, and it is a long-term heritage of industrialization unique to the Anthropocene. We investigated the macrozoobenthos and water in nine mining subsidence wetlands at different developmental stages (3–20 years) in North China. A total of 68 species were found, and the macrozoobenthos community in the newly formed wetlands showed high diversity. We believe that this high diversity is not random; rather, the high diversity was because of the special origin and development of the wetland. We used three time slices from the timeline of the development of the newly formed wetlands and compared them. It was found that the macrozoobenthos community was significantly affected by the change in the subsidence history. We emphasize that coal mining subsidence should not be merely identified as secondary man-made disasters, as they are often secondary habitats with high conservation value, and their conservation potential lies in the fact that these secondary habitats can replace rapidly decreasing natural wetlands. Coal resources play a strategic role in the long-term development of China. The rapid development of the social economy has resulted in an increased demand for energy. Thus, coal mining activities have become more intense. In 2014, coal production reached 38.7 billion tons, accounting for 49% of the world’s gross domestic product ; of this, more than 92% of the coal comes from underground mining, which leads to serious surface subsidence. It has been estimated that when 10,000 tons of coal is mined underground, the settlement area spans 0.20–0.33 hectares. In China, the annual subsidence is expected to increase by 2,104 ha . High grIn stark contrast to valuable habitats such as natural wetlands, coal mining subsidence often reforms the environment, greatly limiting environmental recovery. In this case, it is impossible to maintain the original environmental attributes or to maintain the native species pools, which means that the succession process of the organism basically starts from an initial (or primitive) stage . HoweverMacrozoobenthos, as a potentially important driver of metabolism in freshwater ecosystems, have traditionally been considered a food source for benthic fish and consumers of algae and organic matter . SpecifiIt is generally assumed that the degree of anthropogenic influence is negatively correlated with the health of the macrozoobenthos community. In industrial and post-mining areas, the lower biodiversity is assumed to be related to the surrounding natural habitats . Man-madFor some species, post-mining habitats are the only suitable habitat within a vast area . It has Phragmites australis and Typha angustifolia. The main land-use pattern around the wetland is farmland. The crops are dominated by corn in summer and autumn and by wheat the rest of the year.The study area is located in Yanzhou City , Shandong Province, which is an important coal production base in China . ShandonNewly formed wetlands without anthropogenic interference were the main focus in the current study, and nine wetlands with subsidence periods between 2 and 20 years were selected as targets . We diviPhragmites australis and T. angustifolia, and no fish distributions were found in the wetlands during the study period.IS. In the early stage of the formation of fresh wetlands, the wetland area is small, the environment is fragile, and the water depth is shallow (<1 m). The wetland water volume is greatly affected by precipitation. In years with long-term drought, dryness will occur. The aquatic plants are mainly Phragmites australis and T. angustifolia, and a small amount of fish were found during the research period .MS. Due to the continuous subsidence of the Earth’s surface, the newly developed wetland is in a dynamic and repetitive developmental stage. After nearly 10 years of development, the area becomes enlarged, and the water depth increases (one to two m). The main aquatic plants are Phragmites australis community and T. angustifolia community, is present. Both of these are single-species communities, reducing the diversity of vegetation composition. The surface sediment contains a large amount of organic detritus, and four fish species were found in these wetlands during the study .LS. In MSWs with a subsidence time of approximately 20 years, the subsidence process ends and the wetland area is further expanded to form a subsidence lake with a maximum depth of five m. Additionally, broad coastal vegetation, composed of The three subsidence time phases correspond to the three developmental stages of the new wetland:The samplings were conducted in October 2016 (autumn), January 2017 (winter), April 2017 (spring) and July 2017 (summer). Environmental variables were collected in parallel in April and July 2017 .We established three sites in each MSW, with the average water depth ranging from 0.4 to 1.5 m. The bottoms of the sites were mainly characterized by sediments. Samples were collected three times from each site  using a 1/40 Peterson grab sampler and then combined as one sample. The total amount of sampling effort was equal at all sites. The collected samples were sorted using a 250-μm pore size mesh, placed in a sealed bag, and stored in 7% buffered formalin. The collected samples were classified under the microscope and identified to the lowest possible classification unit. Mollusca and Oligochaeta were identified to species level, and taxa that could not be identified to species level  were identified to morphospecies. The identification data used were mainly those described by a (Chl-a) were measured in the laboratory according to APHA (2012).The physicochemical parameters of the surface water, including dissolved oxygen (DO), water temperature (WT), total dissolved solids (TDS), salinity , oxidation reduction potential (ORP), and pH, were measured using the calibrated Manta™ 2 Multiparameter System . A vertically integrated water sample was also collected and placed in an acid-cleaned plastic container with a volume of five L. The total nitrogen (TN), total phosphorus (TP), and chlorophyll-According to the food source and feeding mechanism , macrozoH′) using the Excel and Biodiversity tools. SPSS was used for statistical analysis.We calculated the macroinvertebrate Shannon–Wiener diversity index (H′):Pi is the proportion of the total sample represented by genus (S) i.Shannon–Wiener diversity index  were explained by canonical correspondence analysis (CCA) (x+1)) before analysis. Both analyses were based on the Bray–Curtis similarity index of the relative abundance and environmental data (pH excluded) after the log(x+1) transformation. The rare taxa (<1%) were removed before analysis. The significance of the influence of each environmental factor on the community composition was analyzed with a Monte Carlo test, and the contribution of the Bonferroni correction was based on the conditional effect of the CCA result.First, permutational multivariate analysis of variance was used to determine the effects of subsidence time on the community composition of macrozoobenthos (999 permutations). The relationships between the macrozoobenthos community and the environmental factors  . Each enH′ of the macrozoobenthos communities, as well as on the richness and the relative abundance of the four FFGs and the major dominant taxa. Data were log(x+1) transformed when they were abnormally distributed. When significant differences were identified from the GLMs, post hoc analysis was conducted for multiple comparisons by Tukey’s honestly significant difference test. Before the analyses, the richness, density, biomass, and H′ were averaged from three ponds and then averaged from the four sampling seasons. Additionally, the seasonal dynamics of the richness, density, biomass, and H’ of the macrozoobenthos communities from the three stages were also analyzed.Second, general linear models (GLMs) were used to test the subsidence time on the total richness, density, biomass, and A total of 108 samples, including 68 taxa of macrozoobenthos and 15,332 individuals, were collected in the current study (see Appendix). The main group was aquatic insects, including 48 species, followed by molluscs (14 species). Furthermore, Chironomidae dominated all the sites and was the most taxonomically rich family (24 species).F = 8.1114, P < 0.001), significant differences were found between IS and LS and between MS and LS , while there was no significant difference between IS and MS .Permutational multivariate analysis of variance showed that the community composition of the macrozoobenthos in the MSWs varied significantly with the time of subsidence ; all three of them were highest in MS. Significant changes in richness and H′ were recorded in LS (P < 0.05). Significant changes in biomass were recorded only in MS (P < 0.05). The density was not significantly affected by the subsidence time , which showed a tendency to decrease as the subsidence time increased (P > 0.05).ANOVA showed that  the richF = 7.636, P < 0.01; F = 17.856, P < 0.001; F = 6.812, P < 0.001, respectively) in the MSWs varied significantly with the time of subsidence, and GC  in the MSWs was not significantly affected by the subsidence time. The highest richness of the four FFGs was recorded in the MS, and the lowest in the LS.ANOVA showed  that theF = 5.623, P < 0.01; F = 3.325, P < 0.05; F = 6.051, P < 0.01, respectively) in the MSWs varied significantly with the time of subsidence, and PR  in the MSWs was not significantly affected by the subsidence time. Significant changes in both GC and SH were recorded in LS (P < 0.05). Significant changes in SC occurred only between MS and LS, where relative densities in MS were significantly higher than those in LS.The relative densities of GC, SH, and SC , whereas there was no significant difference in H′ . However, the richness and density in MS and IS showed apparent seasonal variations (P < 0.05), which was different from the results of LS. The lowest richness and densities in IS and MS were recorded in summer. Significant changes in biomass were recorded only in MS, and the highest biomass was recorded in spring.The results of the GLMs  showed sF = 2.000, P < 0.01)  . The eigSome specific secondary habitats (such as MSWs) can provide enormous biodiversity conservation potential . In thisIn post-mining areas, there could be high heterogeneity in secondary habitats compared with the surrounding landscapes . TherefoThe macrozoobenthos of the MSWs are composed of ubiquitous species, and most species prefer natural habitats at low altitudes. However, massive natural habitats are disappearing due to urban expansion . TherefoAlthough we were unable to immediately measure the macrozoobenthos after the formation of new wetlands in coal mining subsidence areas, the rapid colonization of macrozoobenthos in the MSWs was predictable because this phenomenon is very common in newly created ponds . In factT. angustifolia community and Phragmites australis community), and constitutes a barrier to many species. This finding confirms those of In our study, the diversity of macrozoobenthos increased during the succession period from IS to MS, while the diversity of LS was significantly lower than that of the first two stages. Therefore, another question surfaced from these results: Why does the biodiversity of macrozoobenthos in MSWs decrease over time? One possible explanation is that the elderly wetlands had not yet been colonized by some taxa. The early colonists are usually too generalist to be affected by certain habitat attributes , and somIn our study, the macrozoobenthos communities of the IS and MS were significantly affected by seasonal variation, while the community of the LS was not. This result suggested that the newer subsidence wetlands showed significantly seasonal dynamics, possibly because the ecosystem was less stable. For the LS, which had broad coastal vegetation, the area and depth of water was great enough to enhance strong adaptability to seasonal environmental variations. A change in water quantity is one major factor that affects the seasonal variation of the macrozoobenthos community . BecauseThe high biodiversity of water bodies is because individual ponds usually support different communities , even inPolypedilum sp. increased with increasing DO of the water, while Bellamya purificata was negatively related to the DO of the water  habitats across a broad spectrum of succession stages. These special secondary habitats have been strengthened due to the decreasing natural habitats. Therefore, secondary habitat geography should be an integral part of nature conservation. We should not only protect secondary habitats but also protect their continuous succession process.10.7717/peerj.6456/supp-1Supplemental Information 1Click here for additional data file.10.7717/peerj.6456/supp-2Supplemental Information 2Click here for additional data file.