Upper limb impairments are one of the most common health problems of stroke, affecting both motor function and independence in daily life. It has been demonstrated that intermittent theta burst stimulation (iTBS) increases brain excitability and improves upper limb function. Our study sought to determine the role of iTBS in stroke recovery.The purpose of this study was to determine the efficacy of iTBS in individuals with upper limb impairments following stroke.The databases used included Cumulative Index to PubMed, EMBASE, ESCBOhost, The Cochrane Library, Chinese Biomedical Database, Web of Science, China Biology Medicine (CBM), China National Knowledge Infrastructure (CNKI), Technology Periodical Database (VIP), and WanFang Database. Studies published before November 2021 were included. Each participant received an iTBS-based intervention aimed at improving activity levels or impairment, which was compared to usual care, a sham intervention, or another intervention. The primary outcome measure was a change in upper limb function assessment. Secondary outcomes included impairment, participation, and quality of life measures.n = 401 participants) that met the inclusion criteria were included in this study. There was a slight change in the upper limb function of the iTBS group compared with the control group, as measured by the Fugl-Meyer Assessment-Upper Extremity (FMA-UE) score . Significant improvement in resting motor threshold (RMT) and motor-evoked potential (MEP) was also observed in the meta-analysis of iTBS ; . In addition, we got similar results when the studies were using the Modified Barthel Index (MBI) assessment .A total of 18 studies (Our study established the efficacy of iTBS in improving motor cortical plasticity, motor function, and daily functioning in stroke patients. However, the review requires evidence from additional randomized controlled trials and high-quality research.https://www.crd.york.ac.uk/PROSPERO/ Stroke is one of the leading causes of long-term disability in adults and one of the leading causes of death . SurvivoRepetitive transcranial magnetic stimulation (rTMS) is a non-invasive method for stimulating specific brain areas that have been shown to be useful in stroke rehabilitation . NowadayRecent studies have been conducted to determine the effects of TBS on upper limb motor dysfunction following stroke, but the results are controversial . AccordiThis review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and the protocol was registered in the PROSPERO database (registration number: CRD42021282832) .A complete literature search was conducted using PubMed, EMBASE, ESCBOhost, The Cochrane Library, Chinese Biomedical Database, Web of Science, China Biology Medicine (CBM), China National Knowledge Infrastructure (CNKI), Technology Periodical Database (VIP), and WanFang Database. The searching key terms included “Cerebrovascular Disorders” OR “Brain Ischemia” OR “Cerebral Hemorrhage” OR “stroke” AND “upper limb impairments” AND “Intermittent theta burst stimulation” OR “theta burst stimulation”. Additional publications were discovered by looking through the reference lists of the retrieved articles. The search was conducted in November 2021.The inclusion criteria were: (1) participants had to be clinically diagnosed with upper limb dysfunction, and a CT scan or MRI was used to confirm a stroke; (2) iTBS, which contains a 2-s train of bursts of three 50-Hz pulses repeated every 200 ms (5 Hz) once a day during therapy, must be included in the intervention; (3) regular rehabilitative training was carried out without the use of iTBS or with the use of sham iTBS; and (4) the examination of upper limb function, which may include the evaluation of upper limb coordinated movement and separation movement, dexterity function and coordination function, must be included in outcome indicators. The primary outcome will be the Upper Limb Fugl-Meyer Assessment (FMA). Secondary outcomes will include brain impairment, participation, and quality of life measures; (5) randomized controlled trials (RCTs) or controlled trials should be used in all designs.The following types of studies were excluded: (1) studies with non-primary data such as opinion articles, editorials, letters to the editor, and comments; (2) animal studies; (3) qualitative studies; (4) dissertations; and (5) studies that could not provide sufficient statistical data.Two independent researchers  carried out the screening method. Papers were screened for integrated analysis based on the inclusion and exclusion criteria given earlier to obtain eligible articles. Other relevant researches were found by screening reference lists manually. We compared the results of the two reviewers, and in the cases where the two reviewers could not agree, we sought the advice of the third reviewer (Ya-Dan Zheng) see .www.ClinicalTrials.gov) or contacted the authors. If there were several groups in the included RCTs, only those that were congruent with the systematic review's aims will be extracted. Team discussion was used to settle any discrepancies.Data were extracted independently by the two reviewers (HWH and CJY) using a predesigned data extraction form, which included the following characteristics: articles , participants , intervention , and outcome measurement. If the data was not in the original journal, we looked for them on Clinical Trials . The FMA score, MBI score, RMT, and latency of MEP were continuous measurement data, and the effect size was calculated using the mean difference (MD). After each research intervention, the MD was calculated using the mean, SD, and sample size; the incidence of adverse events was categorized as two-category count data, and the effect size was calculated using relative risk (RR). The number of incidents and sample size retrieved after each research intervention were used to calculate the RR. Calculate MD or RR and the corresponding 95% CI to estimate the total impact size of each indicator. The The risk of bias was assessed independently by the two reviewers (HWH and CJY) using the Cochrane Collaboration risk of bias tool including the following items: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other bias . Accordin = 7); the study's interventions included iTBS and other treatments (n = 6); the study's data were not clear (n = 3)], 18 articles were included in the systematic review and meta-analysis. Many of the articles included in this study had an iTBS that delivered a 2-s train of bursts containing three 50-Hz pulses repeated every 200 ms  at an intensity of 80% active motor threshold (AMT), , –23 whiled (AMT), . Furtherd (AMT), –30 iTBS d (AMT),  and anotd (AMT), , 19, thed (AMT), .In total, 401 stroke patients of mixed gender were included in the study. According to the included articles, the participants ranged in age from 18 to 90 years old, and the average age of the patients included in the study was 52.22 ± 9.91 . The gender distribution of the studies was 109 women and 268 men. The onset time of all subjects included in the study may be as short as 2 weeks or as long as 6 months or more. The average onset time of the patients included in the study is 5.73 ± 4.95 months  see .In all of the trials considered, the items' selective reporting were rated as low risk of bias except one . Random To assess the effect of iTBS on upper limb function, post-intervention data from ten trials involving 247 participants were pooled. The results of this analysis indicated that iTBS had a significant effect on the motor function of stroke patients' upper limbs. In addition, there was a significant positive correlation between iTBS intervention and activities of daily living. And the results of this meta-analysis also indicated that the assessment of RMT and MEP latency time was significantly different in the iTBS group.p = 0.05). The mean effect size for the acute subgroup was 7.46  and homogeneous (I2 = 39.0%). The mean effect size for the subacute subgroup was 0.28 , with no evidence of heterogeneity (I2 = 0.0%). The mean effect size for the chronic subgroup was 3.12 , with was no evidence of significant heterogeneity (I2 = 0.0%). From the results of iTBS intervention in patients with various post-stroke complications, we conjecture that iTBS is most effective in improving motor function in the acute phase after the intervention. Refer to A total of eight trials involving 192 individuals were chosen. The meta-analysis revealed a significant difference in FMA scores between the iTBS and control groups . One trial found that the iTBS group did not significantly improve their BI score when compared with the control group  (see p < 0.00001)  see . Besides001) see . There wiTBS has emerged as a novel method for improving upper extremity function in stroke patients. We conducted a systematic review and meta-analysis to determine the efficacy of iTBS training on limb function in stroke patients.The study included a total of 18 publications and 401 subjects. After analyzing the included articles, we discovered that therapy with iTBS resulted in better treatment outcomes than the control group. The majority of publications subjected to meta-analysis revealed a range of outcomes, both positive and negative. Only one study reported an entirely positive conclusion . FMA–UE,According to the included studies, patients' FMA scores slightly improved and MBI scores improved significantly following iTBS intervention treatment, as did their ability to participate in activities. Diekhoff Krebs' study demonstrated that iTBS stimulation of ipsilesional M1 resulted in a significant increase in MEP in the stimulated hemisphere and a significant decrease in the unstimulated hemisphere . John RoThere were some limitations in this study. First, the articles we evaluated for analysis had a variety of patient demographic features, such as the age, gender, stroke duration, and stroke side of the stroke patient. When patients had varying stroke duration, there was significant heterogeneity in motor recovery after stimulation . From ouThis review has provided supportive evidence for the efficacy of iTBS in improving post-stroke patients' brain excitability, upper limb function, and daily life. Additional research with a larger sample size would be necessary to fully characterize the role of iTBS as a neurorehabilitation treatment for upper limb dysfunction. Future research is necessary to compare various stimulation parameters, such as stimulation site, frequency, and duration, to determine the optimal treatment protocol.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.WH and JC conceived and designed the study and wrote the manuscript. WH, JC, and ZD developed the search strategy. WH, ZD, and JZ screened abstracts and full text reports. JC, XL, and LS extracted outcomes. YL and ZD interpretation of the data. All authors contributed to the article and approved the submitted version.This work was supported by the National Natural Science Foundation of China (Grant No. 81972159), the Natural Science Foundation of Guangdong Province, China (Grant No. 2020A1515010881), and Shenzhen Science technology project (Grant No. JSGG20201102145602006).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.


The prognosis of patients with primary osseous spinal neoplasms (POSNs) presented with distant metastases (DMs) is still poor. This study aimed to evaluate the independent risk and prognostic factors in this population and then develop two web-based models to predict the probability of DM in patients with POSNs and the overall survival (OS) rate of patients with DM.The data of patients with POSNs diagnosed between 2004 and 2017 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Univariate and multivariate logistics regression analyses were used to study the risk factors of DM. Based on independent DM-related variables, we developed a diagnostic nomogram to estimate the risk of DM in patients with POSNs. Among all patients with POSNs, those who had synchronous DM were included in the prognostic cohort for investigating the prognostic factors by using Cox regression analysis, and then a nomogram incorporating predictors was developed to predict the OS of patients with POSNs with DM. Kaplan–Meier (K-M) survival analysis was conducted to study the survival difference. In addition, validation of these nomograms were performed by using receiver operating characteristic (ROC) curves, the area under curves (AUCs), calibration curves, and decision curve analysis (DCA).https://yxyx.shinyapps.io/RiskofDMin/ and https://yxyx.shinyapps.io/SurvivalPOSNs/) were developed. The results of ROC curves, calibration curves, DCA, and K-M survival analysis together showed the excellent predictive accuracy and clinical utility of these newly proposed nomograms.A total of 1345 patients with POSNs were included in the study, of which 238 cases (17.70%) had synchronous DM at the initial diagnosis. K-M survival analysis and multivariate Cox regression analysis showed that patients with DM had poorer prognosis. Grade, T stage, N stage, and histological type were found to be significantly associated with DM in patients with POSNs. Age, surgery, and histological type were identified as independent prognostic factors of patients with POSNs with DM. Subsequently, two nomograms and their online versions (We developed two well-validated nomograms to accurately quantify the probability of DM in patients with POSNs and predict the OS rate in patients with DM, which were expected to be useful tools to facilitate individualized clinical management of these patients. Althof POSNs , 5, and of POSNs , 7.As with other common malignancies, distant metastasis (DM) was also reported to be a significant factor affecting the survival rate of patients with POSNs , and theWithin the last few years, several studies have developed nomograms for primary bone tumors of the spine , 20. ZhoIn the present study, we aimed to perform a population-based analysis of this rare subgroup to develop two online prediction models for quantifying the probability of DM in patients with POSNs and predicting the survival rate of patients with POSNs with DM.via SEER*Stat 8.4.1. Since the SEER database did not publish personally identifiable information, this study did not require the review of the ethic committee of the China-Japan Union Hospital of Jilin University. According to the field of “Primary Site-labeled,” patients histologically diagnosed with POSNs between 2004 and 2017 were included in this study. Patients would be excluded from the study if they met any of the following criteria: (1) race, histological type, T stage, N stage, and tumor size were unknown; (2) the POSN was not a primary tumor; (3) the metastasis status was not clear; (4) the survival time was missing or the survival time was record as 0 month; and (5) POSN was diagnosed only by autopsy or after death. The primary outcome included overall survival (OS) and cancer-specific survival (CSS). OS was defined as survival from diagnosis to death of any cause, and CSS was explained as the span from the diagnosis date until death only caused by POSNs. Ultimately, 1,345 patients with POSNs were included to in this study, 238 of whom presented synchronous DM. All eligible patients were enrolled to form the diagnostic cohort to identify the risk factors of DMs and construct a diagnostic nomogram for quantification of the probability of DM. Subsequently, the 238 patients with POSNs with DM were further included in the prognostic cohort to explore the prognostic factors and establish a prognostic nomogram for OS prediction. The patient selection and workflow of this study are illustrated in The Surveillance Epidemiology and End Results (SEER) database is the largest publicly available cancer dataset, representing approximately 28% of the U.S. population . The resIn this study, eight variables were used to examine the relationship with the occurrence of DM: age at diagnosis, race, sex, tumor grade, histological type, T stage, N stage, and tumor size. For determining independent prognostic factors for patients with POSNs with DM, treatment information was also collected, including surgery, radiotherapy, and chemotherapy. Age at diagnosis and tumor size were transfer categorical variables , respectively. The type of histology was divided into five categories using the International Classification of Diseases for Oncology, third edition (ICD-O-3) Hist/behav: osteosarcoma (9180-9187 and 9192-9194), chondrosarcoma , Ewing sarcoma (9260), and chordoma (9370-9372) including conventional, dedifferentiated, and others. Survival data were also downloaded for survival analysis. In addition, grades I and II (well-differentiated and differentiated) were classified as low grade, and grades III and IV (poorly differentiated and undifferentiated) were classified as high grade.https://www.r-project.org/). P-values <0.05 (both sides) were considered statistically significant. First, Kaplan–Meier (K–M) survival analysis was performed to study the impact of DM on OS and CSS in patients with POSNs. Then, multivariate Cox regression analysis was used to further confirm whether DM served as an independent prognostic factor for patients with POSNs. In both study cohorts, the patients were randomly divided into a training set and a validation set, with a ratio of 7:3 using R software. The chi-square (χ2) test or Fisher exact test was used to compare variables between the two sets. We used univariate logistic regression analysis to find out DM-related factors. Variables with P < 0.05 in univariate analysis were further included in the multivariate logistic regression analysis. Then, independent risk factors  for DM in patients with POSNs were eventually determined. Odds ratios (ORs) and 95% confidence intervals (CIs) were also calculated to show the relevance between clinical characteristics and the development of DM.All statistical analyses in this study were performed in SPSS 26.0 and R software version 4.0.2  and corresponding 95% CIs.In addition, Cox regression analysis was utilized to determine the independent prognostic factors in patients with POSNs with DM. Variables with Afterward, based on determined independent risk factors and prognostic factors, the corresponding nomogram was developed by the “rms” package in R software. Moreover, the two web-based nomograms were further developed using the “DynNom” software package to accurately calculate the probability of DM in patients newly diagnosed with POSNs and the OS rate of patients with synchronous DM. The discriminative ability of the model was evaluated by the receiver operating characteristic (ROC) curve and the value of area under curve (AUC). Calibration curves were plotted to assess the consistency between observational values and predicted values, and decision curve analysis (DCA) was performed to evaluate the clinical value of the nomograms. In addition, net reclassification improvement (NRI) and integrated discrimination improvement (IDI) were used to study whether the model was more accurate in evaluating prognosis than American Joint Committee on Cancer (AJCC) TNM staging system or not. Furthermore, the individual total point of each patient with POSNs with DM was calculated based on the prognostic nomogram. According to the median total point, the patients were assigned into high- and low-risk groups. K–M survival analysis with the log-rank test was conducted to study the difference of OS between the two groups.N = 1145, 85.13%). The distribution of tumor grade was almost equal, with 358 (26.62%) well-differentiated and 353 (26.25%) poorly differentiated patients. In terms of tumor size, the majority of patients  had 5- to 10-cm tumors. In addition, the patients with POSNs often had chondrosarcomas  and stage N0 . Meanwhile, the chi-square test showed that the deviation was completely randomized (P < 0.05)  , and the < 0.05) .p < 0.05) were finally determined as the independent risk factors for DM in newly diagnosed patients with POSNs. Subsequently, a diagnostic nomogram was developed to quantify the probability of DM in patients with POSNs , implying that the predictive accuracy of the comprehensive model was superior to that of the clinicopathologic features alone  in the training set and 0.794  in the validation set, indicating good discrimination of this model . More imes alone . The faves alone . In addies alone . Furtheres alone .Among the included patients with POSNs, DM occurred in 238 cases, accounting for 17.70%. The baseline data of patients with POSNs with DM are shown in P < 0.05) were significantly associated with the survival rate of patients with POSNs with DM  of these points is located on the total points axis, and a line is drawn downward to the survival axes to determine that the probability of overall survival at 24 months was 43%.The univariate and multivariate Cox regression analyses were used to screen robust prognostic factors, which revealed that age, histological type, and surgery   of 0.740 (95% CI: 0.644–0.836) in the training set and 0.710 (95% CI: 0.579–0.841) in the validation set, indicating the adequate discriminative ability of this prediction model. The values of the AUC for OS probability at 24, 36, and 48 months were 0.812, 0.797, and 0.778  in the t 0.0001) , suggestP < 0.0001)  .P < 0.05). A few reasons may account for such discrepancies. First, patients with POSNs with synchronous DM seem less receptive to the advice of complete surgical removal due to its special anatomical location and advanced stage of disease, thus delaying the appropriate timing or even missing out on the opportunity of receiving curative surgery, which ultimately results in the reduction of survival in these patients . This finding was similar to the result of a previous study focusing on the entire population of patients with POSNs .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.


The pandemic has intensified physical and psychological work demands experienced by nurses in a hospital environment. The purpose of this study was to examine personal and work environmental risk factors associated with occupational burnout among hospital nurses.t-test and Mann–Whitney test measured the link between the scopes of occupational burnout and risk factors.We conducted a cross-sectional from April to November 2020. Data from 831 nurses who worked professionally in four educational hospitals were compiled through survey questionnaires to report the prevalence of burnout, occupational and individual factors. Independent r = 0.71, p = 0.001), depersonalization , and personal accomplishment . Mental demand  and effort at work  correlated significantly with emotional exhaustion .About half of the participants indicated moderate symptoms of burnout. The fear of the nurses correlated significantly with emotional exhaustion (The findings indicated a high prevalence of burnout symptoms, particularly emotional exhaustion, among hospital nursing professionals. Occupational health services should consider burnout as an occupational-related condition and provide interventions to reduce workplace chronic stressors and burnout in hospitals. With the spread of the COVID-19 pandemic and cases and hospitalizations surging across the countries, the work environment and workload have highly influenced the well-being of hospital nursing professionals . AccordiThe World Health Organization has classified occupational burnout syndrome as a work-related phenomenon caused by chronic stress . The worBurnout among healthcare providers is a newly emerging challenge that affects healthcare systems and patient safety worldwide . HealthcPrevious studies have shown that occupational burnout is linked to stressful workplaces and leads to the poor health of nurses , 12. FacIncreasing physical and mental work demands on the hospital nursing staff have made it crucial to identify the symptoms, and possible risk factors in the workplace, which lead to occupational burnout . A betteThe present study examined the associations between burnout symptoms, work-related and individual factors, workload, and fear of the SARS-CoV-2 pandemic among hospital nurses.The research hypothesized that 1—Burnout symptoms are frequent in hospital nurses during pandemic crises. 2—The fear due to COVID-19 in the hospital environment contributes to occupational burnout among nurses. 3—The perception of hospital nurses about workplace stressors has a link with burnout symptoms.The present cross-sectional study was performed from April to November 2020. The statistical population comprised around 1,200 nursing professionals working in different wards of five teaching hospitals affiliated with the University of Medical Sciences in the province of Semnan in Iran. The participants were the hospital nursing staff, assistants, and technicians from the surgery, dialysis, intensive care, emergency care, cardiac care, internal medicine, gynecology, and pediatric wards. The inclusion criteria were having a nursing work experience of at least 2 years and signing an informed consent form. The nursing staff contracted with COVID-19 or identified with previous psychiatric or mental disorders were excluded. In this study, of all the copies of the questionnaire distributed among nurses in different wards, 831(69.2%) were returned. Also, 31% of the hospital nursing professionals were excluded because they were not eligible or unwilling to respond or failed to complete the questionnaires.We conducted a paper-based survey and briefed the participants in advance about the project, and sought informed consent for voluntary participation. Three students involved in the study distributed questionnaires and collected data. The questionnaires were in plain Persian language. The first part of the questionnaire was a demographic questionnaire on the nurses' gender, age, marital status, length of nursing work, shift work schedule, education level, and employment status. The second part applied the Iranian version of the Maslach Burnout Inventory- Human Services Survey translated into the Persian language for detecting and assessing the severity of burnout syndrome. It contains 22 items that evaluate burnout with relevant subscales, i.e., emotional exhaustion (EE) (a sense of fatigue and lack of energy), depersonalization (DP) , and personal accomplishment (PA). The EE subscale has nine statements out of which eight items are related to personal accomplishment, and five items to depersonalization. The frequency of these emotions is measured from 0 (never), 1 (sometimes in a year), 2 (monthly), 3 (a few times a month), 4 (every week), 5 , and 6 (every day). Respondents marked their feelings based on the available options.Higher scores in EE and DP subscales or lower scores in the PA subscale demonstrate a high level of occupational burnout. The following ranges of scores were used to determine the level of burnout as low, moderate, or high. Emotional exhaustion is considered low, moderate, or high if EE, respectively, scores ≤18, 19–26, or ≥27. DP scores of ≤5, 6–9, and ≥10 are considered low, moderate, and high for depersonalization, respectively. PA scores of ≥40, 34–39, and ≤33 demonstrate low, moderate, and high levels of personal accomplishment, respectively. A combination of high score levels for the three burnout domains was attributed to a high level of overall burnout. The internal consistencies were estimated for each three burnout dimensions. The Cronbach's factors were 0.84 for emotional exhaustion, 0.76 for depersonalization, 0.79 for personal accomplishment, and 0.80 for the total scale. The reliability and validity of the burnout instrument in Iran were examined and confirmed by Moalemi et al. who reported a test-retest reliability constant of >0.7 for the three dimensions of burnout .The third part of the questionnaire was used to assess perceived nursing workload by measuring four items of the NASA Task Load Index (TLX). While the original version of the NASA-TLX comprises 6 subscales, an earlier study performed a component analysis to determine the causal patterns between NASA-ionTLX and subscales of the Burnout Inventory. The analysis indicated that two subscales including frustration and performance are similar to emotional and depersonalization components along with measures of burnout, which proposed the four subscales including effort, physical, mental, and temporal demands may be a more direct determinant of task load . The iteThe fourth part of the questionnaire assessed the scale of fear perceived by the nurses during the spread of SARS-CoV-2. The fear scale consisted of four items, which were adapted from the perceived threat of the COVID-19 scale : Fear ofAfter the participants completed the questionnaires, the collected data were first scored based on the instructions for the burnout symptom instrument and then analyzed in SPSS 22. This study used statistical tests of percentage, frequency, mean, SD, maximum, and minimum to describe personal and occupational factors, including age, sex, marital status, employment, work hours, and experience.t-test and Mann–Whitney U test to measure the link between the scopes of occupational burnout and personal factors such as sex and marital status. Kruskal–Wallis and one-way ANOVA examined the relationship between occupational burnout and independent risk factors. Spearman's test compared demographic variables with the scopes of occupational burnout. Pearson correlation test assessed the different dimensions and their relations to occupational burnout and task load dimensions. The analysis used frequency percentages to compare occupational burnout in different hospital wards. The significance level was p ≤ 0.05.This study applied an independent We conducted this study according to the rules proposed by the Research Ethics Review Committee of the University Board. Following necessary coordination with the authorities of hospitals, the eligible nurses were enrolled. The nurses were briefed about the study and asked to answer all the questions in the questionnaires. The participation in the study was voluntary and with informed consent. Moreover, we ensured the nurses of data privacy and relevant ethical aspects. The research team coded hospitals, wards, and respondents in the questionnaire to protect their anonymity and confidentiality.Of the 831 nurses, 602 (72.5%) were women and 229 (27.5%) were men. The means and standard deviations of the nurses' age were 34.72 ± 0.7 (ranging 23–49 years), and work experience was 11.19 ± 0.6 (range: 2–29 years). Most of the nurses (93.1%) had a master's degree. Most nurses had received training for safe work procedures in the hospital environment. Over half of the hospital nurses believed that safety and health were acceptable in the work environment. Data related to the characteristics of the hospital nurses who participated in this research are given in The hospital nurses reported high levels of emotion exhaustion , depersonalization , and personal accomplishment . Overall, the nurses had a high task load during the pandemic. The analysis of our data showed that over half of the nurses felt moderate to high time pressure, physical and mental demands, and efforts because of their tasks. Most nurses perceived the fear of COVID-19 threat to their well-being at work (83.87%). The findings showed that 39.1% of the nurses experienced moderate emotional exhaustion, 8.7% had a high score of depersonalization, and 13.9% had a low score of personal accomplishment.p = 0.03), hours of performing work (p = 0.01), and length of work experience (p = 0.01). Depersonalization levels were significant between female and male participants (p = 0.01). The degree of threat caused by the pandemic was statistically different between subgroups of variables of sex (p = 0.001), marital status (p = 0.01), age (p = 0.02), length of work experience (p = 0.005), type of employment (p = 0.01), and hours of performing work in a shift (p = 0.01).r = 0.19, p = 0.001).r = 0.68, p = 0.001). Depersonalization had higher correlation with mental demand , effort (r = 0.51). Personal achievement had higher correlation with mental demand (r = 0.67), effort (0.58). The fear of SARS-CoV-2 perceived by nurses associated significantly with emotional exhaustion , depersonalization , and personal accomplishment .The analyses indicated that emotional exhaustion highly correlated with the nurses' effort .AD, MB, FF, FP contributed to the study material preparation, conceptualization, methodology, data collection, analysis, interpretation, and writing, reviewing and revising the manuscript. All authors reviewed and commented on previous versions of the manuscript. All authors read and approved the final manuscript. All authors contributed to the study conception, design, and investigation.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.


Using trait-based questionnaires to assess MW compared with online probes resulted in an average significant change of 0.30 in the correlation between MW and RC, leading to a null correlation. A significant effect of age was also found, with more negative correlations with increasing age. None of the other moderating variables considered  resulted in a significant effect. From the present meta-analysis, we might suggest that MW and RC are partially overlapping and vary, within a swing effect, in relation to a set of shared factors, such as working memory, interest, and text length. There might also be side-specific factors that drive the movement of primarily one side of the swing, and future research should further consider the role of individual differences in RC. Implications for research and educational settings are discussed.Mind wandering (MW), a shift of attention away from external tasks toward internally generated thoughts, has been frequently associated with costs in reading comprehension (RC), although with some contrasting results and many reported potential intervening factors. The aim of the meta-analysis was to evaluate the relationship between MW and RC, considering the role of participants’ and text’s characteristics, as well as methodological issues in the measurement of the two constructs. From a set of 25 selected full texts (73 correlation coefficients), pooled correlation ( Mind wandering (MW) can be broadly defined as a shift in the contents of thought away from an ongoing task and/or from events in the external environment to internally self-generated thoughts and feelings  and/or stimulus-independent thought  and the attention towards external information may explain the negative influence of MW for comprehension performance during reading, for which the occurrence of MW episodes while reading is associated with deficits in representation at the lexical, propositional, and situational levels of the text  reporting guideline recommendations  between MW and RC. For full-text selection, two independent coders (third and fourth authors) completed the first evaluation with an interrater agreement of 91.7%; if consensus was not achieved, the first and last authors jointly reached a final evaluation. The third and fourth authors firstly coded data reported in Table Of the 314 article titles identified, through the evaluation of two independent coders (third and fourth authors), 61 were considered eligible for further analysis and fully read. Interrater agreement on abstract selection was 93.02%; in case consensus was not achieved, the first and last authors jointly reached a final evaluation. Full texts were included in the meta-analysis when studies (a) reported measures of MW and RC , (b) involved school-aged participants (>10 years old) and/or adult (ages 18–40) skilled readers without any reported clinical condition, (c) reported correlation indexes  correlation indices.All correlation coefficients were entered independently in the case of papers with multiple studies or multiple correlations coefficients between MW and RC under different conditions. For studies reporting correlations involving latent factors , manifest-variable correlations were recovered from appendices included in the studies or by contacting the authors and asking for the original data sets , text type , text length , MW assessment , and RC procedures  could be considered intervening factors of the relationship between MW and RC performance. For identifiability reasons, in regression analysis with categorical predictors, such as some of our moderators, for each moderator , a category  was considered as reference, and its effect is incorporated in the model intercept. The other levels  are measured in contrast with the reference one. In Table Each of the analyses was conducted in R (Version 4.1.1) using the Other potential mediators such as topic interest, text difficulty, and working memory capacity were reported in some studies but only as correlation values with MW  included more than one study, for a total of 73 studies  eventually included in the meta-analysis. Thus, the 25 papers involved a total of 3,926 participants. Table n = 50; 68.5%). Other countries included Germany , followed by Italy  and Oman . Two studies reported in one paper  employed informative written material, while the remaining studies either used narrative texts  or did not explicitly report the type of text used . The length of the texts used was reported in 38 (52%) of the 73 individual studies included in the analyses. On average, texts included M = 2,991.92 words . Across studies, RC was mostly assessed through multiple-choice questions , while 4.1% included open-ended questions and 6.8% included true–false questions; others only reported the use of standardized tests without reporting the specific modality (5.5%). Online probes were most commonly used  to assess MW, followed by 2.7% adopting online self-report, 6.9% posttest self-report, 8.2% trait measures, and 5.5% using eye-gaze measures. Associations between MW and topic interest, text difficulty, and working memory capacity were only reported in 41 (56%), four (5.47%), and 25 (32.5%) studies, respectively.Studies were conducted mainly in English-speaking countries , indicating a significant negative association between MW and RC—that is, people who tend to mind wander more often tend to exhibit lower reading comprehension. The same analysis on probed MW gives similar results, with a pooled correlation of r = −.23 .In the first analysis, correlation indexes from 73 individual studies were considered . Begg’s statistics test is not significant , thus indicating the absence of bias. Finally, the trim and fill procedure added a total of 13 studies and produced a corrected correlation which is still significant . To note, the outliers shown in Fig. r values (±1).An additional sensitivity analysis was conducted to test the effect of studies with more than one experiment by merging them to their average correlation. This analysis yielded an overall correlation of −0.23 CI , which is consistent with the results of the complete data. Finally, to evaluate publication bias and confirm the robustness of these findings, we have applied the Egger’s regression, the Begg’s test statistics, and the trim-and-fill analysis. The funnel plot displayed in Fig. p = .021). Using trait-based questionnaires to assess MW with respect to online probes resulted in an average significant increase of 0.305 in the correlation between MW and RC, thus leading to an almost null correlation. None of the other moderating variables considered  significantly affect the correlation.The effects of moderators considered that might affect the relationship between MW and RC are reported in Table The present study was aimed at conducting, for the first time with respect to previous literature, a comprehensive review and meta-analysis about the relationship between MW and RC and potential moderators.First, we will discuss the strength of the relationships and the role of moderators. Then we will move to define a theoretical approach for interpreting the relationship and the related moderators considered in the light of previous literature and pointing out new perspectives and predictions.r = −.21), with a similar trend when considering only studies where MW was tested through on-tasks probes (r = −.23). According to widely used guidelines, the correlation can be generally considered in a low to moderate range  conducted to assess the relationship between MW and adults’ performance in a wide set of cognitive tasks other than RC  as determined by both shared and side-specific factors see Fig. .Fig. 4ThBased on the present meta-analysis, working memory, text difficulty, topic interest, and text length can be considered amongst the shared factors that equally impact MW and RC processes, possibly modulated by individual differences in attentional control that further impact the extent to which the reader can adapt to the internal and external requests. However, since MW and RC are two constructs that are not completely overlapping, we also recognize that there might be side-specific factors that drive the movement of primarily one side of the swing, such as mood for MW or decoding skills and vocabulary for RC. These side-specific factors, although exerting an influence mainly on one side of the swing , might nevertheless have an indirect influence on the other side .Based on this theoretical approach, some further considerations can be put forward regarding either shared or side-specific factors.and lowered attentional control with increased MW. In other words, this person might be unable to dynamically adjust cognitive resources, resulting in high MW and low reading comprehension. A similar pattern might hold for the other moderators included in the present study, such as text difficulty and topic interest. Some previous studies suggested that MW susceptibility was not dependent on RC context  used to assess MW instead of online probes  would imply an average increase of 0.30 in the correlation between MW and text comprehension, thus leading to an almost null correlation. Conversely, both online and post self-report measures of MW produce similar results as probes  might improve RC, and, on the other side, working on texts to favor RC  might reduce participants’ engagements in MW. A final issue that might open further research is related to the contents of MW. Given that MW, on certain occasions, has been found to have beneficial effects on cognition, further investigation should respond to the question about “which contents of MW interfere with RC and which are, instead, beneficial.”


Autophagy refers to the process in which cells wrap their damaged organelles or unwanted proteins into a double-membrane structure and direct them to lysosomes for degradation. Autophagy can regulate many lung diseases such as pulmonary hypertension, acute lung injury, and lung cancer. However, few bibliometric studies on autophagy are available. The aim of the present study was to clarify the role of autophagy in lung diseases by bibliometric analysis.Publications were retrieved from the 2012–2021 Science Citation Index Expanded of Web of Science Core Collection on 20 September 2022. Bibliometrix package in R software was used for data retrieval. VOSviewer and CiteSpace were used to visualize the research focus and trend regarding the effect of autophagy on lung disease.A total of 4,522 original articles and reviews on autophagy in lung diseases published between 2012 and 2021 were identified. China had the largest number of published papers and citations, whereas the United States (US) ranked first in the H-index and G-index. Moreover, cooperation network analysis showed close cooperation between the US, China, and some European countries, and the top 10 affiliates were all from these countries and regions. Bibliometric analysis showed that “autophagy” and “apoptosis” were the keywords with the highest frequency. During the past decade, most studies were concerned with basic research on pathways related to the regulatory role of autophagy in the inhibition and attenuation of lung diseases.The study of autophagy in lung diseases is still in the development stage. The information published in these articles has helped researchers understand further the hot spots and development trends in the field more and learn about the collaboration network information regarding authors, countries, and institutions, as well as the paper citation correlation. More studies have been performed to gain deeper insights into the pathogenesis of autophagy by focusing on the links and effects between various diseases. More recently, research in this field has paid increasing attention to the function of autophagy in COVID-19–related lung diseases. Autophagy (“self-eating” in Greek) refers to the process in which cells wrap their damaged organelles or unwanted proteins into a double-membrane structure and direct them to lysosomes for degradation , 2. AutoBibliometric analysis pays attention to the literature systems and literature characteristics and broadly serves for understanding the knowledge structure as well as exploring the developmental trends by virtue of the qualitative and quantitative scientific literature analysis . BibliomWe performed a systematic search for the Science Citation Index Expanded (SCI-Expanded) of Web of Science Core Collection (WoSCC) in 2012–2021 during 1 January 2012 and 31 December 2021, and we downloaded the data on 20 September 2022 for avoiding deviations. The search terms included: TS = (autophagy) AND TS= (“pulmonary” OR “lung”). Two reviewers (FH Lin and JX Yuan) took charge of independently identifying this data search and discussing underlying differences, with the final agreement of 0.90 . After eFirst, the original data were extracted from the SCI-Expanded database of WoSCC. The recorded information included the number of papers and citations, H-index, publication year, countries/regions, affiliations, authors, journals, references, and keywords. Afterward, duplicate authors and misspelled elements were moved artificially. Although inaccurate analysis may not be avoided completely due to multiple versions of cited references, the same abbreviated names of different authors, and different forms of cited journals, we pointed out the first extracted original data from the SCI-Expanded database. The recorded information was paper and citation number, H-index, G-index publication year, countries/regions, affiliations, authors, journal, references, and keywords. Then, we removed misspelled elements and duplicate authors. Cited references have different versions, different authors may have the same abbreviated name, and cited journals have different forms, which may lead to inaccurate analysis. Despite this, most raw data were accurate. We removed the misspelled elements and duplicate authors and adopted a thesaurus file for merging duplicates into one word, deleting useless words and correcting the misspelled elements. Later, we imported the cleansed data to VOSviewer (version 1.6.18.0), CiteSpace (version 6.1. R3), and the “bibliometrix package 4.0.1” of R software (version 4.2.1) for the subsequent bibliometric analysis.via the number of publications (NP) and the number of citations without self-citations (NC). Sometimes, H-index is used to evaluate the individual academic achievements or the publication output  stands for the language and environment specific to the statistical computing and graphics. It presents a strong extensibility, capable of automating the analyses and creating new functions. The cleansed data received bibliometric analysis under the assistance of bibliometrix package in R . To furtVOSviewer, CiteSpace, and R (version 4.2.1) were used for the statistical computing and graphics. VOSviewer uses data from WoSCC for establishing the bibliometric maps , capableThe number of retrieved publications was 4,522, including 3,772 original research articles and 750 reviews, with total NC of 114,589, a mean NC/article ratio of 27.91, and a mean H-index of 130.2 of 0.9872 , followed by the US  and South Korea   ranked first, followed by Ryter Stefan W. (28 publications), Wang Jing (25articles), and Wang Wei (24 articles) . The study only included English articles and reviews from the SCI-Expanded. (2) Currently, the limitation of software-based scientific measurement added the difficulty in combining at least two databases for the analysis. Hence, the study only adopted the WoSCC database for the screening and might have missed the other related studies in the literature. Therefore, more databases should be employed for a more rigorous analysis in the future. (3) Open-source journals may have an impact on both citation volume and publication volume. (4) The combination of CiteSpace and VOSviewer for literature analysis may miss information during analysis. Specifically, VOSviewer keyword analysis clustering might not have been able to extract key information, because color was only used to divide the range.According to bibliometric analysis, the research on autophagy in the field of lung diseases has broad prospects and rapid development. We identified the major contributors, regions, and publications in the research area. China published the largest NP and the US made more huge breakthroughs. The latest studies have been published and new progression regarding the field has been made on AUTOPHAGY and ONCOTARGET. Recently, oxidative stress has been revealed to have significant impact on the pathogenesis of autophagy-mediated lung diseases. In addition, the mechanism of autophagy induction may prove crucial as a treatment strategy for COVID-19 over classical antivirals and provide a tool to end the pandemic. Attenuating the progression of COVID-19–associated lung diseases by inhibiting autophagy may become a new research hotspot in this field.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding authors.FL, YC and WM did the bibliometrics analysis and wrote the manuscript. HZ, ZX, SH, XS, ML, JW and WZ participated in the experimental design and manuscript writing. SW and XL designed this study and organized the manuscript writing. All authors contributed to the article and approved the submitted version.


The pre-pregnancy weight and gestational weight gain (GWG) are closely related to perinatal maternal and infant complications, but the relationship between pre-pregnancy weight and GWG and the pattern of interaction have not been reported. This study investigated the influence of weight control during pregnancy on the perinatal maternal and infant outcomes.n = 167) and the control group (n = 668). The pre-pregnancy body mass index (BMI), GWG, and perinatal outcomes of the women and infants were determined in two groups.A total of 835 singleton pregnant women who were hospitalized between January 2018 and December 2018 were retrospectively included in this study and divided into two groups: the diet guidance (DG) group (The dietary modification and reasonable exercise during pregnancy effectively reduced the GWG, and even some women with pre-pregnancy obesity achieved weight loss during pregnancy. The GWG in the DG group was significantly lower than in the control group, especially in the second and third trimesters. GWG was positively related to birth weight. The birth weight in the DG group was significantly lower than in the control group when their mothers had similar GWG. In women with pre-pregnancy obesity, GWG seemed to be negatively related to birth weight. However, after adjusting the mean BMI, the pre-pregnancy BMI and GWG were positively related to the birth weight. Compared with the control group, the incidences of dystocia, postpartum hemorrhage, macrosomia, small for gestational age infants and neonatal complications significantly reduced in the DG group, and the preterm birth rate was comparable between two groups. Some women with pre-pregnancy obesity lose weight during pregnancy, but there was no premature birth or small for gestational age infant. The incidences of macrosomia, postpartum hemorrhage, dystocia, cesarean section and gestational diabetes increased significantly with the increase of pre-pregnancy BMI.For women with increased pre-pregnancy BMI, strict weight control is required to reduce obesity-related complications of the mother and infant. The weight control in the second and third trimesters is especially important and most likely to prevent GWG. Compared with GWG, pre-pregnancy BMI has greater influence on the birth weight and maternal and infant complications, and may even compromise the benefits of weight control during pregnancy. Thus, weight control is recommended before pregnancy. The pre-pregnancy weight and gestational weight gain (GWG) are closely related to perinatal complications. Obesity as a consequence of social factors and hormones during pregnancy has become a common social phenomenon in pregnant women, and excessive increase in the GWG is common in clinical practice. Currently, obesity is one of the most critical health threats worldwide, and the incidence of obesity is still rising in women of childbearing age . Pre-prePre-pregnancy obesity may cause spontaneous abortion and congenital embryo abnormality in early pregnancy , and theIn addition, excessive GWG may increase pelvic pressure, which aggravates the postpartum pelvic dysfunction during delivery, and affects postpartum recovery of body shape and the quality of life. Women with excessive GWG will develop body fat accumulation after delivery, and the elevation of GWG (according to the criteria of the Institute of Medicine [IOM]) may increase the risk of postpartum obesity , and als2), normal weight (BMI = 18.5–25 kg/m2), overweight (BMI = 25 ~ 30 kg/m2), and obesity (BMI = ≥30 kg/m2), and recommended GWG [In 2009, the IOM divided the pre-pregnancy body mass index (BMI) as follows: underweight . Written informed consent was obtained from all subjects prior to study. All procedures were performed in accordance with the Declaration of Helsinki.Singleton pregnant women who were hospitalized in our hospital between January 2018 and December 2018 were included in the present study . A totalAll the pregnant women received routine prenatal examinations once every 4 weeks within the first 28 gestational weeks, once every 2 weeks between 28 and 36 gestational weeks, and once weekly after 37 gestational weeks. In the first prenatal examination, the body composition and diet were analyzed; the vital signs, body weight, medications, comorbidities, findings from physical and imaging examinations, clinical diagnosis, and medical prescriptions were also recorded in the following examinations.Grouping: This was a retrospective study. All the pregnant women were divided into two groups: the diet guidance (DG) group and the control group. In the DG group, subjects received prenatal examinations and consulted obstetrics dietitians. In the control group, subjects received routine examinations without consultation with obstetrics dietitians.In the DG group, there were 167 subjects. Each subject received guidance from an obstetric nutritionist according to the general condition and weight gain, the diet composition was adjusted, and the nutritional education and exercise guidance were administered: (1) At each prenatal examination, the pregnant women received education about the possible risks of excessive GWG , and the physicians emphasized the important of weight control during pregnancy, corrected their wrong knowledge about diet and asked them to cooperate with treatment to avoid excessive anxiety; (2) They were given low-glucose, low-carbon diet, and the coarse grains and dietary fiber increased in the diet; the daily energy intake did not exceed the recommended daily average energy ; (3) They were asked to exercise appropriately  [In the control group, there were 668 subjects who received nutritional education once in the first trimester , and they received oral diet guidance at each examination.The GWG was defined as the difference between the self-reported pre-pregnancy body weight and the body weight before delivery. The GWG was recorded in three stages: the first trimester (difference between the self-reported pre-pregnancy body weight and body weight at 12 weeks of gestation age), the second trimester (difference between the body weight at 28 weeks and body weight at 12 weeks), and third trimester (difference between the body weight before delivery and body weight at 28 weeks). In addition, the cumulative weight gain was monitored at each stage.The maternal outcomes included cesarean section, premature delivery (earlier than 37 weeks of gestation age at the time of delivery), dystocia , postpartum hemorrhage   and GDM.The propensity score weighting was employed to adjust baseline variables, and the constructed weight variable effect estimation target was the average treatment effect (ATE), which was used to weight the outcome variable. Propensity score matching and propensity score regression were used for sensitivity analysis. The propensity score matching employed the greedy algorithm, and the ratio of subjects in the DG group to those in the control group was 1:3.P value of intergroup LS mean were reported. P value of the main effects of the group was reported.The cumulative GWG at different time points was used as the dependent variable, and the Mixed-Effect Model for Repeated Measures was used for analysis. The height, pre-pregnancy weight, group, time, and interaction between group and time were included in the model with a non-structural covariance structure. The Least Square (LS) mean of each group at different time points and its 95% CI, and the P value of groups at different stages were reported.The GWG between two adjacent stages was used as the dependent variable, and the analysis of covariance model (ANCOVA) was used in which the height, pre-pregnancy weight, and group were included. The mean LS, 95% CI, and P values of pre-pregnancy BMI and group were reported. If there was a significant difference in the interaction, only the results of the interaction were reported.Birth weight was used as the dependent variable, and the covariance analysis was employed for comparison between groups. The pre-pregnancy BMI, group, and interaction between the group and BMI were included in the model. If there was no significant difference in the interaction, it was removed from the model, and the Logistic regression analysis was used in which the height, pre-pregnancy weight, and group were included. The Odds Ratio (OR) of the group and its 95% CI were reported.P values of pre-pregnancy BMI and group were reported. If there was a significant difference in the interaction, only the results of the interaction were reported.The baseline metabolic rate in the first trimester was used as the dependent variable, and ANCOVA was used in which the pre-pregnancy BMI, group and interaction between pre-pregnancy BMI and group were included. If there was no significant difference in the interaction, it was removed from the model, and the P values of pre-pregnancy BMI and GWG were reported. If there was a marked difference in the interaction, only the results of interaction were reported.Birth weight was used as the dependent variable, and the general linear model was employed for analysis. The pre-pregnancy BMI, GWG, and their interaction were included in this model. If there was no significant difference in the interaction, it was removed from the model, and the 2, 18.5–24.9 kg/m2, 25–29.9 kg/m2 and 30 kg/m2), and the consistency was employed among different subgroups. A value of P < 0.05 was considered statistically significant. SAS 9.4 was employed for statistical analysis.In this study, subjects were subdivided according to the pre-pregnancy BMI (< 18.5 kg/mP > 0.05)  Table . In addi5) Table A.Table 1P = 0.0838) in the first trimester, 6.07 kg  vs. 7.38 kg  (P < 0.0001) in the second trimester, and 10.40 kg  vs. 12.51 kg  (P < 0.0001) in the third trimester. The F value of the main effect (diet guidance) was 29.91 (P < 0.0001), and the reduction was observed in each stage of pregnancy, especially in the second and third trimesters (P < 0.0001)  and macrosomia  reduced significantly in the DG group. In addition, the incidences of postpartum hemorrhage, SGA, and neonatal complications reduced markedly in the DG group as compared to the control group (OR < 1). However, there were no significant differences in the incidences of GDM, cesarean section and premature delivery between two groups , normal weight (18.5–25 kg/m2), overweight (25–30 kg/m2), and obesity (BMI ≥ 30 kg/m2) subgroups. In the four subgroups, the relationship between GWG and birth weight was evaluated. Results showed the GWG in the underweight, normal weight, and overweight subgroups were positively related to the birth weight: the higher the GWG, the higher the birth weight was. However, in the obesity subgroup, the GWG was negatively related to birth weight. After weight control, the birth weight increased with the reduction of GWG. It seemed that the GWG had no relationship with birth weight .The fitted line in the figure was from the model: birth weight = a + b1 × pre-pregnancy BMI + b2 × GWG + b3 × pre-pregnancy BMI × GWG. The average pre-pregnancy BMI in four subgroups was included into the model, and four regression lines were obtained. The After dietary intervention, the GWG decreased significantly in pregnant women with different pre-pregnant BMI, and the decrease of GWG was more evident in women with higher BMI Fig. A, especiCompared with the control group, a significant difference in the birth weight was only observed in the pre-pregnancy normal weight subjects after dietary guidance, suggesting that the influence of pre-pregnancy weight masked the effect of weight control during the pregnancy Fig. B.P < 0.0001). This suggests that dietary and exercise guidance improves the BMR in pregnant women with higher or lower BMR.The daily energy intake was compared in the first trimester of women with different pre-pregnant BMI. Results showed the daily basal metabolic rate  of pregnant women increased significantly with the increase of BMI Fig. C. After Logistic regression analysis showed that, in the pre-pregnancy underweight women, the OR of clinical indicators was close to 1 between the DG group and the control group, suggesting no marked difference. In the pre-pregnancy normal weight, overweight, and obesity subgroups, the incidences of macrosomia, dystocia, postpartum hemorrhage, SGA, and neonatal complications tended to decrease after dietary guidance (OR < 1). In the women with different pre-pregnancy BMI, the incidences of macrosomia, postpartum hemorrhage, dystocia, cesarean section, and GDM increased significantly with the increase of pre-pregnancy BMI Fig. .Fig. 5CoIn the present study, the singleton pregnant women in our hospital were retrospectively analyzed, the characteristics of GWG were explored in women with different pre-pregnancy BMI, and the effects of diet management during the pregnancy on the maternal and neonatal outcomes were further investigated. Our results showed that the dietary guidance and appropriate exercise were effective in reducing GWG as compared to the simple nutrition guidance, and even some women with pre-pregnancy obesity achieved weight loss during pregnancy. Compared with the control group, the GWG in the DG group reduced significantly in each stage of pregnancy, especially in the second and third trimesters. This indicates it is important to control body weight during the pregnancy. In general, the GWG was positively related to the birth weight. Of note, as compared to the control group, birth weight was lower in the DG group when the GWG was comparable during the pregnancy. It was surprising that the GWG was negatively related to the birth weight in the pre-pregnancy obesity subgroup. That is, after weight control, the birth weight was higher when the GWG was reduced, which suggests no relationship between GWG and birth weight. However, when the mean BMI was used, the pre-pregnancy BMI and GWG positively affected the birth weight. It suggests that the higher pre-pregnancy body weight masks the effect of weight control during pregnancy in the pre-pregnancy obese women.Compared with the control group, the incidences of dystocia, postpartum hemorrhage, macrosomia, SGA, and neonatal complications significantly reduced in the DG group, and the incidence of preterm birth remained unchanged. The dietary and exercise guidance improved the BMR of pregnant women with higher or lower BMR. In addition, our results showed several women with pre-pregnancy obesity achieved weight loss during the pregnancy, but premature birth and SGA were not observed. This indicates that the active weight control during pregnancy in the pre-pregnancy obese women may not increase the risk of preterm birth and SGA, but has the possibility of reducing the risk of perinatal complications because pre-pregnancy weight has greater influence on the risk of complications during the pregnancy and perinatal period.Our study showed that the incidences of macrosomia, postpartum hemorrhage, dystocia, cesarean section and GDM increased significantly with the increase of pre-pregnancy BMI, suggesting that pre-pregnancy weight contributes more to the outcomes such as macrosomia, GDM and way of delivery. This also highlights the importance of weight control before pregnancy. Some studies have shown that increased pre-pregnancy BMI is an independent risk factor for GDM because high pre-pregnancy BMI increases the adverse maternal and infant outcomes, and the incidence of GDM further increases in pregnant women with overweight or obesity –27. The Therefore, both pre-pregnancy obesity and excessive GWG may increase the transfer of heat to the developing fetus and affect fetal development, which threatens the maternal and infant health and are related to the increased risk of miscarriage, GDM, stillbirth, premature delivery and cesarean section . For exaIn addition to active weight control before pregnancy, reasonable pregnancy management is also needed to control the GWG, which may effectively reduce the birth weight and decrease maternal and infant complications during the perinatal period. A meta-analysis of clinical studies in 2022 has revealed that dietary and excise guidance seems to be an optimal way to prevent GDM and overweight during pregnancy . The proThe American College of Obstetrics and Gynecology and the Physical Activity Guidelines for Americans in 2018 recommend ≥30–150 min of aerobic exercise per week , 35. TheIn a randomized, parallel-group, controlled trial, the influence of telehealth lifestyle intervention on the GWG was investigated in women with overweight or obesity. The results showed telehealth lifestyle intervention could improve the healthy behaviors and insulin resistance and reduce the GWG in these women . In the Barone et al. reported that higher sedentary behavior and lower standing, stepping, and steps per day trajectories in the second and third trimesters increased the risks of adverse pregnancy outcomes . AnderseIn summary, for pregnant women with higher pre-pregnancy BMI, strict weight control is required to reduce the maternal and neonatal complications related to obesity. Compared with GWG, the pre-pregnancy BMI has greater influence on the birth weight and the maternal and infant complications, and may even compromise the benefits of weight control during pregnancy.Therefore, the control of body weight before pregnancy is of great importance. For women with high pre-pregnancy BMI, weight control program  is recommended to reduce GWG or even reducing weight during the pregnancy, which may reduce the birth weight, decrease the incidences of dystocia and postpartum hemorrhage without increasing maternal and infant complications, and tend to reduce the incidences of premature delivery and SGA.


P values below 0.05 were considered statistically significant. Positive thinking training led to better thinking (p < 0.001), higher resilience (p < 0.001), and greater life satisfaction (p < 0.001). The study's findings showed the effectiveness of the positive thinking training approach in improving resilience and life satisfaction in older adults. It is recommended to evaluate the long-term outcome in populations with different social, economic, and cultural statuses in future studies.The cumulative effects of adversity and unhappiness affect life satisfaction and quality of life in the growing older adult population. Most of the interventions aimed at improving the health and quality of life of older adults have adopted a problem-oriented or weakness-focused approach. However, a positive or strengths-focused approach can also have a virtuous but more effective capacity to contribute to the well-being and life satisfaction of older adults. Therefore, the present study was conducted to investigate the effect of positive thinking training on improving resilience and life satisfaction among older adults. A randomized controlled trial was conducted on 100 older adults with simple random sampling. The intervention group received 90-min weekly sessions for eight weeks on positive thinking training through written homework for reflection, group discussion, and media. The data were collected using Ingram and Wisnicki Positive Thinking Questionnaire, Connor-Davidson Resilience Scale, and Tobin Life Satisfaction Questionnaire at baseline and one week and two months after the training. The collected data were analyzed using descriptive and inferential statistics in SPSS software 26.  The simultaneous effects of health disorders experiences and socioeconomic problems throughout life lead to life satisfaction challenges and low tolerance of problems during old age2. Older adults care programs have often focused on secondary care for some physical and psychological illnesses with a negative health approach. Psychological research and theory on welfare and quality of life have also focused on the influence of negative aspects3. In contrast to this traditional attitude, however, the past two decades have witnessed the occurrence of an alternative positive viewpoint, which originates from developmental psychology and explores the personal and environmental factors that can improve psychological happiness and quality of life, particularly during hardship or stress5.The older adult population is growing because of improved healthcare and education systems. These individuals encounter physical, psychological, and social adjustments that challenge their sense of self and capacity to live. Many people experience loneliness and depression episodes in old age due to living alone or lacking a close family, which results in the inability to participate in community activities6. Several features of resilience, including physical, mental, and social features, have been well-known among older people9, representing the multi-dimensionality of this feature. High resilience during later years of life has been accompanied by ideal outcomes, such as reduced depression and anxiety, increased quality of life, and improved lifestyle behaviors12. In general, individual factors, such as level of education, cognitive and emotional abilities, self-care skills, beliefs, and attitudes, as well as physical-social environment factors, including family, healthcare system, social welfare, and physical environment facilities for the safe presence of older adult's individuals in the community have vital effects on their physical and mental health. In this way, these factors can affect their efficiency and life satisfaction14. Studies have indicated that life satisfaction and happiness do not depend solely on external conditions; individual mental states, such as hope, self-esteem, and a sense of efficiency, are also important. Individuals with a positive mental structure can evaluate many negative events positively16. Resilience is one of the most important determining factors of older adults’ mental health. Resilience refers to individuals’ traits and skills that empower them to thrive in the face of hardship or a disruptive event11. Resilient people have flexibility, high confidence, life expectancy, the ability to forgive others, purposefulness, social participation, and a positive view of life and the future that prevents anxiety and depression in older adults17. In addition to internal and personal factors, external and environmental factors affect resiliency18. Thus, resilience is not a static phenomenon. In this context, resiliency can be improved by interventions, such as positive thinking techniques, reviewing past events, having social participation, strengthening self-confidence and motivation, using a semantic approach, e.g., yoga, and reinforcing internal powers20.New positive approaches have focused on the importance and role of individual components and skills, including resiliency, and increased emphasis on ideal or successful aging22. The positive approach aims to identify the structures and methods that lead to well-being, happiness, and increased life satisfaction. Therefore, using positive training techniques to increase older adult's individuals’ resilience can act as a barrier to the physical and emotional weaknesses of older adults. Studies in Iran have evaluated the impact of positive thinking on older adults' mental health, psychological well-being, life expectancy, and loneliness25. However, these studies have not been able to directly investigate the impact of positive thinking on the improvement of resilience in this population. In other countries, the effects of positive thinking skills on increasing the resilience level have been somewhat proven26. However, resilience is an individual-social process that is significantly affected by culture and religion. Even the aging phenomenon is defined differently in various societies24.The pattern of individual thinking is important; individuals with positive thinking can overcome problems, while negative thoughts can lead to greater problems. Therefore, people can overcome life difficulties and events by abandoning negative thoughts and replacing them with positive ones27.In Iranian society, older adults are highly respected, and there is a positive attitude toward their knowledge and experiences, which gives them a deep sense of usefulness. However, negative stereotypes about their abilities prevent them from being active in society and interfere with their creativity, liveliness, and care priorities. Accordingly, overcoming these negative stereotypes leads to a sense of empowerment, resilience, and life satisfaction. Thus, providing effective educational, emotional, cultural, and social interventions can be helpfulHence, the results of these studies cannot be generalized to Iranian society without independent evaluations. To our knowledge, no empirical studies were found in the current research framework. Additionally, the previous studies have only considered a part of the relationships, and a few similar studies have yielded inconclusive results. Considering the transition to old age in Iranian society and considering cultural, social, religious, and economic factors that vary among communities, the present study aims to investigate the effects of positive thinking training on increasing the resilience level and life satisfaction in a population of Iranian older adults.This study was conducted with the clinical trials registration number IRCT20171212037844N1 and the registration date of 15/01/2018. In addition, all methods were carried out following relevant guidelines and regulations. The study objectives and procedures were explained, and the participants were asked to sign the written informed consent forms.23, using the appropriate formula with the type I error rate of 5% and the test power of 80%, considering a 10% attrition rate, the sample size was calculated as 45 participants in each group. Participants were selected in each center with the simple random sampling technique. For this purpose, the list of names of older adults covered by the center was considered the basis for sampling. The sampling interval was calculated by considering almost equal sex proportions using a randomization number between 1 and 10. The selected people were checked in terms of the inclusion criteria, and in case of ineligibility, the next person was selected from the list. All the participants had normal vision and hearing, scored ≥ 26 on the Mini-Mental State Examination (MMSE), and had the physical and mental ability to answer the questions. The participants had no psychiatric or neurological disorders and received no psychoactive drugs. Writing and reading literacy was another inclusion criterion. However, the exclusion criteria were being absent for more than two sessions, participating in similar training courses, and reluctance to continue participating in the study. The CONSORT diagram of the study is shown in Fig. This educational randomized controlled trial was conducted in Shiraz, Iran, in 2018. The study population included people aged 60–70 covered by the older adult daycare centers affiliated with Welfare Organization in Shiraz. Based on a similar study28, the Connor-Davidson Resilience Scale29, the Tobin Life Satisfaction Questionnaire30, and a demographic information questionnaire.The participants were asked to complete four questionnaires, including the Persian version of the Ingram and Wisnicki Positive Thinking QuestionnaireThe demographic data included age, sex, level of education, marital status, having children, housing situation, employment status, monthly income, and suffering from diseases."I have a good sense of humor"; scored using a 5-point Likert-type scale ranging from 1 (never) to 5 . Thus, the total score of this questionnaire ranged from 30 to 150, with an average score of 90. Total scores above 90 and closer to 150 indicate a higher degree of positive thinking. The reliability index of this questionnaire was found to be 0.92 using Cronbach’s alpha28, which was 0.96 in the present study.Ingram and Wisnicki's Positive Thinking Questionnaire contained 30 items, e.g., "I take pride in my achievements." The reliability of the questionnaire was calculated with Cronbach’s alpha of 0.8929, which was 0.97 in the present study.Connor-Davidson Resilience Scale included 25 items graded on a five-point Likert scale ranging from 1  to 5 , with higher scores reflecting greater resilience. An example of the items in this questionnaire is ., "I have gotten more of the breaks in life than most of the people I know." The rest had positive content, e.g., "I have made plans for things I’ll be doing a month or a year from now." The statement “I do not know” was assigned two scores. In addition, positive statements received three scores for positive responses and one for negative ones. In contrast, negative statements were assigned three scores for negative responses and one for positive ones. Thus, the total life satisfaction score ranges from 13 to 39, with higher scores representing a higher level of life satisfaction. The reliability coefficient was calculated as 0.93. Cronbach’s alpha and Guttmann coefficients were found to be 0.79 and 0.78, respectively30. Cronbach’s alpha was 0.96 in the present study.Tobin Life Satisfaction Questionnaire consisted of 13 items. Five items had negative contents, e.gBaseline (Pre-test) and demographic data were collected one week before starting the training sessions. Post-intervention data were collected one week (Post-test) and two months (Follow-up) after the end of the intervention.32 in the field of positive thinking, including Strengths of Character , Engagement and Flow , and Meaning (Class Assignment). The training was performed using teaching/learning methods, including Interactive lecturing, group discussion, and media, such as PowerPoint presentations and audio and video clips. Based on scientific evidence, writing thoughts, feelings, and experiences, especially in combination with their expression, strengthens the character, reduces distress, and improves mental health. It is important to note that group discussions are more effective in these cases37. Hence, at the end of each session, participants were given written homework for reflection at home to practice positive thinking; they explained and discussed it in the group at the beginning of the next session (Except session 8). It should be noted that their practical experience was introduced as a method of positive thinking. The topics, as well as the objectives of each training session, are summarized in Fig. The individuals in the intervention group participated in training sessions on positive thinking consisting of one 90-min session per week for eight consecutive weeks. The session's content was based on the theories of positive psychology38 and G-Power 3.1.9.2 . Data normality was checked by Shapiro–Wilk test. Additionally, a chi-square test was used to analyze the demographic data. Moreover, Repeated Measures ANOVA and independent T-test were performed to compare the research constructs' means. Bayesian inference was also used to update the probability of the hypothesis as more evidence or information became available. In all statistical tests, a p value below 0.05 was considered statistically significant.The collected data were analyzed using descriptive and inferential statistics in the SPSS software version 26All the participants were required to complete a written informed consent form. This study was approved by the Ethics Committee of Shiraz University of Medical Sciences (IR.SUMS.REC.1396.122).p = 0.52; BF = 5.36]. The frequency distribution of other demographic data in the control and intervention groups is summarized in Table The descriptive findings of this study showed no statistically significant differences in terms of the mean age (year) between the control group  and the intervention group ; there was moderate evidence for the equal mean of age between two groups  and in the follow-up phase . In the intervention group, there was very strong evidence for the mean scores difference of positive thinking in the pre-test, post-test, and follow-up stages , and the effect of the intervention was maintained over time . However, moderate evidence for the difference was observed between the two groups in this regard 1 week after the intervention  and in the follow-up phase . In the intervention group, there was extreme evidence for the difference in the mean score of resiliency in the pre-test, post-test, and follow-up stages  . Nonetheless, extreme evidence for the difference was found between the two groups in this regard after the intervention  Table .Table 3Tp < 0.001] and in the follow-up phase . In the intervention group, there was strong evidence for the difference in the life satisfaction scores in the pre-test, post-test, and follow-up stages  . However, extreme evidence for the difference was found between the control and intervention groups in this regard after the intervention [t (98) = −4.53, 17. Similarly, Ruiz-Rodríguez et al. conducted an interventional study and reported a significant relationship between social support, positive thinking, and social relationships with the degree of resilience39. Lysne PE et al. reported a significant positive correlation between resilience and different dimensions of health and life satisfaction40. Resiliency leads to life satisfaction through improving mental health and indirectly affects life satisfaction. In other words, resilience leads to a positive attitude and life satisfaction by affecting individual feelings and excitement41. The current study's clear and practical results can be implemented as training programs for many similar aging centers. However, this study had several limitations, including limited follow-up for only two months, selection of the study groups from older adult centers, and non-generalizability of some findings, such as resilience due to ethnic and cultural differences.The main purpose of the present study was to investigate the effect of positive thinking training on increasing resilience levels and life satisfaction in a population of Iranian older adults. Designed positive thinking interventions are very sparse, specifically those targeting older adults. Most existing projects and studies have focused on high-risk younger adults, most of which are theoretical research studies with methodological weaknesses, small populations, and no exact outcome measures, which are inaccessible or invalid for older adults. Considering the cultural and social differences amongst societies, the lack of a similar study on an Iranian population, and low scores of positive thinking, resilience, and life satisfaction among Iranian older adults based on the present study findings, it seems necessary to perform appropriate interventions. The results of this study showed that the positive-thinking intervention significantly increased the mean scores of positive thinking, resilience, and life satisfaction in the intervention group one week and two months after the intervention. Several studies have been conducted on promoting resilience through older adults’ capability to enjoy positive experiences, activities to predict future events, and tools to reinforce relationships that activate feelings of pleasure and well-beingIn conclusion, the current study findings revealed a relationship between resilience and positive thinking. Positive thinking and interventions can increase older adults’ resilience, and thereby improve their quality of life. High quality of life can lead to greater life satisfaction. In addition, positive psychological training can directly contribute to positive and healthy thinking, ultimately leading to a better dynamic life for older adults.Supplementary Information.


Existing studies reporting on the levels of physical fitness among high school students use relatively few fitness tests for indicators of physical fitness, thus, incomprehensively evaluating the levels of physical fitness. Therefore, this study investigated the relationship between body mass index (BMI) and physical fitness index (PFI) by investigating five physical fitness indicators and calculating PHI.Z-scores based on sex-specific mean and standard deviation were calculated, and the sum of Z-scores from the six fitness tests indicated the PFI. The findings were fitted to a linear regression model to elucidate the potential relationship between BMI and PFI.Anthropometric measurements and indicators from five measures of physical fitness  were assessed. BMI was calculated to classify individuals into underweight, normal weight, overweight, and obese categories. p < 0.001), and PFI in the obese category was significantly lower as compared to all the other BMI categories for both male and female groups (p < 0.001). The association between PFI and BMI showed an inverted U-shape relationship.In total, 176,655 high school students  in Jinan, China, completed the physical fitness tests between 2020 and 2021. The one-way ANOVA models showed that PFI in the normal category was significantly higher as compared to all the other BMI categories within both male and female groups (This study demonstrated that BMI affects the PFI in both males and females. As compared to the obese and overweight categories based on BMI, significantly higher scores of PFI were observed for males and females. The prevalence of obesity among adolescents has been rising globally due to the accelerated rate of unhealthy eating, and reduced or lack of adequate physical activity, and has become a public health problem . The higBody mass index (BMI) is universally considered a marker of health and is widely used to measure malnutrition, overweight, and obesity –13. StudThis study aimed to analyze the levels of different physical fitness components among high school students and evaluate the association between BMI and health-related physical fitness. We hypothesized that BMI could effectively reflect the physical fitness levels of Chinese high school students.n = 176,655, male: 88,243, female: 88,412, age: 17.1 ± 1.05years, height: 168.87 ± 11.1 cm, weight: 62.54 ± 15.15 kg; see The data were collected from a national survey on physical fitness conducted among high schools between 2020 and 2021 in Jinan of Shandong province, China. Students aged 15–18 years completed the physical fitness tests , and finally the cardiorespiratory endurance test. In the standing long jump test, the “best of three jumps” was considered the result; “the best of two” results were considered for the 50-m running test, while other tests were performed once. We adopted intelligent physical health monitoring equipment, through non-contact measurement using the infrared multi-point sensor array, which automatically recorded the students' scores and uploaded these values to the system for storage.2. Students were divided into four categories based on their BMI values according to the criteria recommended by the World Health Organization (WHO) as follows: < 18.5 kg/m2, 18.5–23.9 kg/m2, 24–27.9 kg/m2, and ≥28 kg/m2, representing underweight, average weight, overweight, and obese individuals, respectively /height (m)ectively .The tests for physical fitness included 50 m sprints, sit and reach, standing long jump, 800/1,000 m runs, pull-ups, and bent-leg sit-ups.To evaluate students' speed and explosive strength a 50 m sprint was conducted. Students were tested in groups of four. When the investigator indicated, “go,” the subjects began the 50 m sprint. They finished the run as fast as they could. The time in minutes and seconds was recorded .To assess lower hamstring flexibility, a sit and reach test was conducted. Each subject was barefoot and sat on the test instrument. They gradually reached forward as far as possible with their knees extended. The test was conducted twice, and the best of the two scores was retained .Standing long jump was conducted to assess lower-limb strength. Each subject stood at the starting line and was asked to jump forward as far as they could. The distance was measured in meters from the starting line to the heel of the closest foot. The test was conducted twice, and the best of the two scores was retained .Each student stood at the starting line and was asked to complete the 800- or 1,000 m run as fast as they could. The time in minutes and seconds was recorded. Female students ran 800 m run, while male students ran 1,000 m .Pull-up was used to evaluate the upper body's muscular strength. The test was scored as the number of pull-ups. The subject jumped up and pulled the bars with both hands. After standing still, subjects pulled with both arms simultaneously. Only the male students performed this test .Each subject was instructed to lay on a mat with knees bent at 90 degrees, raise their upper body, and touch their knees with their elbows. The number of bent-leg sit-ups completed in 1 min was recorded. Only the female students performed this test .Z-score for each physical fitness test was /national standard deviation; the shorter the time for the 50 m run, 1,000 m run for boys, and the 800 m run for girls, the better the performance. Therefore, the PFI was—Z pull-ups or 1-min sit-ups + Z standing long jump + Z seated forward bend-Z 50 m running-Z 1,000/800 m running . An independent sample t-test or one-way analysis of variance (ANOVA) was conducted to compare the mean differences among groups. When a significant interaction was observed, the LSD post hoc correction was performed to confirm the significance. The linear regression model in the Stata package was used to determine the trends in PFI throughout the study duration. The level of significance was set at p < 0.05 for all tests.Experimental data were processed using the IBM SPSS statistical software . All data were presented as “mean ± standard deviation” (p < 0.001), and PFI in the obese category was significantly lower as compared to all the other BMI category for males and females (p < 0.001). No significant effect on PFI for all the BMI categories was observed within the male and female groups (p > 0.150).The one-way ANOVA models showed that PFI in the normal category was significantly higher as compared to all the other BMI categories in both male and female groups (p < 0.001). The logistic regression analysis showed that PFI in both males and females was related to BMI (p < 0.001). Additionally, the logistic regression analysis showed that PFI in both males and females of different ages was related to BMI  in young adulthood, whether it is in the form of individual or team sports, or an unstructured physical activity like backyard games . School The results of this study suggested that both low weight and obese categories according to BMI would induce a negative effect on physical fitness and physical health levels, consistent with the findings of previous studies , 27–29. Several limitations of the pilot study should be noted. First, this cross-sectional study cannot establish a causal relationship between physical fitness, body size, and fitness level, but it does identify an association between BMI and PFI. Second, the sample does not truly represent the number of high school students in China, as more than 95% of the study participants were from Jinan, Shandong Province. Additionally, though many of the observed results in physical fitness can be observed in these outcomes, body composition, and daily nutritional intake are more exact factors related to the level of physical fitness. Future studies consisting of body composition, food habits, and eating behaviors are thus demanded to confirm the findings of our study. Studies with larger sample sizes and comprising participants from different provinces, as well as other cohorts , are warranted to examine and confirm the observations in this study in the future.In conclusion, BMI affects the PFI in both males and females. Compared to the obese and overweight categories based on BMI, significantly higher scores of PFI were observed for males and females. Nevertheless, this study provided preliminary evidence that BMI affects the PFI in both males and females. Compared to the obese and overweight categories based on BMI, significantly higher scores of PFI were observed for males and females. Thus, PFI should be highly demanded to predict the physical fitness of high school students. Future prospective and longitudinal cohort studies must accurately identify the causal relations and potential mechanisms.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by the Ethics Committee of Shandong Normal University (2021036). Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.GQ, BL, and YQ: design and/or conceptualization of the study. GQ and YQ: analysis and/or interpretation of the data. GQ drafting and/or revising the manuscript. All authors contributed to the article and approved the submitted version.