This study aimed to analyze spatio-temporal changes in habitat quality in Guizhou Province during the 1990–2018 period and identify factors influencing habitat quality. Land-use data for the period were used to evaluate spatio-temporal variations in habitat quality using the InVEST model, and factors influencing habitat quality were analyzed using GeoDetector. According to the results, cultivated land and forestland decreased by 0.48% and 0.88%, respectively, during the study period. Grassland, water, and construction land areas increased, with construction land increasing the most (0.92%) followed by water area (0.37%). The main land-use changes included conversion of cultivated land to forestland, grassland, and construction land. The average habitat quality index for Guizhou Province changed from 0.633 to 0.627 over the 1990–2018 period, showing an overall downward trend. The distribution pattern of habitat quality was spatially "high in the north, south, and, east, and low in the west". The most significant improvement of habitat quality was in the western region, whereas the most significant decline of habitat quality was in the central region. Land-use was the major factor influencing the spatio-temporal variations in habitat quality, and the interactive effect between any two factors was stronger than that of a single factor. Natural factors and human factors co-dominated the temporal-spatial changes in habitat quality. HQ reflects the suitability of an environment for human survival, reproduction, and productivity2. In addition , it is a key indicator of ecological health, which is essential for human well-being4. Land is the carrier of habitat and land-use change is a primary manifestation of the impact of human activities on the land surface, including changes in proportions, structure, and intensity of land-use. Land-use changes fundamentally alter HQ and the composition and structure of ecosystems, which affects energy flow and nutrient cycling between habitat patches6. The increase in land-use changes and structure has led to habitat fragmentation, degradation or even habitat loss, in turn, resulting in a continuous decline in HQ7.Habitat quality (HQ) refers to the ability of an ecosystem to provide suitable conditions for the survival of organisms, and is a prerequisite and basis for ecosystem functions and services8. Generally, methods for assessing HQ at the landscape scale fall into two categories9. The first assessment method is based on field surveys and is mostly applicable at small scales. The survey-based assessment method is time-consuming, laborious, and obtaining long-term species data is a challenge, often unable to assess the spatio-temporal dynamics of biodiversity10. The second assessment method is based on ecological assessment models, such as the habitat suitability index (HIS) model11, integrated valuation of ecosystem services and trade-offs (InVEST) model6, and social values for ecosystem services (SolVES) model12 to assess regional HQ. Among these models, the InVEST model is currently the most developed and extensively applied ecological function assessment model13. InVEST model is a geographic information system-based model that can rapidly evaluate the impact of various land-use changes and threats to biodiversity3. The results obtained by the InVEST model are more spatially visualized14 and can reflect the distribution of habitats and their degradation in different landscape types. The InVEST model has recently been used to evaluate the impact of land use and land cover (LULC) changes and protection tactics on habitats to sustain biodiversity15. Existing studies have mainly assessed HQ in mountainous areas16, watersheds17, nature reserves18, counties4, urban agglomerations8, and provinces19. However, most studies at the provincial scale have focused on the spatio-temporal evolutionary characteristics of HQ21, with few studies investigating the factors influencing HQ.HQ is a significant foundation for ecosystem service capacity and biodiversity maintenance22. High quality habitats support a rich biodiversity, whereas low quality habitats denote poor biodiversity23. In recent years, HQ changes based on LULC changes have been extensively studied25. For example, the expansion of urban areas has severely damaged natural habitats, leading to biodiversity loss27. In addition, natural factors  and land-use types substantially influence HQ changes29. Therefore, determining factors that influence HQ could provide basic information for biodiversity maintenance, improvement of the ecological environment, and enhancement of ecosystem services and functions30. Although previous research has focused on the spatiotemporal evolution characteristics and influencing influencing HQ, further studies regarding the subject are required. The main methods used to explore the factors influencing HQ include correlation analysis31, ordinary least squares model (OLS) and geographically weighted regression model (GWR)32 model, GeoDetector33, and other statistical models. However, correlation analysis, OLS and GWR cannot explore the effects mechanism of multiple factors on the spatial pattern of HQ. GeoDetector is a widely used spatial analysis tool that can explore the heterogeneity and explanatory power of various factors in space34, and is widely used in geography and environmental science. Guizhou Province is an important ecological barrier in the upper reaches of the Yangtze and Pearl Rivers and is crucial to the sustainable development of the Yangtze River Basin. However, few studies have investigated HQ and factors influencing HQ in Guizhou Province.HQ is the ability of an ecosystem to support species survivalGuizhou Province is the transportation hub of southwest China and an important part of the Yangtze River Economic Belt. With the rapid development of the economy, various land types have undergone drastic changes, and environmental problems have become increasingly prominent. Moreover, Guizhou Province is one of the first national ecological civilization pilot areas. To effectively implement ecological strategies and accelerate the development of early demonstration zones of ecological civilization, it is crucial to explore the variations in spatio-temporal patterns of HQ. Therefore, this study used the InVEST-HQ model to (1) analyze the spatio-temporal changes in HQ in Guizhou Province during the 1990–2018 period, (2) assess the evolutionary patterns of regional HQ, and (3) identify the factors influencing spatial changes in HQ using the GeoDetector. The results could guide future planning and development of ecological environments, in addition to promoting the development of ecological civilization.5 km2. Guizhou Province belongs to the low-latitude zone and experiences a subtropical humid monsoon climate with abundant annual precipitation of 1000–1400 mm and relative humidity is above 70%. The annual average temperature is 15 °C. Guizhou is a unique mountainous province in China without plains, more than 90% of the total area is occupied by mountains or hills with the altitudes ranging from 143 to 2889 m. The complex topography and climate contribute to the diversity of land-use types. The study area has nine municipalities and is quite underdeveloped. The population pressure is generally high, with the province having a population of more than 36 million population in 2019. Majority of the residents are poor and live in poverty in remote mountain villages . Guizhou Province is a relatively unique regional environment unit, where over 60% of the total area is covered by an outcrop carbonate karst. The unique geological structure makes the area a vulnerable ecosystem.Guizhou Province, which is located in the hinterland of southwest China   and the spatial resolution was 30 m × 30 m35. The land-use data included six primary land-use types and 20 secondary land-use types  data was acquired from the Geospatial Data Cloud with a resolution of 30 m (http://www.gscloud.cn/) using ASTER global DEM (v2). Slope and elevation were acquired from DEM data. Temperature, precipitation, net primary productivity (NPP), normalized difference vegetation index (NDVI), population density, and gross domestic product (GDP) data were obtained from the Data Center for Resources and Environmental Sciences of the Chinese Academy of Sciences at a resolution of 1 km × 1 km.Land-use data for 1990, 2000, 2010, and 2018 were obtained from the Data Center for Resources and Environmental Sciences of the Chinese Academy of Sciences  comprises a monthly vegetation index dataset generated since 1998 based on the SPOT-VEGETATION NDVI satellite remote sensing data of continuous time series and the maximum synthesis method. GDP dataset, which is based on the national GDP data of a county, describes the spatial relationships among land-use type, night lighting brightness, settlement density data closely associated with human activities and GDP, and generates spatial grid data through spatial interpolation. The spatial distribution data for population density is basically consistent with GDP. NPP is the fixed energy or organic matter produced per unit area and time left after a green plant respires, and is based on simulations of the light energy utilization model, GLO-PEM. In addition, due to the availability of data, NPP, temperature, precipitation, and population density data were from 2015; while GDP and NDVI data were from 2018.38. To determine land-use and HQ changes in Guizhou Province over the 1980–2018 period, growth map, decrease map, and HQ grade transfer map of land-use changes for the period were obtained using the following formula40:Geographical Atlas analysis can simultaneously express the spatial dynamic changes in landscape structure over time, as well as synthesizing land-use changes and HQ patterns by mapping land-use and HQ25. The assessment depended on the distance and intensity of habitat and non-habitat land-use. HQ was reflected by the HQ index that was calculated as follows22:xj denotes the HQ of pixel x in land-use type j, Dxj is the threat level of pixel x in land-use type j, Hj is the habitat suitability of land-use type j, and k is half the saturation constant .R denotes the number of stress factors, Yr is the total number of grid cells of stress factors, ωr is weight of the stress factor, ry is the number of stress factors in a grid cell, βx is the accessibility level of grid x, Sjr is the sensitivity of land-use type j to stress factors, with a value range of 0–1, and irxy is the maximum distance of influence of the stress factors.dxy denotes the distance between grid x and y, and drmax is the maximum impact scope of the threat factor r.The InVEST-HQ model was used to assess HQ of Guizhou Province, which was estimated based on information regarding LULC changes and biodiversity threats41, where 1 represents the highest suitability. Construction land reflects the threat to biodiversity threat posed by human activities. As a semi-natural and semi-artificial ecosystem, cultivated land has a negative impact on the natural environment42. Therefore, construction and cultivated lands were used as threat factors. Considering that the study area is a typical karst landform, predominantly a mountainous and hilly plateau with scattered rural settlements, construction land was converted to urban construction land, rural settlements, and other types of land-use. Based on the model manual22 and literature review44, the relative weight of threat factors, the maximum distance between habitats and each threat source, and the habitat sensitivity of each threat were determined , required to run the InVEST-HQ model include multiple-date LULC maps, threat sources and impacts, habitat types, habitat sensitivity to the threats, and the half-saturation constant. InVEST-HQ model finally generates an HQ map with values ranging from 0 to 1d Tables .Table 2T45. Spatial autocorrelation refers to the degree to which an attribute of a geographical location is related to different spatial locations, and can be used to describe whether HQ has a clustering effect over the entire area, with a value range of 46. Global Moran’s I was calculated using the following formula:i and yj are the habitat quality indices for i and j study areas; wij is the spatial weight coefficient matrix of regions i and j, which reflects the spatial relationship between regions i and j, and is defined as wij = 1 or otherwise wij = 0; and E(I) and VAR(I) represent the expected value and variance of the global Moran’s index y, respectively.Global Moran’s I is a measure of spatial autocorrelation proposed by Patrick Moran47. A significantly positive G* value shows HQ is a clustering of high values, which is a hot spot, whereas a significantly negative G* value shows HQ is a clustering of low values, which is a cold spot48. The G*value was calculated using the following formula:Hot spot analysis is a method of evaluating the distribution of clusters in local areas and can be used to indicate whether there are statistically significant high and low values in the spatial distribution pattern of HQ49. We analyzed the extent to which factors influence spatial variations in HQ using factor and interaction detectors. The factor detector is typically used to measure the extent to which each factor is associated with spatial variation in HQ while the interaction detector is used to measure the interaction between two factors. The magnitude of the divergence is determined by the q-value of the GeoDetector, which is calculated using the following formula50:h and N are the numbers of cells in stratum h and the entire area, respectively; σn2 and σ2 are the variances of HQ in stratum h and the entire area, respectively.GeoDetector is a statistical tool used for detecting spatially stratified heterogeneity and revealing the factors associated with it. The GeoDetector has four main components: divergence and factor detection, interaction detection, risk zone detection, and ecological detection, which are mainly used to analyze the factors influencing various phenomena and the interactions among multiple factors50.Interaction detection focuses on determining the interaction between various factors and assessing whether multiple factors acting together increase or decrease the driving power of HQ or whether there is no interaction between the factors Table 50.Table The study area was sampled based on a 5 km × 5 km grid using ArcGIS 10.7 and a total of 7036 evaluation units were obtained. The factors influencing HQ were divided into natural and human factors, where natural factors included elevation (X1), slope (X2), temperature (X3), rainfall (X4), NPP (X5), NDVI (X6), whereas human factors included population density (X7), GDP (X8), and land-use type (X9). The HQ index was the dependent variable and the factors influencing HQ were the independent variables. In addition, the natural breakpoint method of ArcGIS 10.7 was used to discretize and classify each factor, and correlation results were calculated using the GeoDetector.From 1990 to 2018, substantial changes in land-use patterns occurred in Guizhou Province and forestland, cultivated land, and grassland were the main land-use types Table . Grassla2, which was sporadically distributed across the province; forestland was transformed into grassland 4707.10 km2, which was largely distributed in the central and western regions; grassland was transformed into forestland 3810.20 km2, which was distributed in the western region; other land-use types were converted to construction land 1664.16 km2, which was distributed in the central region of the study area. Specifically, the conversion of cultivated land during the 1990–2018 period was the most notable land-use change, with 1357.50, 218.67, and 968.39 km2 of cultivated land area being converted to grassland, water, and construction land, respectively. A total of 3526.27km2, 337.85km2, and 371.26 km2 of forestland were transformed into cultivated land, water and construction land, respectively. A total of 1689.22, 130.14, and 321.57 km2 were transformed into cultivated land, water, and construction land, respectively , moderately low (0.2–0.4), medium (0.4–0.6), moderately high (0.6–0.8), and high (0.8–1.0). The habitat areas and percentages of each grade over the four periods are summarized in Table From a spatial scale Fig. . HQ for Based on temporal changes, the proportion of low HQ areas decreased by 0.66% (from 6.88 to 6.22%) over the 1990–2018 period; the proportions of both moderately low and medium HQ areas increased by 0.95% (from 10.73% to 11.32%) and 0.28% (34.88% to 35.16%), respectively. The proportions of moderately high and high quality habitat areas decreased by 0.18% (from 21.75 to 21.57%) and 0.03% (from 25.75 to 25.72%), respectively, during the study period (Table Overall, the average HQ indices for Guizhou Province in 1990, 2000, 2010, and 2018 were 0.633, 0.629, 0.630, and 0.627, respectively, indicating that the HQ declined slightly over the period. HQ initially decreased, then increased, and eventually decreased. The overall habitat change in Guizhou Province was negligible due to the relatively stable proportions of forestland, grassland, and cultivated land that make up the landscape patch of the province. The percentage decreases in HQ over the 1990–2000, 2000–2010, and 2010–2018 periods were 0.63%, 0.15%, and 0.47%, respectively.To gain insight into the spatial and temporal characteristics of HQ, ArcGIS was used to generate a map showing the spatial variations in HQ in Guizhou Province from 1900 to 2018 Fig. . HQ remaSpatial variations in HQ of Guizhou Province were assessed by performing global Moran’s I statistical test and hot spot analysis. To begin with, global Moran’s I statistic was used to examined the distribution of HQ in Guizhou Province. Global Moran’s I values of HQ in 1990, 2000, 2010, and 2018 were 0.210, 0.206, 0.203, and 0.213, respectively, and P values were 0. The results indicate that HQ had significant spatial agglomeration. An increase in the global Moran's I value in 2018 indicated an increase in the spatial clustering of HQ. Subsequently, hot spot analysis was performed to detect local agglomeration and distribution characteristics of HQ. We analyzed data for 2018 owing to the slight variations in the spatial distribution patterns of HQ during the 1990–2018 period Fig. . The ove51. Human activities have altered the spatial patterns of land-use, thereby resulting in habitat change and biodiversity loss. To better understand the impact of land-use change on HQ, the mean values of HQ indices for different land-use types in Guizhou Province in 1990, 2000, 2010, and 2018 were analyzed (Fig. Land-use has a significant impact on regional HQ and changes in land-use lead to changes in HQzed Fig. .Figure 6HQ indices for the different land-use types varied over the four study periods. During the 1990–2018 period, forestland had the highest average HQ index, followed by grassland and water, and the lowest average HQ value was observed in construction land. HQ indices of forestland, cultivated land, and unused land did not exhibit significant variations; however, the HQ index of water initially increased and then decreased. The HQ indices of grassland, cultivated land, and water remained unchanged from 1990 to 2000, while those of forestland and cultivated land exhibited a decreasing trend from 2000 to 2010. The HQ indices of cultivated land and forestland improved and exhibited an increasing trend from 2010 to 2018, whereas those of grassland and water decreased. With the increase in population, the demand for land is likely to increase accordingly, and more forestland and grassland will be cleared for cultivation, as well as the conversion of large areas of cultivated land to construction land. Therefore, HQ indices of various LULC are affected by human activities. However, the implementation of active interventions, such as restoration of forestland and grassland and relevant environmental conversation activities, has led to a decline in habitat degradation of land-use types disturbed by anthropogenic factors has declined and improved HQ. The HQ index of forestland over the 1990–2018 period remained above 0.73, which could be because the forestland in Guizhou Province is mainly distributed in high altitude and sloping areas. Furthermore, mountainous areas are not conducive to activities, such as cultivation and construction land development. Although the HQ index of forestland remained high during the 1990–2018 period, the total forestland area decreased, which is attributed to the considerable degradation of forestland through its conversion to cultivated and construction land. However, topographic conditions of forestland limit human activities and the high vegetation cover makes it more resistant to disturbances. HQ has been maintained at a high level due to the implementation of various ecological conservation activities and restoration practices.GeoDetector analysis results Table  revealedThe interaction detector of the GeoDetector was used to test the explanatory power of two-factor interactions on HQ and the results Table  indicateThe present study assessed the spatio-temporal changes in HQ of Guizhou Province from 1990 to 2018 and factors influencing HQ using the HQ module of the InVEST model and GeoDetector. The research has significant implications for biodiversity conservation and the construction of ecological civilization in karst regions.52. The results of the present study have shown that land-use has changed considerably over the last few decades, with cultivated land, grassland, and forestland being the predominant land-use types in Guizhou Province. The results of the present study revealed that cultivated land and forestland areas decreased during the 1990–2018 period, while construction land area increased with increasing economic development and urban expansion, which explains the decline in HQ in Guizhou Province. Moreover, the development of rural infrastructure has accelerated due to the revitalization of the countryside and tourism, in turn, promoting sustainable development of the regions in Guizhou Province. These projects have provided favorable conditions for addressing poverty in rural regions, although they have also had considerable negative impacts on the ecosystem, leading to a reduction in HQ. The average HQ index of Guizhou Province during the 1990–2018 period decreased slightly and was characterized by an initial decrease, followed by an increase, and then a decrease. However, the implementation of a range of restoration and protection measures, such as returning cultivated land to forestland and grassland and rocky desertification treatment, have substantially enhanced the ecological environment in Guizhou Province. The increase in population, economic development, and urbanization during the 1990–2018 period has led to an increase in construction land area by nearly four times. The expansion of construction land has created new sources of threats, disturbed and destroyed the surrounding habitats, leading to a decline in HQ.The essence of land-use transformation is to change the form of land-use during socio-economic development. The primary cause of land-use transformation is the change in land-use types leaded by human activities on natural ecosystems53. According to the interaction detection results, n atural and socio-economic factors had a substantial effect on the spatio-temporal variations in HQ of the study area. The interaction between factors enhanced the effect on HQ, indicating that two-factor interaction effect was greater than that of a single factor. The interactive effect between land-use and other factors was considerably stronger than that between other factors, indicating that land-use is a major factor influencing HQ changes.The dominant factor influencing HQ during the study period was land-use type, as determined by single factor detection. Land-use type is a key factor determining regional HQ, and land-use types determine the distribution patterns of various ecosystems, especially the occupation of ecological spaces by construction land, which accelerates landscape fragmentation and leads to a decline in HQ. Followed by NDVI index, which exhibits a strong influence on HQ, and is a key parameter that reflects vegetation growth status and cover. NDVI is closely associated with HQThe InVEST-HQ model was used in this study to provide a feasible method for the quantification of HQ and visualization of the calculated results. However, our study had some limitations. First, the results of regional-scale analysis can only be used as a reference for the relationship between LULC changes and variations in HQ in Guizhou Province. However, specific conservation measures need to be studied on a more comprehensive scale. Second, the InVEST-HQ model requires several parameters, and the relevant parameters used in this study were obtained from the model manual, previous studies, and expert experience that are associated with a certain degree of subjectivity in the parameter settings, which could lead to uncertainty in the evaluated results. Final, inconsistencies in data accuracy, which result in certain deviations in factor extraction when using fishnet sampling, may have led to deviations in the driving force results obtained using the GeoDetector model.The main land-use types in Guizhou Province during the 1990–2018 period were forestland, cultivated land, and grassland. Cultivated land and forestland decreased by − 98.27% and − 98.37%, respectively, while grassland, construction land, and water increased by 100.41%, 398.71%, and 264.21%, respectively; unused land was relatively stable.The average HQ index of Guizhou Province during the 1990–2018 period initially decreased, then increased, and eventually decreased. The spatial distribution of hot and cold spots associated with HQ showed a pattern of "high in the south and east, low in the central and west, and high and low in the north".Single and interactive factor detection using the GeoDetector showed that the major factor influencing HQ changes was LULC, followed by natural factors, such as NDVI and slope. Socio-economic factors such as population density and GDP were minor factors influencing HQ changes .The present study investigated the spatio-temporal variations in HQ and factors influencing HQ changes in Guizhou Province, using the InVEST-HQ model and GeoDetector. The main conclusions are as follows:Supplementary Information 1.Supplementary Information 2.Supplementary Information 3.Supplementary Information 4.Supplementary Information 5.


Objective: To explore the risk factors of postpartum hemorrhage (PPH) in patients with pernicious placenta previa (PPP) and to develop and validate a clinical and imaging-based predictive model.Methods: A retrospective analysis was conducted on patients diagnosed surgically and pathologically with PPP between January 2018 and June 2022. All patients underwent PPP magnetic resonance imaging (MRI) and ultrasound scoring in the second trimester and before delivery, and were categorized into two groups according to PPH occurrence. The total imaging score and sub-item prediction models of the MRI risk score/ultrasound score were used to construct Models A and B/Models C and D. Models E and F were the total scores of the MRI combined with the ultrasound risk and sub-item prediction model scores. Model G was based on the subscores of MRI and ultrasound with the introduction of clinical data. Univariate logistic regression analysis and the logical least absolute shrinkage and selection operator (LASSO) model were used to construct models. The receiver operating characteristic curve andision curve analysis (DCA) were drawn, and the model with the strongest predictive ability and the best clinical effect was selected to construct a nomogram. Internal sampling was used to verify the prediction model’s consistency.Results: 158 patients were included and the predictive power and clinical benefit of Models B and D were better than those of Models A and C. The results of the area under the curve of Models B, D, E, F, and G showed that Model G was the best, which could reach 0.93. Compared with Model F, age, vaginal hemorrhage during pregnancy, and amniotic fluid volume were independent risk factors for PPH in patients with PPP (p < 0.05). We plotted the DCA of Models B, D, E, F, and G, which showed that Model G had better clinical benefits and that the slope of the calibration curve of Model G was approximately 45°.Conclusion: LASSO regression nomogram based on clinical risk factors and multiple conventional ultrasound plus MRI signs has a certain guiding significance for the personalized prediction of PPH in patients with PPP before delivery. The concept of pernicious placenta previa (PPP) was first proposed by Chattopadhyay et al., 1993 . Due to Ultrasound and magnetic resonance imaging (MRI) are commonly used in prenatal diagnosis; however, some controversies still exist in the diagnostic results and accuracy of the two methods . UltrasoMagnetic resonance imaging (MRI) is a multi-planar imaging technique where the signal generated by the resonance of the nucleus in a strong magnetic field is reconstructed. It has the characteristics of no angle limitation, high soft tissue resolution, large field of view, and it is less influenced by placental position, intestinal gas, maternal body size, and other factors. Therefore, it can clearly show the placenta’s shape and position in the case of oligohydramnios or the placenta located in the posterior wall of the uterus. Particularly, it can clearly visualize the uterine-placenta interface, placenta and muscular layer, parametrical tissue, and adjacent pelvic organs . In addipostpartum hemorrhage (PPH)  . It has ge (PPH) .Accurate prenatal diagnosis and assessment of the degree and extent of placenta accreta in PPP are crucial for selecting obstetric surgery, particularly for preventing the risk of massive hemorrhage during surgery. Therefore, to improve the evaluation rate of intraoperative hemorrhage in patients with PPP, this study proposes to construct a clinical prediction model based on the clinical risk factors of PPP combined with preoperative ultrasound and MRI examination to predict the risk of intraoperative hemorrhage. Through the intuitive, concise, and convenient expression of the nomogram, the possibility of hemorrhage during PPP can be predicted as early as possible, which can effectively ensure the safety of mother and child, avoid excessive medical treatment, allow complete preparation before surgery, and prevent adverse events.This retrospective study was performed in accordance with thelaration of Helsinki and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. Ethics approval was granted by the Human Research Ethics Committee at the Shengjing Hospital of China Medical University (Ethics Code: 2022PS132K).A retrospective cohort from January 2018 to June 2022 was developed in Shengjing Hospital of China Medical University. All patients were suspected of having PPP due to routine ultrasound examination during pregnancy and received MRI scoring of PPP in the second trimester and ultrasound examination and scoring before delivery. The exclusion criteria were : gestatiColor-Doppler ultrasound examination was performed using the GE Voluson E8/E10. The frequency of the probe was set at 3.6–5.0 MHz. Next, the patient was placed in a supine position with full bladder, and the abdomen was continuously examined. Subsequently, the fetus and other structures were carefully observed. According to the PPP ultrasound scale, the review signs including the location of the placenta, placental thickness, continuity of the clear space, bladder line, placental lacunae, condition of subplacental vascularity, and cervical morphology in the cervical sinus, and also the number of previous cesarean delivery were evaluated . TransvaA Philips Ingenia 3.0 T superconducting magnetic resonance imager  equipped with 4- and 8-channel body-phased coils and a built-in 3T MR system was used in this study. Scanning the patient with a full bladder ensured that the bladder floor and walls could be more clearly presented. The patients entered the scanner bore feet first and in the supine or lateral position. Magnetization-prepared turbo field echo (T1-TFE), turbo spin echo (T2-TSE), and T2-TSE-SPectral Attenuated Inversion Recovery (SPAIR) sequences were selected to perform coronal, sagittal, and axial scans, respectively. T1-TFE sequence parameters were: repetition time (TR) 10.13 m, echo time (TE) 2.30 m, slice thickness 8 mm, and pitch 1 mm; T2-TSE sequence parameters were: TR 1100 m, TE 75 m, slice thickness 8 mm, pitch 1 mm, a field of view (FOV) 450 × 398 mm, and matrix 312 × 241. T2-TSE-SPAIR was used for fat suppression .The diagnosis of PPP was based on the comprehensive diagnosis of surgery and pathology. Surgical criteria included having a previous cesarean section, placenta previa pregnancy, the placenta attached to the original uterine scar, placental thickening, and difficulty in manually removing the placenta after delivery. There were multiple “placental lacunae” in different shapes and sizes in the placenta, and uterine hemorrhage was uncontrollable. Pathological diagnosis was defined as abnormal adhesion of the placenta to the myometrium or chorionic tissue in the smooth muscle of the uterus.The clinical data of patients with suspected PPP were collected through the Hospital Information System, including the patient’s age, neonatal weight, gestational age, and parity. Using a picture archiving and communication system (PACS), the MRI and ultrasound images in the second trimester and before delivery, respectively, were reviewed by two experienced radiologists/sonographers (PW and LZ) independently, and the images were scored according to the MRI and ultrasound risk scores. When there was disagreement, a third physician participated (TW) in the discussion and reached a consensus. The MRI and ultrasound scales were previously developed and validated by our academic group  Table1;. IntraopThe risk factors related to PPH were selected to construct different prediction models, which are shown in To evaluate the discriminatory ability of the prediction model, receiver operating characteristic (ROC) curves were constructed, and area under the curve (AUC) values were calculated . The clihttp://www.r-project.org). To evaluate the risk factors associated with PPH in clinical data, univariate logistic regression analysis was performed on the clinical data, and odds ratios and 95% confidence intervals were calculated. Statistical significance was set as p < 0.05.Data were analyzed in an R Studio environment using R  has been extensively studied and plays a crucial role in patient management. According to the 2005 Royal College of Obstetricians and Gynaecologists guidelines, routine ultrasound screening at 20 weeks of gestation should determine the placenta position, and follow-up imaging should be performed if abnormalities are detected . For patDistinct sonographic features indicative of PPP with placenta accreta include increased blood flow in the placenta , disordePlacental abnormal lacuna is a recognized ultrasound sign strongly associated with abnormal placentation. The presence of lacunae significantly increases the positive prediction of placenta accreta and is positively correlated with severe complications during and after the operation . The conMRI offers advantages over ultrasound, such as higher sensitivity and specificity, excellent soft tissue and spatial resolution, wide imaging field, absence of ionizing radiation, and independence from maternal factors. Various MRI signs have been identified for diagnosing and evaluating PPP . DiffereIn 2016, Ueno et al.  developeAdvancements in radiomics have contributed to prenatal imaging diagnosis, therapeutic effect prediction, and prognostic evaluation . TextureThe strength of this study is that clinical risk factors, MRI signs in the second trimester, and ultrasound signs before delivery were included simultaneously. Logistic regression analysis was used to control confounding factors and facilitate a more comprehensive evaluation. The nomogram for predicting PPH in PPP based on the high-risk parameters had high accuracy (AUC = 0.930), and the calibration curve showed that the predicted probability of the model also agrees with the actual probability. The nomogram can visually show the scores corresponding to multiple independent risk factors of PPH in patients with PPP, and the probability of occurrence can be predicted by simple addition operation, which provides a simpler, visualized, and effective auxiliary method for predicting PPH and is easy to popularize and apply in clinical practice.This study had some limitations. First, this was a single-center retrospective study with limited cases, which may have impacted the diagnostic efficacy of the model. Second, there was no external validation; therefore, the accuracy, repeatability, and value of the model in clinical practice require further verification. Moreover, our study utilized an 8 mm slice thickness due to adherence to customary clinical requirements of retrospective data, which has inherent limitations for radiological research, and future prospective studies can employ thinner slice thicknesses to improve imaging quality.The LASSO regression nomogram established in this study was simple to visualize based on clinical risk factors and multiple conventional ultrasounds plus MRI signs. Therefore, it provides a simple and practical tool for obstetricians to evaluate and predict the risk of PPH in patients with PPP, select appropriate surgical methods to reduce intraoperative hemorrhage, ensure the safety of pregnant women during delivery, and improve the prognosis of patients. Furthermore, prospective, multi-center, and large-sample studies are expected in the future to verify and improve the prediction model.


However, these results suffered from inconsistency and the number of trials dealing with these outcomes remains low, calling for further studies. Conclusions: Virtual reality seems to be well accepted by older people and its use with this population is feasible. However, more studies are needed to conclude its effectiveness in promoting exercise in older people.Context: This review aimed to synthesize the literature on the acceptability, feasibility, and effectiveness of immersive virtual technologies to promote physical exercise in older people. Method: We performed a literature review, based on four databases . Eligible studies had to use immersive technology with participants aged 60 years and over. The results regarding acceptability, feasibility, and effectiveness of immersive technology-based interventions in older people were extracted. The standardized mean differences were then computed using a random model effect. Results: In total, 54 relevant studies (1853 participants) were identified through search strategies. Concerning the acceptability, most participants reported a pleasant experience and a desire to use the technology again. The average increase in the pre/post Simulator Sickness Questionnaire score was 0.43 in healthy subjects and 3.23 in subjects with neurological disorders, demonstrating this technology’s feasibility. Regarding the effectiveness, our meta-analysis showed a positive effect of the use of virtual reality technology on balance (SMD = 1.05; 95% CI: 0.75–1.36;  According to the World Health Organization, the number of people aged 60 years and over will reach 2 billion by 2050, while those aged 80 years and above are expected to grow from 125 million (in 2018) to 434 million in 2050 [Many studies, as summarized in ,7, have Virtual reality (VR) is often defined as immersive or non-immersive according to the devices used to submerse users’ senses. In immersive VR, the immersion is created through the use of a head-mounted display or a cave automatic virtual environment (CAVE). VR must also be distinguished from mixed reality systems such as augmented reality (AR), where real-world elements are being included into the virtual environment . In thisImmersive virtual technologies have emerged as effective tools to perform exercises aimed at improving balance and strength in the community-dwelling adults ,13. ThesAlthough immersive technologies were found to be effective in numerous areas, their integration into clinical practice remains a challenge , with unThis review has been performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines . The seaStudies were included if they reported results (1) addressing acceptability, feasibility, and/or effectiveness; (2) of immersive VR or AR technology in the physical therapy or rehabilitation context; (3) on adults with a mean age of 60 years or older (as defined by the United Nations); and (4) that were published in English or French, with no limit on the date. Systematic reviews with or without meta-analysis, reviews, conference or congress papers, and case report studies were excluded. Pre-post interventional studies assessing the effectiveness of immersive VR or AR in older adults and providing sufficient data to analyze changes in outcomes were included in the meta-analysis.www.covidence.org) [References retrieved from MEDLINE, CINAHL, Embase, and Scopus were exported into the Covidence systematic review software  . In addiTwo independent reviewers extracted the data from the included studies. Each reviewer had half of the articles selected to read. All relevant data were combined in a single Excel table (Microsoft 365). For each study, the following information was retrieved: the date of publication, the country in which the study took place, the population and its main characteristics , the experimentation performed , and the results and assessment methods for the three targeted outcomes , as well as the authors’ conclusions.Following the selection and the data extraction, each reviewer assessed the methodological quality of the randomized control trials using the PEDro scale . This 11Afterward, the score of each study was interpreted as suggested by Foley et al. , in whicRegarding the non-randomized experimental studies, the National Institute of Health Quality Assessment Tool was used to assess their methodological quality, whereas for qualitative studies, the grid of the Centre for Evidence-Based Medicine (CEBM) for Critical Appraisal of Qualitative Studies  was used2 statistical test was also considered to estimate results’ heterogeneity. As suggested by the Cochrane Handbook, heterogeneity was defined as non-significant for I2 < 30%, moderate for 30% ≤ I2 < 50%, substantial for 50% ≤ I2 < 75%, and considerable for I2 ≥ 75%. In case of heterogeneity, a random effect model was always considered. Outlier study removal was always motivated by a sensitivity analysis. Subgroup analyses were considered to assess the influence of time (studies published after 2020 vs. before 2020), the type of device (AR vs. VR), and the participants’ health status  on immersive technologies effectiveness when at least 10 studies were included in the analysis.Meta-analyses were considered when at least four studies provided quantitative measures of effect for the same outcome. The changes induced by VR and AR were computed from the included studies. For each relevant outcome, the following information was introduced into the RevMan 5.3 software: pre- and post-intervention mean scores ± standard deviation and the total number of participants. This enabled us to generate forest plots, underlining the treatment effectiveness. When different scales were used for one outcome, the standardized mean difference (SMD) and 95% confidence interval were calculated for each study. The magnitude of the effect was interpreted according to Cohen’s guidelines: small for SMD ≤ 0.5, medium for 0.5 < SMD ≤ 0.8, and large for SMD > 0.8 . The I2 The strength of the body of evidence was evaluated according to the GRADE approach. The certainty of the evidence was consequently established depending on the risk of bias of the included studies, the number of participants, the statistical heterogeneity, the effect size, and the design of the studies.The electronic search strategy in the MEDLINE, CINAHL, Embase, and Scopus databases yielded 2542 records. Handsearching led to 41 additional articles . As a reAs shown in In total, 10 studies (9 VR and 1 CAVE ) exposedTwenty-one articles  have addJaneh et al.  highlighTwelve studies ,56,61,64Appel et al.  carried With a home-built questionnaire evaluating the usability and engagement in AR, Bank et al.  reportedp < 0.001) with a large magnitude of effect (SMD > 0.8). However, the heterogeneity between the studies was found to be moderate (I2 = 42%). According to the GRADE approach, owing to the limited number of studies and sample size, the potential risk of bias, and the significant heterogeneity of these results, the strength of the body of evidence was decreased by two and therefore considered as low.There was sufficient data (n ≥ 4) to quantify the effect of VR and AR on older adults’ balance and gait functions. Thirteen studies used instrumental measures to assess balance outcomes. These were the ABC scale, the Mini-BESTest, the Berg Balance Scale, the Tinetti Balance Test, the One-Leg Standing Balance Test, and the limits of stability (a posturography index). As underlined in p = 0.53). The studies published before 2021  led to similar balance benefits as the studies published between 2010 and 2020 .Subgroup analyses revealed that the effect of immersive technologies on balance outcomes was not influenced by the years (p < 0.006). The effect size was considered as moderate (0.2 < SMD < 0.8) and the heterogeneity between the studies was found to be substantial (I2 = 61%). Given the low number of included studies, the potential risk of bias, the moderate effect size, and the substantial heterogeneity, the certainty of evidence was considered as very low.Fourteen studies used instrumental measures of gait outcomes. These were the gait speed, six-minute walk test, and Timed Up and Go test. As underlined in p = 0.001), whereas AR did not significantly enhance the gait outcomes . However, as underlined by Subgroup analyses revealed that immersive VR led to significant gait speed improvements . They also reported a gait speed improvement after VR exposure. The participants walked significantly faster after exposure, from 1.08 ± 0.34 m/s to 1.12 ± 0.27 m/s and from 1.16 ± 0.18 m/s to 1.20 ± 0.18 m/s, respectively, for healthy adults and people with Parkinson’s disease. Yoo et al. [Kim et al.  used theo et al.  also repPhu et al.  also invJaneh et al.  used theBenham et al.  used VR p = 0.027) of 6.82% over the initial score [p = 0.02). However, they did not report a significant change in the biomechanical measures of hand or grip strength (p > 0.20) but reported that the AR would allow faster transitions between tasks and more opportunities to practice gripping objects that would not be available in the conventional clinical environment.Furthermore, as presented in al score . Fischeral score  used AR Lastly, Kanyilmaz et al. have assessed the effect of immersive VR on older adults suffering from dizziness . The resThis review summarized what is currently known about the use of immersive VR and AR technologies in older people. The following subsections discuss the results regarding the main research purpose, such as the acceptability, the feasibility, and the effectiveness of VR. We also highlight the limitations of the present study.Our review identified 21 articles addressing the acceptability of immersive technology in older adults . The resDuring the immersive experiences, some studies have focused on the environments that older people preferred to visit. Appel et al.  and BrowContrastingly, most commercial applications could be too complex and difficult to be used by older adults , especiaThe most commonly reported measure for determining the feasibility of a VR technology was the use of the Simulator Sickness Questionnaire (SSQ) . The SSQPeople with physical limitations may have to make more effort to succeed in virtual task completion, potentially limiting the treatment adherence and inducing some stress . In addiThe types of headsets used  are esseThe most important results of this systematic review also concern the effectiveness of the VR technology among the community-dwelling older adults . The resFirst, as shown in Second, VR can be used to correct the gait pattern. Indeed, thanks to the screen embedded in the headset, the participant’s virtual foot appears to take a larger step in contrast to reality, exaggerating the decrease in the step length on the more affected side and thus forcing the user to take more symmetric steps on both sides . Thus, tp < 0.05) decrease in pain among participants after one session of VR. This decrease in the pain can be attributed to the distraction provided by the immersion. In fact, several studies have suggested that the immersive aspect of VR might be responsible for the reduced subjective experience of pain as the interaction with the real-world cues are being limited by the use of HMD [Third, Benham et al.  have shoe of HMD . This efe of HMD .The effect of VR was also shown for other outcomes. VR resulted in fine motor skills improvements in a group of participants with Parkinson’s and a slight improvement in the Unified Parkinson’s Disease Rating Scale (UPDRS) . An imprThe results reported in this work provide several perspectives for the use of immersive technologies among older adults. While these technologies (VR and AR) are not yet implemented in our daily life, their increasing popularity, the decrease in their price, and their potential in terms of realism, interaction, and communication might reverse the situation. For instance, with the development of the metaverse, a parallel immersive virtual world intended to supplant the internet, it could be that rehabilitation is delivered remotely more often ,95. SuchMoreover, VR devices (and metaverse development) also hold potential to deliver rehabilitation and promote activity among people who have no/few access to healthcare services, such as in low-income countries. Several studies have demonstrated the feasibility of implementing such interventions in developing countries ,97.Despite the positive effects of VR reported in different studies and summarized here, the generalization of these results ais limited by the small number of articles available for each population and for each type of outcome, as discussed above. The overall low methodological quality of the articles included in this review potentially reduces the strength of the reported conclusions. Despite these limitations, this first systematic review shows encouraging results for further research and decisions in clinical settings.Virtual reality is well accepted by older people and provides an enjoyable experience. The results suggest that the use among this population is feasible since few symptoms were reported and the increased SSQ scores were not significant in most cases. Currently, despite the several advantages described above, it is impossible to conclude on the effectiveness of VR in relation to different pathologies and deficiencies since few studies with good methodological quality and sufficiently large sample sizes are available. However, the beneficial effects have been observed regarding balance, risk of falling, and gait pattern in studies with acceptable methodological quality.


Obstructive sleep apnea (OSA) is associated with cognitive impairment. However, the broad trends of the research publications on OSA and cognition are unclear. This study aimed to investigate patterns of research on the relationship between OSA and cognitive function using bibliometric analysis and to identify future research directions by analyzing research trends and emerging hotspots in the field.We searched Web of Science for relevant publications from 2003 to 2022 and conducted a bibliometric analysis of OSA and cognitive research using CiteSpace, R, and VOSviewer.A total of 1995 articles met the eligibility criteria for the analysis of OSA and cognition research. There was a notable increase in publications over time, with significant contributions from the United States, particularly Harvard University, leading to substantial academic impact. Gozal D emerged as the most prolific author (59 articles) and influential researcher  in this field. Hotspot analysis revealed that investigating the pathological physiology and mechanisms of OSA-associated cognitive dysfunction is a recent area of focus, while burst detection analysis identified sleep quality and mild cognitive impairment as top investigation topics. The study by Canessa N published in the American Journal of Respiratory and Critical Care Medicine received the highest number of 77 citations.Researchers are increasingly focusing on OSA and cognition. Currently, the majority of studies on OSA-related cognitive dysfunction are focused on correctable aspects of the condition. Future investigations into the pathology of OSA-induced cognitive impairment will facilitate more precise therapeutic interventions. A recent study using the 2012 diagnostic criteria by the American Academy of Sleep Medicine found that approximately 936 million adults aged 30–69 years have mild to severe OSA, while 425 million adults in the same age range have moderate to severe OSA  has shown improvements in cognitive function for OSA patients. Despite the benefits of CPAP treatment in improving cognitive function in OSA patients , the durBy employing bibliometric analysis, researchers can identify emerging trends, transformative studies, and novel technologies in their fields. This approach enables biomedical scientists to better grasp the bibliometric structure and the intellectual structure of the research field . Here, w2.2.1.The flow of the search procedure is presented in 2.2.WoSCC included data that were converted into texts, including the basic information such as title, abstract, keywords, countries, institutions, journals, authors, and co-cited articles. The texts were imported into the analysis software.Microsoft Office Excel 2017 software  was used for descriptive statistical analysis of Annual Outputs and Growth Trends. Bibliometrix package of R software (version 4.2.1) was applied for bibliometric analysis and data visualization. VOSviewer software (version 1.6.19) was utilized to constitute bibliometric visualization networks of countries, institutions, authors, and keywords. Using VOSviewer co-occurrence analysis, keywords can be grouped into different “clusters” and expressed in different colors, which can forecast potential trends.The Journal Citation Report 2022 included the impact factor, H-index, and category ranking quartiles. The H-index is defined as a useful indicator to characterize the scientific output of a journal, or researcher . CiteSpa3.3.1.A total of 1995 articles on OSA and cognition research were published between 2003 and 2022. Research outputs related to OSA and cognition research showed an overall growing trend from 2003 to 2022 . The USA3.2.A network of national collaborations between OSA and cognition studies was shown in The network of institutional collaborations between studies on OSA and cognition research was shown in 3.3.VOSviewer was used for visualizing authors . A total3.4.3.5.3.5.1.The titles and keywords of the 1995 literature included in this study were analyzed using VOSviewer software. Meantime, VOSviewer was utilized to measure the frequency of keywords to calculate their density, which was presented as a density map . The hig3.5.2.By analyzing 1,995 articles retrieved from the WoSCC database, we identified keyword bursts from 2003 to 2022 . A strai3.6.3.6.1.In this study, 74,552 cited references including 1995 articles were analyzed for co-citation correlation, and the clustering network diagram was obtained according to the analysis results. 3.6.2.The hot point in studies of OSA and cognition research can be found by ranking the co-cited articles produced in the co-citation network.“Sleep-Disordered Breathing,” “Alzheimer’s Disease,” “Sleep Apnea,” “Child,” “Working Memory,” “Cognitive Impairment,” “Adenotonsillectomy,” and “Pediatric” were the 8 key clusters of co-cited references . The timThe top 20 most frequently cited articles were listed in 4.The bibliometric analysis conducted in this study revealed a significant increase in research on the link between OSA and cognitive function within clinical medicine and public health domains over the past two decades. Notably, 48% of the total articles analyzed, corresponding to 957 papers, were published in the last 5 years only. This surge highlighted the clinical relevance of OSA-related cognitive impairment and emphasized the need for continued research to advance effective therapeutic interventions. It is worth noting that this study is of great interest as it provides the first comprehensive analysis of existing literature and data, utilizes the bibliometric analysis to explore the relationship between OSA and cognitive impairment, and identifies potential future research direction.4.1.Our research indicates a growing number of studies exploring the link between OSA and cognition, highlighting the importance and advances in the field. A recent large cohort study suggested a correlation between enhanced sleep maintenance efficiency, absence of OSA, and improved cognition over a five-year period . It was Our results showed the USA had the most publications and the highest centrality scores in OSA and cognitive research, indicating that USA made important contributions to the research network and may be an influential node in collaboration and knowledge dissemination. Furthermore, Harvard University published the highest number of articles and exhibited the highest centrality score among the top 10 institutions included in the analysis, indicating the significant contribution of Harvard University to institutional collaborations in OSA and cognition research. Additionally, China, Australia, Italy, and Canada have increased their research output on OSA and cognition in recent years, indicating a positive trend toward closer international collaborations and knowledge sharing. Academic interactions among different countries and regions have become increasingly frequent and close, resulting in fruitful results in OSA and cognitive research.Our mapping of prolific authors offers a graphic depiction of the most productive researchers in the field. From 2003 to 2022, a total of 9,094 authors contributed to publications related to OSA and cognition. Among them, Gozal D was not only the author with the highest output of articles (59 articles), but also the most cited researcher  in OSA and cognition. His work has greatly increased his centrality compared to other authors, indicating that he is a key figure in this field known for high-quality research. Studying highly productive authors is beneficial for identifying emerging trends in OSA and cognition research. Moreover, the influence of academics can be evaluated based on their publication output and citation frequency, which is a measure of their scholarly ability and recognition within the academic community , indicating its significant impact and recognition within the academic community. Our findings emphasize the significance of selecting publication outlets wisely and high-impact journals when seeking to disseminate research findings in the field of OSA and cognition.4.2.Keyword analysis was conducted to summarize the themes and research directions within the field of OSA and cognitive research. Our results indicated that research themes related to OSA and cognitive dysfunction have become increasingly focused and interconnected over the years, suggesting a growing convergence of interest in this research area and closer relationships between different topics. By keyword analysis, OSA-related Mild cognitive impairment (MCI) has emerged as one of the most widely discussed topics in the field. MCI is frequently recognized as a pre-dementia cognitive stage of Alzheimer’s disease and is reported to develop into dementia at a rate of about 10–15% per year . OSA hasBesides MCI, sleep quality is also an important and promising topic in the area of OSA and cognitive research. Maintaining adequate and high-quality sleep is crucial for preserving cognitive function. However, OSA-induced sleep fragmentation can reduce sleep quality . Poor slRecent research trends suggest that pathological physiology and mechanisms of OSA-associated cognitive dysfunction may become a research hotspot. OSA is clinically associated with biomarkers of attention deficit disorder pathology in middle-aged and elderly patients. These include amyloid protein detected by PET imaging, Aβ and tau levels in cerebrospinal fluid and serum, neurofilament light chain in cerebrospinal fluid, and plasma cytokines . It is pCitation analysis is a useful method for identifying the most influential studies in a given research field and the academic connections among published researches . Citatio4.3.One of the strengths of this study is the informative and instructive application of bibliometric analysis to examine the relationship between OSA and cognitive impairment. Indeed, bibliometric analysis is prevalent in both clinical practice and research. For instance, within the medical field, the utilization of bibliometric analysis allows for the tracing of significant historical origins . MoreoveA potential limitation of this study is that it only analyzed publications indexed in the Web of Science. It is important to acknowledge that different databases may yield slightly different results, potentially limiting the complete generalizability of our conclusions. Furthermore, we should note that bibliometric analysis is primarily designed to assess the scientific output and the research performance of scientific publications, rather than to provide a comprehensive overview of cognition affected by OSA. In future research, we will summarize and analyze the findings in this area to facilitate a more in-depth exploration of this research topic. In addition, our analytical framework restricts our enumeration of studies on pediatric, adult, and geriatric patients with OSA. Nevertheless, we recognize the importance of such age-specific delineation for fully comprehending cognition in OSA. In follow-up, we will address this issue by conducting targeted bibliometric assessments of different age groups.4.4.In summary, our bibliometric analysis revealed that studies on cognition functioning in OSA have primarily focused on MCI and sleep quality. Our study also highlights the need for future research to investigate the pathological physiology and underlying mechanisms of OSA-related cognitive dysfunction. Overall, our findings contribute to identifying research trends and potential therapeutic targets in this field, providing guidance for future studies.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.JD: Methodology, Software, Writing – original draft, Writing – review & editing, Data curation, Investigation. XY: Methodology, Software, Visualization, Writing – original draft, Writing – review & editing. YW: Data curation, Methodology, Software, Writing – review & editing. HZ: Data curation, Methodology, Writing – review & editing. RG: Investigation, Project administration, Supervision, Writing – review & editing.The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Although numerous studies have investigated the association between problematic internet use (PIU) and social anxiety, the findings have no yet reached consistent. The present meta-analysis aims to examine the association between PIU and social anxiety within adolescents and young adults (age range: 14–24 years old).The meta-analysis systematically retrieved the studies prior to September 7, 2023 from Web of Science, PubMed, PsycINFO, Scopus, CNKI, and CQVIP. The meta-analysis based on random-effects model to conduct the research. Stata Version 17.0 and JASP 16.3.0 was used to analysis.r = 0.333, 95% CI , p < 0.001]. Their association was significantly moderated by publication year, measurement tools for PIU and social anxiety but not significantly by culture context, developmental level and gender.The meta-analysis ultimately included 37 studies , involving a total of 36,013 subjects. Our findings indicated that the overall correlation between PIU and social anxiety was significant positive [This meta-analysis suggests that social anxiety is a predictor of the development of PIU in adolescents and young adults. Furthermore, the study also finds the possibility that contemporary adolescents and youth may exhibit a more “global” behavior pattern, potentially emphasizing fewer differences between cultures, generations and genders. Concurrently, there is a significant upswing in the incidence of psychological issues associated with excessive online behavior, known as problematic internet use (PIU) . PIU is Social anxiety in adolescents and young adults can lead to poor academic performance due to avoidance of classroom activities, hinder social interactions , elevateSeveral theoretical models have shown that PIU can lead to social anxiety. The cognitive-behavioral model suggests that individuals with social anxiety may resort to social networks or video games as an avoidance strategy, leading to potential PIU . The comWhile previous meta-analyses have demonstrated a positive association between PIU and social anxiety, they did not extend their subgroup analyses beyond developmental levels, or the results across different subgroups have not been consistent , 25. DifAlthough the exponential increase in the number of empirical studies exploring the relationship between PIU and social anxiety among student populations, to the best of our knowledge, no meta-analysis has been conducted to evaluate the overall effect of this relationship within adolescents and young adults. Thus, the current study aims to conduct a meta-analysis to explore the relationship between PIU and social anxiety among adolescents and young adults, with a specific objective to discern whether there are differences compared to other age groups from previous studies. Additionally, we also attempt to explore whether the strength of the relationship between PIU and social anxiety is moderated by effect of subgroups, with the aim of resolving inconsistencies observed in previous meta-analyses regarding subgroup analyses: (a) measurement tools used for PIU, (b) measurement tools used for social anxiety, (c) gender, (d) publication year, and (e) cultural context.2.The current meta-analysis was conducted following the PRISMA  guidelin2.1.The present meta-analysis employed a comprehensive approach to identify relevant studies prior to September 7, 2023, utilizing multiple databases including Web of Science, PubMed, PsycINFO, Scopus, CNKI, and CQVIP . Each database was queried using a distinct search formula, as provided in the 2.2.To be eligible for inclusion in this meta-analysis, primary studies had to meet the following PICOS criteria : (1) pop2.3.the quality assessment tool for observational cohort and cross-sectional studies  or not (14–18 years old). To ensure the accuracy of the coding, 2 researchers coded the studies successively with an interval of more than 30 days between the two coding sessions, and the Kappa coefficient was tested to be 0.866, indicating the accuracy of the coding. However, in some cases, there were inconsistencies between the two coders. To resolve these discrepancies, the researchers have consulted with each other and a third-party was consulted to reach a consensus. The meta-analysis utilized  studies  for asse studies . The use2.4.In meta-analysis, we often encounter situations where it is necessary to combine correlation coefficients from individual studies into an overall effect size. However, directly combining correlation coefficients poses two major challenges . FirstlyIn the present study, prior to conducting meta-analysis using Stata 17.0 software, the extracted data were subjected to the following transformation according to the formula :a.Fishe2.5.Q-test results and the I2 value, and if the Q-test results are significant or the I2 value is above 75%, the cause of heterogeneity should be explored as much as possible , involving a total of 38,333 subjects, spanning the years 2003 to 2023. The research samples included in the meta-analysis are from China, Iran, Colombia, Bangladesh, Italy, the United States, Switzerland, Turkey, Spain, France, Australia, and Germany. The age range of the participants was from 14 to 24 years old, and there was a total of 16,680 male participants. Basic information of the original studies included in the analysis were shown in 3.2.Q test for the effect value of the relationship between problematic network use and social anxiety was significant, with a Q value of 553.55 (p < 0.001) and a value of 93.1% for I2, which exceeded the 75% rule  with a 95% CI of , as determined by Fisher’s Z transformation of the correlation coefficients. According to the classification criteria for the size of the correlation, the correlation between the two was relatively strong and varied between 0.10 and 0.40 ; shown in Meta-regression was conducted on publication year to investigate the sources of heterogeneity and publication year could explain the heterogeneity of meta-analysis [3.5.N test was used.In testing for publication bias, the results were first examined by means of a funnel plot. As seen in N is greater than 5K + 10 (K represents the number of independent samples)  indicating that there was no significant publication bias in the current study. In conclusion, there was no significant publication bias in the current meta-analysis.Publication bias is less likely if fail-safe samples) . Fail-sa3.6.The meta-analysis tested several potential changes, including excluding certain studies, using different statistical methods, and evaluating potential publication bias, and the results consistently showed that the main conclusions remained unchanged. Therefore, we conclude that the meta-analysis results in this study are highly reliable and robust, suitable for informing decision-making and clinical practice in this field. The sensitive analysis table can be seen in the 4.The present meta-analysis revealed a significant positive correlation between PIU and social anxiety. The study also advances the current understanding of the relationship between PIU and social anxiety is moderated by effect of subgroups: measurement tools, publication year. Specifically, we found that publication year does in fact explain some of the heterogeneity observed across studies while previous meta-analysis have indicated that publication year does not moderate the relationship between PIU and social anxiety . The fin4.1.This study employed a meta-analytic methodology to investigate the association between PIU and social anxiety within the adolescent and young adult sample. The meta-analysis revealed a robust and positive correlation between PIU and social anxiety. The results suggest that individuals with elevated levels of PIU are more likely to report greater levels of social anxiety. The compensatory Internet use theory suggests that individuals with social anxiety may treat Internet as a “compensatory” mechanism for their lack of social and emotional connections in the offline world, which can lead to dependence on the Internet for social interactions, exacerbating symptoms of social anxiety and leading to PIU . TherefoIn addition, among the 39 studies included in this meta-analysis, only one study reported a significant negative correlation between PIU and social anxiety among adolescents and young adults . Notably4.2.The present meta-analysis utilized subgroup analysis to explore the potential effects of publication year, measurement tools for PIU and social anxiety, cultural background, and gender on the association between PIU and social anxiety. The findings revealed that while the subgroup analysis of measurement tools for PIU and social anxiety and publication year demonstrated a significant effect, the subgroup analysis of cultural background, and gender did not yield significant effects.4.2.1.The current meta-analysis indicated a significant meta-regression effect of publication year on the correlation between PIU and social anxiety among adolescents and young adults while previous meta-analysis found that early studies on PIU and social anxiety may have had a biased sample leading to publication years not explaining heterogeneity . Specifi4.2.2.The finding regarding the moderating effect of measurement tools on the relationship between PIU and social anxiety highlights the importance of careful tool selection in research, this was inconsistent with the findings of previous meta-analyses , 66. One4.2.3.Through subgroup analysis, we found that the cultural context may contribute to reduced heterogeneity of the sample. While previous research has suggested that cultural background may moderate the relationship between PIU and social anxiety within adult sample , the pre4.2.4.We also found that the gender may contribute to reduced heterogeneity of the sample through subgroup analysis. Previous research has suggested that there may be differences in the preferences of males and females for gaming and social applications, which could affect their use of mobile devices and their risk of potential addictive behaviors. For example, a study found that males were more likely to use game applications with competitive and adventurous characteristics, while females were more likely to use social applications . However4.2.5.We found no significant difference between adolescents and youth in the relationship between PIU and social anxiety. This may be due to the pervasive use of internet across these age groups, and the relatively similar social contexts they are embedded in, such as school or university environments where Internet use is prevalent and often necessary for both academic and social purposes. It is possible that the similar exposure to online environments and the comparable pressures they face in these stages of their lives lead to no significant variance in the PIU-social anxiety relationship across these groups.Previous research has revealed a significant difference between adolescents and the adult group  . This co5.The principal merits of the meta-analysis are its revelation of the association between PIU and social anxiety in the adolescent and young adult population and the meta-analysis has also identified heterogeneous explanatory factors that were not previously reported in the literature, while also providing novel insights for cross-cultural research in this field. Nevertheless, the study possesses several limitations. For starters, the prime demerit is undeniably that the predominantly cross-sectional nature of the literature, limiting our ability to infer causality. Longitudinal designs would allow researchers to identify whether PIU precedes social anxiety, or if social anxiety leads to PIU, or if the relationship is bi-directional. Understanding these dynamics could be crucial for developing effective preventative measures and interventions. The second noteworthy demerit is the method of conducting a survey, The majority of the studies included in our meta-analysis collected data through online questionnaires. A potential limitation of this method lies in the self-selection bias inherent to online research. Future research should aim to address this limitation by adopting more diverse data collection methods. For instance, offline methods such as in-person interviews or paper-and-pencil questionnaires can be used to include individuals who might be less inclined to participate in online research.Given that college students comprise the primary study subjects in the field, subsequent research in the field should include more representative sampling methods, such as stratified sampling or random sampling, can be employed to ensure the inclusion of diverse demographic groups, including individuals with varying levels of internet use and interest.6.The meta-analysis utilized the random effects model to quantitatively analyze the association between PIU and social anxiety among adolescents and young adults (age range: 14–24 years old). The results revealed a significant positive correlation between PIU and social anxiety, indicating that social anxiety is a predictor of PIU development in this age group. Subgroup analysis and meta-regression results identified significant differences in the relationship between PIU and social anxiety based on the publication year and measurement tools used. However, no significant differences were found with regards to developmental level, gender or cultural context.HD: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Validation, Writing – original draft, Writing – review & editing. BC: Project administration, Software, Writing – review & editing. QS: Visualization, Writing – review & editing.


Acinetobacter spp., Enterococcus spp., and Staphylococcus aureus predominated. Fifty-six patients harbored multidrug-resistant bacteria and had a significantly greater TBSA. The mean time to colonization was 6 days overall and 14 days for multidrug-resistant bacteria; it was significantly longer for methicillin-resistant S. aureus than for methicillin-susceptible S. aureus. (4) Conclusions: This is the first report describing the dynamics of microbial colonization of burn wounds in Uruguay. Similarities were found with reports elsewhere, but early colonization with yeasts and the absence of Streptococcus pyogenes were unique. Each burn center needs to monitor its microbial ecology to tailor their antimicrobial strategies effectively.(1) Background: Infections are a main cause of morbidity and mortality among burn patients. The spectrum of microorganisms depends on the epidemiological context and treatment practices. We aimed to describe the evolution of microbial flora colonizing burn wounds among patients hospitalized during 15 or more days at the National Burn Center in 2015. (2) Methods: Demographic data, length of stay, total body surface area burn, and status at discharge were collected from electronic records and culture results from the laboratory database. (3) Results: Among 98 included patients, 87 were colonized. The mean length of stay was 39 days overall and 16 days in the ICU.  Burn patients have a high susceptibility to infections, mainly due to a disruption of the skin barrier and a dysbiosis of the immune system ,2. InfecStaphylococcus aureus and Pseudomonas aeruginosa are among the most important colonizers and agents of infection [Candida spp. are the most frequent fungi that originate from the patients’ own flora, while molds are usually from an exogenous origin [nfection ,9. Candis origin ,11.It is usually described that Gram-positive bacteria are the first MOs that colonize and eventually infect burn wounds, followed by Gram-negative bacteria and, later, by fungi . NeverthThe general objective of this study was to analyze the evolution of the microbial flora that colonized the burn wounds of patients admitted to the National Burn Center in Uruguay (CENAQUE) between 1 January and 31 December 2015. The specific objectives were: (a) to describe the epidemiology of microbial flora from wound cultures; (b) to compare the time to colonization (TTC) between different groups of MOs and between MDR and non-MDR bacteria; and (c) to compare the total body surface area burn (TBSA) and the length of stay (LOS) of patients colonized with different groups of MOs.CENAQUE, which is located in the capital city, Montevideo, is the only adult burn center in Uruguay. Patients younger than 18 are occasionally admitted. It is equipped with 6 intensive care unit (ICU) beds, 8 intermediate care beds, and 2 plastic surgery beds. One hundred and fifty five patients were admitted during the year 2015, with a country population of 3,440,000 inhabitants. All patients that were admitted between 1 January 2015 and 31 December 2015 and were hospitalized for 15 or more days were included. The choice of this minimal length of stay (LOS) was due to the fact that since burn wounds are normally sterile in the acute phase, we included patients hospitalized for a length of time that would be enough to get colonized at the center. Of note, the mean LOS at the center was 26 days in 2015. Demographic data, LOS, days in the ICU, TBSA, and status at discharge were collected from the electronic records. ® and interpreted according to CLSI 2015 [Staphylococcus spp. or Corynebacterium spp. as their main MOs were considered “normal flora”, except if these bacteria grew from biopsy specimens in significant numbers . Bacteria were classified as MDR or non-MDR according to the criteria proposed by Magiorakos et al. [Enterococcus spp. were not classified, as not enough antimicrobial classes were tested.Culture results from all second- and third-degree burn wound swabs and biopsies were collected through a review of the laboratory records. Routine cultures from burn wounds are performed twice a week to all patients. Additional swabs and/or biopsies are taken when an infection is suspected. Swabs are cultured on tryptic soy agar supplemented with 5% ovine blood and on McConkey lactose agar. Biopsies are quantitatively cultured  in the sLSI 2015 . For thes et al. : acquiret-test. Correlation between the TBSA and the number of groups of colonizing MOs, and between the TBSA and the TTC were determined with Spearman coefficient. The mean TTC with non-MDR and with MDR bacteria was compared using the Student’s t-test. The number of microorganisms colonizing each patient with respect to their LOS was analyzed with the Chi-square test with R software , Gram-negative bacilli (GNB), yeasts, and molds. In some cases, individual genus or species were separately analyzed. Time to colonization (TTC) was defined as the time between hospitalization and the first positive culture. It was described in days for different MOs. The mean TBSA between patients that were colonized and not colonized with MDR MOs was compared using the Student’s on 3.4.4 .This study was conducted following the ethical principles for medical research involving human subjects of the World Medical Association . The proNinety-eight patients were hospitalized for at least 15 days during 2015, while only fifty-seven patients stayed for shorter periods, i.e., 63% of all admitted patients were included in this study. Sixty-five patients were male and thirty-three were female . The mean age was 44 years (range: 16–89 years). The mean TBSA was 16.8% (range: 1–65%).Eighty patients were discharged alive; thirteen were transferred to their medical institution and five died .Acinetobacter spp., Klebsiella spp., and P. aeruginosa were the most frequent GNB observed, while GPC were equally distributed between enterococci and S. aureus. Candida spp. Were the most frequent fungi observed (p = 0.0039). Twenty-two patients (22%) were colonized with only one group of MOs , thirty-five (36%) were colonized with two, twenty-seven (28%) were colonized with three, and only three patients (3%) were colonized with the four groups. The most frequent combinations were GPC + GNB and GPC + GNB + yeast. Different morphotypes and susceptibility patterns were found among P. aeruginosa isolates. In contrast, most Acinetobacter spp. strains were resistant to ampicillin/sulbactam, ceftazidime, piperacillin/tazobactam, imipenem, meropenem, amikacin, ciprofloxacin, and trimethoprim/sulfamethoxazole, were only susceptible to colistin and tigecycline, and had a variable expression of resistance to gentamycin. Most MDR Enterobacterales were Enterobacter spp. and Klebsiella spp., resistant to third-generation cephalosporins (extended spectrum beta-lactamase and/or hyperexpression AmpC mechanisms). Of note, although carbapenemase-producing Enterobacterales were first detected in 2010 in Uruguay [p < 0.01). Thirty-one of the eighty-seven patients were colonized with non-MDR bacteria (36%), while fifty-six (57%) were also, or exclusively, colonized with MDR MOs. p = 0.41 and 0.42, respectively). Patients colonized with MDR MOs had a greater TBSA than those not colonized with MDR MOs . The mean LOS was longer for patients colonized with MDR MOs than for patients only colonized with non-MDR MOs or not colonized at all . The mean LOS in the ICU was 10 days for patients not colonized with MDR MOs and 21 days for patients colonized with MDR MOs (p < 0.05).Three thousand and seventy swabs and one hundred and seventy-seven biopsies were performed on the ninety-eight included patients; one thousand one hundred and forty swabs (29.5%) and sixty biopsies (33.9%) were positive for at least one relevant MO; two thousand and twenty-four of the positive samples (swabs or biopsies) grew two or three pathogens, while the remaining nine hundred and seventy-seven were monomicrobial. Eighty-seven patients (88.8%) had at least one positive culture at some point during their hospitalization; seventy-six patients (76.5%) were colonized with Gram-negative bacilli (GNB), sixty-eight (69.4 %) with Gram-positive cocci (GPC), and forty-one (41.8%) with fungi. observed . Eleven p < 0.05). Fifteen of the eighty-seven colonized patients (17%) were first colonized with a MDR MO. As well as the TBSA, the LOS in the ICU is a surrogate of the severity of the patients; hence, it could be a confounder. The mean TTC was 6 days for any MO (range from 0 to 37), 9 days for non-MDR bacteria (range from 0 to 54), and 14 days for MDR bacteria (range from 0 to 59)  were the first colonizers (with a mean TCC of 16 days), followed by yeast (17 days), molds (18 days), Enterobacterales (19 days), Enterococcus spp. (20 days), and P. aeruginosa (22 days). p = 0.042), while MDR GNB tended to appear earlier than their non-MDR counterparts (not significant)  . We evaluated part of the CENAQUE population  to describe the dynamics of microbial colonization. Acinetobacter spp. in most of them and the absence of Streptococcus pyogenes in our study. Even though not all studies included comparable populations, the spectrum of MOs and the global mean TTC was quite similar to that described in other studies from different decades ,21,22,23Acinetobacter spp. colonization (54% of included patients). Furthermore, it was found that the TTC with this genus was shorter than the TTC with any other GNB. This was not expected, as Acinetobacter is basically a hospital-acquired MO that is likely to occur a long time after admission in debilitated patients. Actually, an outbreak of A. baumannii colonization (predominantly at the rectum and skin) started in 2013. It was followed by an endemic situation that finished in 2017. Nevertheless, very few infections were diagnosed. This situation demanded a change in patients care, since most isolates were MDR. It was necessary to introduce antimicrobials, for prophylaxis or for treatment, that were not usually needed . These first measures ended with the carrying out of important building works: replacement of the plumbing network, solenoid valves, hoses, faucets, and application of chlorine shock in balneotherapy rooms. Work continued in the intermediate care sector, with the replacement of wooden elements, change in lighting, doors, and windows. Once the works were completed, beds and furniture suitable for hospital cleaning were purchased. The strongest hypotheses for the early colonization with Acinetobacter spp. is that it was highly prevalent, it was found in the center’s environment, and it was probably acquired via cross transmission. Although colonization with endogenous flora was more frequent than colonization with exogenous flora (like Acinetobacter), it was acquired later during the course of the hospitalization, presumably because it appeared in response to a selection pressure due to the use of extended-spectrum antimicrobials. A study from India showed that A. baumannii was also an early colonizer in a setting similar to that described in our center [A. baumannii infections in a burn unit in France, colonization with this MO was detected with a mean TTC of 13 days [One of the most striking observations of this study was the high prevalence of r center . On the  13 days . Enterobacterales, enterococci, S. aureus, and Candida spp.) than with exogenous flora (non-fermentative GNB and molds). Nevertheless, cross transmission is not negligible. Control of colonization/infection with endogenous flora mostly depends on the rationalization of the use of antimicrobials to avoid the selection of multi-drug-resistant MOs, whereas colonization/infection with exogenous flora depends on multiple other factors, like cleaning of the environment, thorough hand hygiene, and contact precautions to avoid cross transmission. Overall, more patients were colonized with endogenous flora  that could be due to other pathophysiological conditions associated with the burns themselves. As described in other studies ,22, S. aixth day , was theixth day , and a lixth day . P. aerun center . RecentlCarolina . AlthougS. aureus (MRSA vs. MSSA). In fact, in the case of Acinetobacter spp. and Pseudomonas spp., MDR strains tended to appear earlier than their non-MDR counterparts, although these differences were not significant. As expected, patients colonized with a MDR MO had a much longer hospital stay than those not colonized with a MDR MO. Hospitalization in the ICU was also associated with a greater risk of colonization with MDR MOs. Patients colonized with specific MDR MOs were subjected to differential care treatments depending on the MO; for example, patients colonized with MDR Acinetobacter spp. during the outbreak were assigned specific staff teams. As we did not detect carbapenemase-producing GNB during this study period, no specific measures were needed. Extended-spectrum beta-lactamase (ESBL)-producing Enterobacterales are endemic in many centers in Uruguay but were infrequent at CENAQUE in 2015; these patients were not subjected to specific infection control and prevention (ICP) measures, as contact precautions were applied to all patients at the center. It is important to point out that all patients at the center are hospitalized in individual rooms, so contact precautions are easily practicable. More severely ill patients (with a greater TBSA and longer ICU stay) got colonized earlier and with a more diverse flora. The association between a greater TBSA and a longer ICU stay was attributed to the severity. The greater and deeper the burnt area, the easier it is for the MOs to adhere, and in some cases produce biofilms, and persist until the area heals. Measures applied during the early stages of the injury, consistent with debridement of devitalized tissue and hygiene measures regarding wound care, are crucial in the primary management of burn patients to prevent the most frequent complications.More than half of the included patients were colonized with a MDR MO. The overall TTC was significantly longer for the MDR MOs than for the non-MDR MOs, which is similar to what has been described in other studies ,29, but A. baumannii was detected, a restriction in colistin use was agreed upon, consisting of the authorization by the ICU chief.These findings have to be evaluated in the context of the ICP practices in the institution. The ICP team is led by a specialized nurse and integrated via intensive care and plastic surgery physicians and a doctor specialized in microbiology. There is a strict control on hand hygiene and contact precautions that are applied to all patients. At the time of the present study, there was not a general policy on antibiotic use, but a set of rules were established by the ICP team when a particular problem arose. For instance, when the outbreak of The present work has included all patients hospitalized for 15 or more days at the center and followed them throughout the whole hospitalization. It allowed us to monitor the dynamics of colonization. The duration of this study was of one year. Although the number of patients was small compared to other published studies, the Uruguayan population was 3,402,818 in 2015 .As the main limitations, we did not include samples other than wounds, and we were not capable of distinguishing between colonization and infection. Also, these data reflected the situation at CENAQUE in 2015, and it probably changed in the last years. Nevertheless, we believe that this first communication provides an approximation to the knowledge of the epidemiology of the institution. It contributes to the strengthening of infection prevention and control protocols in the event of the appearance of unusual microorganisms or outbreaks of MDR microorganisms. In turn, it constitutes a baseline for continuing surveillance and analyzing long-term trends. Also, we compared our findings with published data from about the same time and older. We expect to add data from 2016 and to publish a long-lasting trend.To the best of our knowledge, this is the first report on burn wound colonization in Uruguay and also one of the few published from South America. Although the information dates from eight years, we believe that it is important as a starting point for future surveillance and that it gives valuable information for ICP practices.Acinetobacter spp. colonization, due to an outbreak during the study period, an early colonization with yeast compared to bacterial pathogens was observed. Also, we did not find S. pyogenes. Both characteristics can be explained by the fact that we included patients that were hospitalized for at least two weeks. It is very likely that these patients had broad spectrum antibiotic treatment during that time.Similarities have been found with the epidemiology described both in developed and in developing countries, but particular characteristics were seen in our study. In addition to the high rates of Each burn center must monitor their microbial ecology and establish protocols and guidelines according to it.