Mood disorder, impulsivity and aggression are common in drug users compared to healthy controls. However, no study has focused on the difference in various types of drug users. Therefore, the objective of this study was to explore the differences in depression, anxiety, impulsivity, and aggression among methamphetamine, heroin and polysubstance users and to further explore the risk factors for severe depression in the three groups.Drug users over 18 years old who met the DSM-V diagnostic criteria for substance -related disorders were included in the study. All participants completed a general questionnaire, the Zung Self-Rating Depression Scale (SDS), the Zung Self-Rating Anxiety Scale (SAS), Barratt impulsiveness Scale Version 11 (BIS-11), and the Buss-Perry Aggression Questionnaire (BPAQ). One-way ANOVAs or Chi-square tests were used to test the differences among the groups, correlation analysis was used to test the relationship between drug use and other parameters, and multiple logistic regression was conducted to assess the risk factors for severe depression.A total of 1,486 participants were included, comprising 86.3% males with a mean age of 38.97 years. There was a significant difference in the percentage of severe depression and SDS scores among the three groups, but no significant difference was found in SAS, BIS-11 and BPAQ scores. Using methamphetamines, hostility and anxiety were risk factors for developing severe depression in all the participants and anxiety remained constant in the other three groups. Moreover, methamphetamine use was 2.16 and 3.35 times more likely to cause severe depression than heroin and polysubstance use, respectively. The initial age of substance use was negatively correlated with BPAQ, SAS, and SDS scores, whereas the drug use duration and addiction duration were positively correlated.In this study, we found that the highest prevalence of severe depression was in participants using methamphetamines and that using methamphetamines, hostility, and anxiety were risk factors for developing severe depression. This result addressed an important gap in our knowledge of the different characteristics of depression, anxiety, impulsivity and aggression in various types of substance users and provides clinicians and policy-makers with directions for intervention and preventing relapse. Drug abuse issues have become a social problem that affects millions of people with the development of the economy. According to the World Drug Report 2019, nearly 270 million people used drugs, 35 million were addicted to drugs, and 600,000 died from drug abuse that year around the world [Mental disorders, especially mood disorders, are common in drug abuse patients. Previous studies have found a bidirectional relationship between mood disorders such as depression or anxiety and drug abuse –5. GrantImpulsive behaviours such as impulsivity and aggression were also common in drug abuse patients. Impulsivity could promote the initiation, maintenance and relapse of drug addiction, which typifies the at-drug abuser group –12. CompA relationship between drug use, mood disorders and impulsive behaviour was also found. Studies have suggested that individuals who use drug such as marijuana , heroin To our knowledge, the relationship among drug use, mood disorders and impulsive behaviour has not been studied before. We speculated that drug abuse may induce mood disorder such as depressive, anxiety symptoms and emotion regulation difficulties, which may in turn cause impulsive behaviours, such as gambling and using alcohol and drugs. Moreover, previous studies only compared the prevalence of mood disorders and impulsive behaviour in a specific drug user  compared to healthy controls. The difference in mood disorder and impulsive behaviour among various types of drug users, especially among a group with compulsory detoxification has not been studied. This research may provide clues for individualized therapy, preventative strategies, and specific management measures in different drug users. Therefore, the purpose of the study was to explore differences and the relationships among depression, anxiety, impulsivity and aggression and to further explore the risk factors for the development of severe depression in various types of drug users.This cross-sectional study examined depression, anxiety, impulsivity, and aggression among methamphetamine-only, heroin-only, and polysubstance groups. All clinical data were collected from August 2016 to July 2018 at the Compulsory Detoxification Centers in Sichuan, Shaanxi, Qinghai, Gansu, Ningxia Province. A face-to-face interview was conducted by experienced psychiatrists. This study was approved by the West China Hospital of Sichuan University Biomedical Research Ethics Committee. All the participants who were willing to participate in this study were informed of the study purpose, methods, and possible risks and benefits they could receive from this study in advance. Those who agreed to participate signed the informed consent form.Participants who were over 18 years old and diagnosed with a substance-related disorder according to DSM-V criteria with recent usage of methamphetamine or heroin and detoxified for at least two weeks at the time of enrolment were invited for screening. They should also understand the study protocol and be able to sign the informed consent form. Participants with lifetime/current diagnosis of severe mental illness (SMI) according to the Standards for the Management and Treatment of Severe Mental Disorders in China  or personality disorder, alcohol use disorder, cognitive impairment, and any other serious physical diseases were excluded. A participant flow chart is presented in Fig. Age, gender, ethnicity, education, employment status, type of substance use, initial age of substance use, substance use duration and substance addiction duration were collected from all participants. Participants who reported that they had repetitive and compulsive self-medication behaviour with increasing use of substance doses were considered as addicted. The substance addiction duration was the time they had the above behaviours to the time when they participated in this study. Addiction duration for those who did not have the above behaviours was 0 years.The Zung Self-Rating Depression Scale (SDS) and Zung Self-Rating Anxiety Scale (SAS) were used to assess the presence and severity of depression and anxiety in all participants , 28. TheImpulsivity was measured by the Chinese version of Barratt Impulsiveness Scale version 11 (BIS-11) , 30, whiThe Buss-Perry Aggression Questionnaire (BPAQ) is a self-reported scale to evaluate four domains of aggression, including physical aggression, verbal aggression, anger and hostility. The Chinese version of the BPAQ we used in the study was revised by Lv et al. , and is p < 0.2 in the univariable analysis were included in the multivariable analysis. Statistical analyses were performed using SPSS software (version 26.0), and p < 0.05 was defined as statistically significant.Continuous variables are presented as the mean ± standard deviation, while categorical variables are presented as the number (N) and percentage (%). Comparisons of continuous variables and proportions among groups were performed using one-way ANOVA followed by the LSD post-hoc test and chi-square test. The homoscedasticity of the data herein was tested prior to one-way ANOVA. Pearson correlation analysis was used to evaluate the correlation between substance use vs. depression, anxiety, impulsivity, and aggression. Univariate logistic regression analysis was performed before multivariate logistic regression analysis to determine the possible risk factors related to severe depression. Independent variables with p = 0.18 and p = 0.82, respectively).A total of 2120 participants were invited to participate in the study and 1486 were available for the final analysis, including 232 participants in the methamphetamine-only group, 843 participants in the heroin-only group and 411 participants in the polysubstance group. A participant flow chart is illustrated in Fig. p = 0.005). The mean SDS score of the methamphetamine-only group was 58.06 ± 10.94, which was higher than that of the heroin-only group  and the polysubstance group , and there was no difference between the heroin-only group and the polysubstance group (p > 0.05) . In Fig. p = 0.03). However, no significant difference was found between the heroin-only group (52.09 ± 11.92) and the methamphetamine-only group or the polysubstance group.For anxiety, there was no significant difference in the percentage of severe anxiety evaluated by SAS in the three groups . In addition, the scores on attention (p = 0.97), motor (p = 0.44) and nonplanning impulsivity (p = 0.29) showed no significant differences among the three groups.The BIS-11 score is shown in Fig. p = 0.84). In addition, the hostility, verbal aggression, physical aggression, and anger domains also showed no significant differences among the three groups. However, the verbal aggression score was significantly lower in the methamphetamine-only group than in the heroin-only group  and the polysubstance group .As shown in Fig. As shown in Fig. In Table p = 0.005). However, most components of impulsivity and aggression scores showed no significant difference among the three groups. Drug use types were a risk factor for severe depression in all participants, as they were 2.16 times and 3.35 times more likely to develop severe depression in the methamphetamine-only group than in the heroin-only and polysubstance groups, respectively. Moreover, the SDS and SAS scores were correlated with the initial age of substance use, substance use duration, substance addiction duration, impulsiveness and aggression evaluated by the BIS-11 and BPAQ respectively. The aggression evaluated by the BPAQ was also correlated with substance addiction duration.In this cross-sectional study, we explored the differences in depression, anxiety, impulsivity and aggression and risk factors for severe depression in methamphetamine-only, heroin-only, and polysubstance groups among 1486 participants. We found that the prevalence of severe depression (defined as an SDS score > 72) was the highest in the methamphetamine-only group, middle in the heroin-only group, and lowest in the polysubstance group  than heroin abusers . The intStudies have indicated that individuals who are young men and have a low educational level, low income, and unemployment status are more likely to take drugs , and theThese findings have implications for clinicians and policy-makers. For clinicians, the meaning of these findings is that they need to assess not only levels of severity of substance use disorders but also mood disorders that may be a cause for relapse when treating patients with substance use disorders. For policy-makers, more mental health services should be offered to patients with substance use disorder, and targeted strategies for various types of drug users should be conducted to prevent relapse.There are some limitations that may affect the interpretation of the results. First, due to the different types of drugs and various dosages, it was difficult to estimate the quantities of drug-taking. Therefore, the effect of drug use frequency and dosage on mood and behaviour disorders is unknown. Second, because of some social problems, substance abusers may be more likely to conceal some information, which may affect the accuracy of the data. Third, the samples were from compulsory detoxification centres, which that may limit the generalizability of conclusions to other populations. Fourth, the estimates reported in our article were based on SDS and SAS cut-offs rather than clinical appraisal, and they should be interpreted with caution as depression and anxiety prevalence estimates in drug users. Finally, the group of methamphetamine users was considerably smaller than the heroin and polysubstance use groups, which could have affected the statistical power to detect relevant determinants of severe depression in the regression analyses presented in our study.The current study was the first to compare the differences in characteristics, mood disorders, impulsivity, and aggression in various types of drug users and to explore the risk factors for the development of severe depression. We found a higher prevalence of severe depression in participants using methamphetamine than in those using heroin or using multiple substances, and methamphetamine abuse, anxiety, and hostility were risk factors for developing severe depression in substance users. Anxiety remained a steady risk factor for developing severe depression in drug users. These results addressed an important gap in our knowledge of the different characteristics of depression, anxiety, impulsivity, and aggression among various types of substance use and provide a clue for further study.


BW was recorded retrospectively from the children’s Road-to-Health cards. Weight and height were measured using standard procedures, and D2O dilution was used to determine total body water and, subsequently, to determine body fat. Fatness was classified using the McCarthy centiles, set at 2nd, 85th, and 95th . BW correlated with body composition measures, such as body weight , height , and fat free mass . When multiple regression analysis was employed, BW significantly and positively associated with FFM  and fat mass  in girls and boys combined. A total of 13% of the children had a low BW, with 21% being overweight and 17% obese. More girls than boys were overweight and obese. Intervention strategies that promote healthy uterine growth for optimal BW are needed in order to curb the global obesity pandemic.Low and high birth weight (BW) are associated with obesity later in life; however, this association has not been extensively studied in African countries. This study determines the association between BW and body composition derived from deuterium oxide (D Childhood obesity is increasing at an alarming rate globally, with approximately 50 million girls and 75 million boys affected . ChildhoThe risk of obesity is further increased by environmental factors such as low physical activity, poor diet, socio-economic status (SES), and breastfeeding practices ,7,8. AltBirth weight (BW) has been used as an indicator of intrauterine growth . High biThe need to report body composition using FM and FFM, especially in children, is of paramount importance. Yet, inconsistent findings have been reported on the impact of BW on both FM and FFM ,19. Bern2O in 6- to 8-year-old South African children. We hypothesized that BW would be positively associated with the body composition components of FM and FFM in childhood. This information will be useful in designing strategies for improving maternal health status in order to prevent either obesity or underweight in childhood.It is, therefore, not known whether similar associations between birth weight and body composition are present in South African children, who are faced with the paradoxes of the nutritional transition linked to both underweight and obesity. It was against this background that we aimed to determine the association between BW and body composition as determined by DIn this study, a cross-sectional descriptive study design was used in a sub-sample of 91 children (40 boys and 51 girls) from a larger study on body composition, using a stable isotope technique (BC–IT study) ,24. The Permission for the study was received from the school principals and district office of the Department of Basic Education in the Dr Kenneth Kaunda District Municipality of North West Province. Subsequently, the Human Research Ethics Committee in the Faculty of Health Sciences (HREC) of North-West University approved the study protocol (ethics no: NWU-00025-17-A1). Participant recruitment was conducted through advertisement in primary schools in the district, with permission from the Department of Education. A sample that best represented both high and low SES was selected from the schools within Potchefstroom in the North West province of South Africa. The class lists for Grade R to Grade 3 were requested from the five participating schools, and every third child on each class list was nominated to participate in the study. Subsequently, only children with parental informed consent and verbal assent (6-year-olds)/written consent (7–8-year-olds) were included in the study. Furthermore, in this sub-sample, only children who provided the completed RtHC were included. Data collection started in September 2017 and lasted until May 2019.Information on families’ socioeconomic status (SES) , were collected by trained fieldworkers, as previously described .For each participating child, BW was retrieved from the RtHC and recorded in kilograms (kg). For analysis, BW was then categorised into low birth weight , normal birth weight  and high birth weight , in line with the World Health Organization (WHO) definitions ,28,29.Body height (cm), weight (kg), and waist circumference (cm) were determined by following the International Society for the Advancement of Kinanthropometry (ISAK) procedures . MeasureBMI z-scores were calculated using WHO reference data, and subsequently, as previously described in the BC-IT study , partici2O was guided by the protocol provided by the International Atomic Energy Agency (IAEA) [2O method has precision and accuracy rates of 1–2% for measuring TBW. The hydration factor is assumed to be 73%, and the FFM is estimated from TBW using this assumption. Since the percentage of water in the FFM was found to be between 70% and 76% in most species, it would be ideal to use population-specific hydration factors of FFM. The estimates of %BF from the TBW method showed small differences (<1% BF) as compared to the 4-compartment model [The determination of FM% by Dy (IAEA) . The impy (IAEA) . After ant model ,33,34. Int model ,33,34. Mnt model  centilesnt model .p ≤ 0.05.Data were analysed using the Statistical Package for the Social Sciences (SPSS) software version 26 . Normality was assessed by visual inspection of QQ plots and the statistical one-sample Kolmogorov–Smirnov normal distribution examination. Logarithmic transformations were performed for data that were not normally distributed . In order to describe participants’ characteristics, descriptive statistics in terms of means and standard deviations were calculated for continuous data. Independent Welch’s unequal variances t-tests were performed to determine the differences between the birth weight categories. For all categorical variables, percentages were calculated, and Pearson’s Chi-square (χ2) was calculated to determine the differences between categories. Multiple regression analysis  and partial correlation were determined in order to show the relationship between BW (independent variable) and childhood body composition (dependent variables). In performing regression models and summarizing data in a correlation matrix showing correlation coefficients between variables, analyses were adjusted for age, sex, and selected socio-economic factors. The probability level of significance was set at A total of 91 children (40 boys and 51 girls) with birth weight data were included. 2O based on body fatness  of the total participants were born with LBW. The prevalence of overweight and obesity was 21% and 17%, respectively, when using the D fatness . In contp = 0.08).p = 0.03), height , FFM , and FM . After adjustment of age and sex, only height showed a significant correlation with BW. This correlation was no longer significant after adjustment for parent education level and household income.p = 0.013; 95%CI: 0.032; 0.441) and FM  in girls and boys combined. When the group was separated according to sex, BW was positively associated with FFM  and showed a trend of positive association with FM  in girls. After adjustments were made for age, sex, and household income in the total group, only FM remained positively associated with BW ; however, sex (p = 0.007) showed a positive association with FM in the same model. In the adjusted regression model for girls and boys separately, BW explains a very low percentage of variance in the body composition variables.The aim of the study was to determine the association between BW and body composition in 6- to 8-year-old South African children. In summary, the results from a sample of children from Potchefstroom in the North West province of South Africa showed that BW was significantly and positively associated with body composition measures of FFM and FM. LBW was reported in 13% of the children, and children with LBW were significantly smaller in terms of height compared with children with NBW. A high prevalence of overweight and obesity was reported in children, with girls more affected than boys.p = 0.08). The small number of children in the LBW group (n = 12) is probably the reason why statistically significant differences could not be detected. In addition, it is noteworthy to mention that sex was the strongest predictor of FM in this age group. The observed significant association between BW and FM in our study is somewhat different from other studies. To cite examples, Bernhardsen and colleagues [The positive association between BW and body composition in childhood has been shown in several studies ,21,36. Illeagues  did not lleagues . The meclleagues . This hiThe prevalence of overweight and obesity in children is rising at an alarming rate in Sub-Saharan Africa . SimilarIntrauterine growth indicated by BW is one of the factors that drives the global epidemic of obesity . The not2O, in contrast to many previous studies, which have used the more crude outcome variable of BMI-for-age. This allowed us to examine the association between BW and body composition using objective measures in South African children. Findings from this study can be used to guide larger studies on which method to use to measure adiposity. However, there are limitations, for example, missing retrospective BW from RtHC from the larger BC–IT study affected the sample size of the sub-study, and might have influenced the result, particularly the finding of no difference in FFM and FM between the LBW and NBW groups. The use of retrospective BW has been acknowledged by some researchers [The strength and novelty  of this study is that it reports body composition in terms of FM and FFM determined by the Dearchers  as a sigearchers , which iearchers , due theearchers . To citeearchers , it was In line with our hypothesis, BW was significantly associated with FFM and FM at age 6 to 8 years. However, sex appeared to be the strongest predictor in the relationship between BW and FM in this study. The prevalence of overweight and obesity was higher and more pronounced in girls compared to boys. As such, sex-specific intervention strategies that will help promote healthy body composition and normal BW are needed in order to curb the obesity pandemic.


This study aimed at analyzing preferences in technology-based cardiac physical therapy programs in older adults with CAD. Additionally, a comparison by sex was performed. (2) Methods: Cross-sectional study. 70 older adults with CAD  were evaluated. Technology use and preferences in technology-based cardiac physical therapy programs (Technology Usage Questionnaire) were assessed. (3) Results: 97.1% of the sample had Smartphones and 81.4% accessed the Internet every day, mostly with their Smartphones (75.5%). A total of 54.3% were interested in receiving rehabilitation via their Smartphone, and most of the sample considered ideas to manage stress (92.9%), healthy meal ideas and recipes (85.7%), exercise ideas (84.3%), exercise prompts (72.9%), setting goals (67.1%), exercise taught by a virtual therapist (65.7%), ideas to overcome cigarette cravings (62.9%), information on local exercise opportunities (60%), ideas to remember to take medications (57.1%), steps to achieve goals (54.3%) and eating tips for takeaways (51.7%) very useful. Additionally, men considered the technology-based advice about exercise prompts, healthy meal ideas and recipes, and ideas to manage stress more useful than women, and had more frequently a Smartphone, less frequently made phone calls, had more regular access to the Internet, and used the Internet more often. (4) Conclusions: Clinicians should encourage older adults to engage in cardiac technology-based physical therapy programs to provide meaningful exercise counselling, promote healthy lifestyle and healthy aging. One of the most important events of the 21st century is that the world population is ageing and, although this is somewhat desirable, the fact is that the number of people over 60 years of age is increasing more than other groups. Therefore, a population with comorbidities is growing at the same time .Coronary artery disease (CAD) is defined as the pathological process characterized by the accumulation of atherosclerotic plaque in the coronary arteries that triggers arterial narrowing and reduces heart flow (obstructive or not), and is a common issue in older adults in the developed world which has considerable impact on their morbimortality .Cardiac physical therapy programs (CPP), which focus on physical and psychosocial recovery and on the promotion of healthy lifestyles, have a pivotal role in the standard treatment. CPP aims at reducing the progression of CAD and at obtaining an improvement in older adults’ health. It focuses on the underlying cause of cardiovascular disease and thus promotes healthy aging; so, older adults can preserve and resume optimal functioning in their community ,6,7. HowTele-rehabilitation (TR) is a new alternative that has revolutionized physical therapy programs, and can be defined as a rehabilitation treatment based on the use of information and communication technologies . PublishHowever, although in the general population the usability, usefulness, acceptability and acceptance of cardiac TR seems to be high, there may be other factors that influence the acceptability of these programs, such as the patient’s knowledge about technologies, taking into account that an efficient use would imply a greater use of TR . ConsequThe main objective of this study was to analyze the preferences in technology-based CPP in older adults with CAD. Additionally, a comparison by sex was performed.A cross-sectional study was undertaken in the present study at the University of Valencia, Valencia (Spain). Participants were recruited from cardiac rehabilitation centers.All participants were informed about the purpose and content of the project and provided written informed consent to participate in the study. All procedures were approved by the Committee of Ethics in Experimental Research of the University of Valencia (IE1529270) and complied with the requirements listed in the 1975 Declaration of Helsinki and its amendment in 2008.A total sample of 70 subjects was included in this study. Inclusion criteria were having a diagnosis of CAD and being able to maintain independent ambulation. Those who presented recent symptoms of chest pain, decompensated hypertension or any other musculoskeletal condition that could affect the ability to perform physical activity were excluded.First, an interview with the study participants was conducted to collect sociodemographic information .The technology usage of older adults was assessed with the Technology Usage Questionnaire , concretSecond, preferences of patients regarding technology-based CPP were assessed with the Technology Usage Questionnaire , concretp < 0.05. All statistical analyses were carried out in IBM SPSS Statistics software .Analysis of survey responses was largely descriptive. Items were re-coded such that 1 equaled a positive response , while 0 indicated a negative response. Gender was coded as one for male and two for female. Descriptive measurements were shown as mean, with their standard deviation, or frequencies. Moreover, the Chi square test was employed to find differences between sex in qualitative variables. Statistical significance was set for all statistical tests with a degree of significance p > 0.05), although statistically significant differences were found with respect to education  and employment .A total of 70 patients constituted the final sample. Sociodemographic variables are depicted in 2 = 8.235, p = 0.04), with a low to moderate relationship. Also, the use of a mobile phone for phone calls , regular access to the Internet  and frequency of Internet use  presented a low-to-moderate association when comparing by sex. No further significant associations were found for the rest of the variables analyzed by sex (p > 0.05)  .Heart rate monitors to measure heart rate during exercise sessions were used by 60% of the participants (50% of women and 62.50% of men).p > 0.05) (2 test showed no significant association in any variable with respect to sex (p > 0.05). Finally, all patients were asked whether they thought it would be useful to perform a CPP through Nintendo Wii, as well as the level of interaction , as well as whether they considered virtual rehabilitation useful. When comparing by sex, the χ2 test showed no significant associations in any variable (p > 0.05).Regarding preferences in technology-based CPP programs, most of the participants were interested in receiving continuing advice and support about cardiac rehabilitation through a mobile phone/Smartphone, and the most preferred form of communication was email. Most of the participants would like to sign up to a free program that offered this type of communication, although they would prefer not receiving messages. No significant association was found in any of the variables when comparing by sex ( > 0.05) . In addi2 = 14.73, p = 0.005), with a moderate relationship. Similar results were found regarding the association between the utility of healthy meal ideas and recipes  and the utility of practical ideas to manage stress  and sex, with a low to moderate relationship. No further significant relationships were found for the rest of the variables analyzed by sex  (p > 0.05)  .A total of 94.6% of men and 50% of women reported they were not interested in wearing any other type of device to measure their physical activity level.This is the first study that shows the technology use and preferences in technology-based cardiac physical therapy programs of older adults with CAD. Our study suggests that patients with CAD are interested in technology-based cardiac physical therapy but do not present many differences by sex in the variables that analyze the use of technology, as well as preferences in technology-based physical therapy programs. In this regard, differences were found in having a Smartphone, use of the Smartphone, regular access to the Internet, and frequency of Internet use. By contrast, older men made phone calls less frequently. Moreover, older men found exercise, healthy meal, recipe and managing stress ideas more helpful than older women with CAD.This information is relevant given the fact that technological progress in mobile applications, social networks, wearable sensors for vital signs and virtual games is more immediate every day. Then, an approach using new technologies to the elderly seems to be a challenge that needs to be overcome in order to promote healthy aging . In addiRegarding access to the Internet, we found significant differences between men (87.5%) and women (57.1%). By contrast, Peels et al., (2013) , Or et aOn the other hand, both physical activity and the decrease of sedentary behaviors could reduce several comorbidities. Therefore, the use of technologies and devices focused on increasing physical activity could improve wellbeing ,29. In oA total of 62.5% of men and 50% of women in our sample used heart rate monitors while performing exercise. However, it should be noted that in our sample, 96.60% of men and 85.70% of women who did not use heart rate monitors were not interested in using another type of monitoring device. By contrast, Buys et al., (2016)  pointed Lastly, regarding the preferences of older adults about the useful advice of technology-based cardiac physical therapy programs, several outcomes such as exercise ideas, exercise prompts, healthy meal ideas and recipes, practical ideas to manage stress and how to overcome cigarette cravings were considered very useful by the sample. These results are similar to those obtained by Buys et al. , who obsIn summary, the future of technology-based physical therapy programs seems to be promising, as an increasing percentage of the population uses new technologies. In addition, due to the health situation experienced during the COVID-19 pandemic, the percentage of face-to-face physical therapy programs has been reduced, whilst uptake and use of remote technologies has increased allowing services to be delivered to patients’ home. Finally, to promote healthy aging, future research should investigate the usefulness of technology-based CR programs in promoting adherence to CR guidelines, to test its impact on improving physical activity, functional capacity and overall quality of life in patients with CAD.In conclusion, most older adults with CAD had Smartphones and accessed the Internet every day. In addition, most of them were interested in receiving rehabilitation via their Smartphone, and considered ideas to manage stress, healthy meal ideas and recipes, exercise ideas, exercise prompts, setting goals, exercise taught by a virtual therapist, ideas to overcome cigarette cravings, information on local exercise opportunities, ideas to remember to take medications, steps to achieve goals, and eating tips for takeaways in technology-based cardiac physical therapy programs very useful. Additionally, older men considered technology-based exercise prompts, information on healthy meals and recipes, and ideas to manage stress more useful than older women, and had greater use of Smartphones, made phone calls less frequently, accessed the Internet more regularly, and used the Internet more frequently. The overall use of technology has improved over the years, however, some gender-specific considerations need to be made to motivate greater uptake of technology-based cardiac rehabilitation programs and adherence to cardiac rehabilitation guidelines.


Salmonella enteric, Listeria monocytogenes, and Escherichia coli were identified. Due to convenience, rapidity, and accuracy, the label-free method we report here has great potential for the identification of diverse foodborne microorganisms at single-cell sensitivity.Foodborne pathogenic microorganisms have become major threats that endanger human life and health. The current technology cannot perform rapid screening of foodborne pathogenic bacteria, and fail to timely control food safety risks. Here, we develop a novel microfluidic sensor for real-time and label-free bacteria classification at the single-cell level. Concretely, a low-aspect-ratio SiN micropore with PDMS coating was fabricated, which could significantly reduce the noise of the sensing system, and makes the microfluidic pore sensor sensitive to bacteria discrimination. The prepared SiN micropore equipped with the high temporal-spatial resolution was applied to observe bacterial translocation “events” and the current pulse signals could be obtained, which depend on the size, charge, and morphology of the target bacteria. According to the variation of the current pulse signals produced by different bacteria across the micropore, three common foodborne pathogens such as  Salmonella, Listeria monocytogenes, Staphylococcus aureus, Vibrio parahaemolyticus, Escherichia coli, etc. These pathogenic bacteria can cause diarrhea, vomiting, fever, septicemia, and even death. It is estimated that there are 37 million illnesses caused by the foodborne pathogenic microorganisms in the world each year, with 230 thousand hospitalizations and 2.6 thousand deaths (CDC). Once the food is potentially contaminated, the bacteria may proliferate in large numbers in a short period of time, which may cause serious harm to human health. Therefore, it is important to determine the bacterial species timely and accurately, which helps to control risk and ensure food safety , Salmonella enterica (S. enterica), and Listeria monocytogenes (L. monocytogenes), which are commonly found in diverse food matrices. Since the bacterium is electrically charged, it can migrate through the micropore under an electric field, causing large current changes in a very short period of time. Each current pulse represents a bacterial translocation “event”  with a microfluidic SiN pore in potassium chloride  and 1 × PBS . Luria–Bertani (LB) and Brain Heart Infusion (BHI) medium were purchased from the Beijing Land Bridge Technology Co. . The bacteria used in the experiment were from the National Culture Collection Center (NCCC) . Ultrapure water was used for the experiments. All the reagents and other chemicals used in this work were of analytical grade or better.E. coli (CICC 25922), S. enterica (CICC 10871), and L. monocytogenes (CICC 21635) were cultured in the shaking incubator for ~ 14 h at 37°C until the stationary phase in LB or BHI broth. After that, the obtained bacterial cells were centrifuged at 6,500 g for 5 min, washed twice, and resuspended in 0.1 × PBS for further use. Then bacteria were stained with 1 × SYBR Green and counted under an inverted fluorescence microscope.The microfluidic SiN chip was prepared according to a previously reported method . BrieflyThe chip was mounted in between two halves of a conductivity cell. Both sides of the chip were filled with 0.1 × PBS. A pair of self-made Ag/AgCl electrodes were inserted into the cell. A constant voltage of 0.02V was applied across the chip and ionic current was measured over time by CHI 660e. For bacteria identification, a sample solution was added to one side of the cell. With the applied voltage, bacteria were electrophoretically driven through the pore and the temporal changes in ionic current across the pore were recorded. Peaks below the background baseline of the ionic current were defined as resistive pulses, the width and height of the pulse peaks were counted, frequency distribution histograms were plotted, and the accuracy of the current sensor for bacterial morphological classification was assessed.I–V curves were used to characterize SiN chips. A single micropore with 2.56 μm in size can be seen in the SEM  can be calculated from Equation (2).CEOF represents the electric double layer capacitance, CSiN represents the capacitance of SiN, CPDMS represents the capacitance of PDMS. When a thin PDMS is coated, the total capacitance of this sensor (Csensor) will be decreased. Therefore, the background noise in the I–t curve would be reduced and signal pulses will be more pronounced. Besides, the PDMS thermally deposited by high temperature is only a few nanometers thick according to previous research work  and the pulse width td as a function of the aspect ratio of the bacteria (L/D) were constructed. As shown in L. monocytogenes is smaller than that of E. coli, so the volume of ions to be excluded from the pores is smaller than that of the E. coli, and the current drop is smaller than that of E. coli. The S. enterica enters almost at a vertical angle, so the volume of ions excluded is smaller than E. coli and L. monocytogenes, and a smaller current drop is obtained. The linear relationship of different bacteria with td-L/D was observed in The size of three pathogenic bacteria is shown in A simple microfluidic pore sensor was developed to classify three kinds of foodborne pathogenic bacteria commonly found in diverse food. Results demonstrated that the ion-blocking currents have adequate sensitivity to sense single-bacterium translocation, which allowed us to differentiate bacteria by analyzing the current pulses for their morphological characterization successfully. Factors such as bacterial size and single pore diameter, electrolyte concentration, applied voltage, and sampling interval that affect the signal were optimized in detail. This simple bacterial classification strategy has further practical applications because of its convenience and speed. But, the sensor still requires pre-processing of food samples to filter out the influence of large particles in complex matrices to prevent clogging of our microfluidic nano/micropores. In future work, we will focus on developing sensor chips that can be directly used for rapid detection of pathogenic bacteria in complex food matrices, and further improve their anti-interference and anti-fouling capabilities.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.TY: investigation, formal analysis, visualization, and writing—original draft. ZSL: investigation, formal analysis, and visualization. RW: review and editing. LL: conceptualization and formal analysis. YQX: conceptualization and supervision. TD and XYL: critically revised and improved the manuscript. All authors contributed to the article and approved the submitted version.This work was supported by the National Key Research and Development Program of China (2019YFD1002300), the National Natural Science Foundation of China (22004107), the Zhejiang Provincial Natural Science Foundation of China (LR22C200002), and a project supported by Scientific Research Fund of Zhejiang University (XY2021017).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.


To investigate the combined impact of aerobic exercise and Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) diet on brain cells longevity in spite of sex hormones deficiency in obese postmenopausal women. Subjects/Patients. Sixty-eight eligible postmenopausal women were randomly assigned to one of two groups, one experimental and one control. The participants' age ranged from 60 to 75 years, and their body mass index ranged from 30 to 39.9 kg/m2.  A parallel randomized clinical trial.  An experimental group whose members followed moderate-intensity treadmill exercise three times/week for three months with MIND diet and a control group whose members followed the MIND diet only. In addition to serum sex hormones, pre- and post-12-week assessments were performed to measure serum sex hormones as well as cognitive and functional levels. p < 0.01) in sex hormones, cognitive functions, and functional levels compared with the control group (p < 0.05). In addition, no correlation was found between the measured variables in both groups after intervention (p > 0.05).  The experimental group showed after intervention highly significant changes ( Aerobic exercise combined with the MIND diet improves cognitive and functional levels and substitutes sex hormones deficiency in postmenopausal women, which affects the longevity of brain health. Cognitive functions are brain skills that control the behavior of people. These functions are essential for daily life activities, especially in older adults who have a higher rate of cognitive disorders . CognitiSex hormones are widely distributed in brain cells, including the cells of the cerebral cortex, amygdala, hypothalamus, and hippocampus, where they enhance brain activities in memory as well as emotional and rewarding circuits . FurtherRegular exercise and a healthy diet are the main corners of a healthy lifestyle recommended to prevent cognitive decline and improve cognitive abilities in older adults . AerobicThe Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) diet, which is abundant in antioxidants and anti-inflammatory compounds like vitamin E, flavonoids, folate, and carotenoids, enhances cognitive performance by slowing brain aging caused by free radical damage and inflammatory cytokines . FurtherPostmenopausal women are at higher risk of cognitive decline, and this reflects negatively on functional performance and QoL. Therefore, the aim of the present study was to investigate the impact of aerobic exercise and the MIND diet on cognition and functional levels in relation to the change in sex hormones in older adult women after menopause. In this study, we hypothesized that aerobic exercise and the MIND diet are effective interventions to improve cognition and functional level in spite of sex hormones deficiency in postmenopausal women.NCT04492540 on https://register.ClinicalTrials.gov.The present study is a parallel randomized clinical trial according to consort guidelines, carried out from December 2020 to July 2021 after getting the approval of the Ethical Committee of the Faculty of Physical Therapy, Cairo University, Egypt (no. P.T.REC/012/002773). All the procedures in this study were performed according to the Helsinki Declaration. The included participants signed informed consents for participation after a full explanation of the study's purpose. The registration identifier number of this study is: 2, and being a nonsmoker. All patients had sedentary lifestyles according to Godin's leisure time questionnaire (less than 14 units) [Eighty postmenopausal women were enrolled in the outpatient clinic of the Department of Obstetrics and Gynecology and Internal Medicine, Cairo University Hospitals, Egypt. After assessing and reviewing the medical examinations of these participants by the study physician (AR-coauthor), 68 women were found to be eligible to safely take part in exercise and MIND-low caloric diet. The inclusion criteria in this study are as follows: being in the postmenopausal stage  level between 0.12 and 0.60 ng/ml, free testosterone (FT) level ≤ 2.85 pg/ml, and absence of menstrual cycle for more than one year), suffering from MCI  assessment score ranging from 23 to 26 and duration of disease diagnosis ranging from 6 to 24 months), decreased functional activity level  score ranging from 90 to 111), age ranging from 60 to 75 years, body mass index (BMI) ranging from 30 to 39.9 kg/m4 units) . The socNine women were excluded according to the exclusion criteria: having diabetes mellitus, drinking alcohol, undergoing hormonal therapy, having any cardiovascular diseases, orthopedics or neurological disorders that affect exercise performance, participating in any weight reduction program at least six months before the study, and taking medications known to affect cognition, psychological status, and body weight. Two women refused to take part in the study, and one woman was excluded for other reasons. Finally, 60 women completed the intervention and all the assessments because eight women discontinued the study for personal reasons, as shown in The experimental group used a treadmill  to perform continuous moderate-intensity aerobic exercise three times per week for three months, following the recommendations of a recent international lipid expert panel on how to regularly train individuals who require statin therapy . The traThe experimental and control groups followed an individualized MIND-low caloric diet according to the recommendations of the American Heart Association Nutrition Committee , which wBlood samples were drawn before the beginning and after the completion of intervention (12 weeks) after at least 10 hours of fasting. Each participant's blood samples were analyzed in the same batch, and blood collection took place between 7 : 00 and 10 : 00 a.m. There is a chemiluminescence hormonal analysis for all hormones .RUDAS is a scale evaluating 6 items: visuoconstructive praxis, verbal memory, motor praxis, visuospatial orientation, language, and judgment. The highest score is 30, which indicates the best cognition, while lower scores indicate lower cognitive impairment .The FIM scale investigates the individual performance of daily life activities such as social cognition, self-care, locomotion, sphincter control, transfers, and communication. The score of independent performance starts with 1, which indicates total dependence, in contrast to 7, which indicates complete independence. Scores ranging from more than 1 to 5 reflect the need for assistance. The total score for the tasks performed was calculated; 126 represents the highest total score, and 18 represents the lowest independence level .2).Weight and height were determined through a physical examination using a Human Body Digital Height and Weight Scale AC110V-220 V 50HZ/60HZ. DHM-16/200/300, Zhengzhou to calculate BMI with this equation: BMI = body weight (kg)/height  (two-tailed test: the difference between two independent means (two groups)). A sample size of 30 women per group  was determined to allow the detection of an effect size (Cohen's d) of 0.53 with a 95% confidence interval. The significance level of 0.05 (type I error) for the outcome of cognitive functions was used.The sample size was detected before the study using Gn = 30) of participants per group was made through R Software (version 2.11). The sequence of random allocation was hidden in numbered envelopes showing the treatment assignment for each participant by a staff member not involved in the study. So, the participants and the study team were unaware of the assigned treatment.For the randomization of the present study, random permuted blocks were used as 1 : 1 randomization. The size of blocks was 2, 4, and 6 to ensure that an equal number  was used for statistical analysis. The Shapiro–Wilk test was used to determine whether the data were distributed normally or not. The mean standard deviation (SD) was used to describe continuous data. Baseline characteristics between both groups were compared using the independent samples p values less than 0.05 were considered statistically significant.Furthermore, Pearson's correlation coefficient and stepwise multiple linear regression were used to determine the correlation between the changes in cognitive and functional levels and sex hormones for each group, and p > 0.05) is illustrated in The experimental and control groups showed no statistically significant differences in terms of weight, height, BMI, age, or serum concentration of sex hormones. The assessment of cognitive functions and functional activity at baseline . Also, statistically significant differences were detected between the two groups in terms of BMI, weight, sex hormone concentrations, cognitive functions, and FIM scores postintervention according to the p independent t-test (p = 0.01) where the experimental group showed highly statistically significant differences compared with the control group as illustrated in In each of the experimental and control groups, there were statistically significant differences in BMI, weight, concentrations of sex hormones, cognitive functions, and FIM scores pre- and postintervention according to the paired sample Pearson's correlation was performed, followed by multiple linear regression analysis to determine whether the change in cognitive functions and functional levels was associated with the change in sex hormones.p > 0.05)  .p > 0.05)  .No adverse events related to the intervention were reported in either group during the study.This study showed no correlation between the change in sex hormones and in cognitive and functional levels after a program of aerobic exercise with a MIND-low caloric diet or only the MIND-low caloric diet program. However, our results showed significant improvement in cognitive and functional levels despite the decreased levels of estrogen and testosterone after our approach. We believe that this is attributed to the beneficial effect of aerobic exercise and the MIND diet on improving cognition through different mechanisms than those previously introduced. This is similar to the effect of estrogen and testosterone on cognitive functions. This emphasizes that aerobic exercise and the MIND diet can successfully substitute for the deficiency of sex hormones in terms of improving cognition.p < 0.01) compared to the control group (p < 0.05). This finding agrees with the systematic review by Schmitz et al. [The results of this study showed a highly statistically significant reduction in weight, BMI, and serum levels of estradiol, TT, and FT as well as an increase in SHBG in the experimental group (z et al. , which sz et al. . As a rez et al. .Also, our results showed a highly statistically significant improvement in the RUDAS and FIM scales postintervention in the experimental group. This is consistent with the McAuley et al.  study, wIn the introduction, we mentioned different mechanisms to explain the improvement in cognitive functions noticed in the elderly when performing aerobic exercise , 11, 12,Moreover, the MIND diet protects the brain tissues against oxidative stress and inflammation, inducing neurogenesis and neural signaling, which results in the increase of the volume of gray matter and inferior frontal gyrus, and consequently, neuronal plasticity in frontal-temporal brain regions . PhytochDespite our positive outcomes in this study, some limitations should be considered. The choice of participants was limited to women without any cardiovascular disorders or medical problems. Only illiterate and low-educated women participated for eligibility, but high-level educated women did not participate. Women with surgical menopause and those who are undergoing hormonal therapy were excluded, which may have limited variations in the study results. Also, only one specific diet program and one type of exercise with a specific intensity were applied. We recommend including a larger number of women with more variability in the demographic data to evaluate cognitive abilities and investigate different types and intensities of exercise as well as other diet programs. In addition, we recommend further studies on the effect of exercise and diet on other common diseases in women after menopause because of the hormonal change, for example, but not limited to, breast cancer and cardiovascular diseases.Aerobic exercise combined with the MIND diet has a positive effect on cognition and functional levels and counteracts the change in sex hormones in the postmenopausal period. So, we reported these noninvasive therapeutic approaches in this study to gain better cognition and improve QoL for women after menopause.


Lumbar disc herniation (LDH) is a common degenerative disease that severely impacts the quality of life of patients. Thunder-fire moxibustion is an ancient Chinese medicine-based external therapeutic procedure that has been employed for pain relief until this day. The focus of our study was to demonstrate the effectiveness and safety of thunder-fire moxibustion in the treatment of LDH.The literature databases searched included the Cochrane Library, Web of Science, Springer, PubMed, Wanfang digital periodicals database, China national knowledge infrastructure, VIP, and Chinese biomedical literature database, and the search period was from database creation to March 2022. These include randomized controlled trials of Thunder–Fire moxibustion alone or in combination with other therapies for LDH. Two evaluators independently extracted data. We accessed the quality of inclusive studies through a Cochrane risk of bias tool. Meta-analyses were performed using Review Manager (Version 5.5). Data was analyzed using fixed-effects or random-effects models, depending on the heterogeneity test results.P < .00001), the Japanese orthopaedic association score , the pain score . Only 2 reported no adverse events in the included literature, and the remaining had no relevant records. The quality of the evidence in the 17 papers we examined was low or very low.The meta-analysis included 17 studies involving 1344 patients with LDH. The analysis results were as follows: compared with other therapies, the efficacy of thunder-fire moxibustion was statistically significant; the total effective rate (RR = 1.20; 95%CI ; Thunder–Fire moxibustion is effective in relieving discomfort in patients with LDH. It has significant clinical efficacy, but there is still a need for prospective, multicentre, large-sample randomized controlled trials to enhance the clinical evidence due to the quality of included studies and methodological limitations. The main manifestations of LDH are nerve compression symptoms such as pain in the lower back and legs, restricted movement, reduced muscle strength, and abnormal skin sensation. The prevalence of LDH is 2% to 3%, and 95% of patients have lesions involving the L4/5 and L5/S1 segments. Studies have shown that LDH is associated with age, obesity, smoking, exertion, and lumbar spine loading. Current treatments for LDH include conservative and surgical therapies. Due to the high cost and unknown risks associated with surgical treatment, most patients choose conventional treatment, including health education, physiotherapy and medication. Surgical treatment is not required when the patient has a short course of disease and the protrusions do not significantly compress the nerves, and there are no clinically significant symptoms of nerve damage. Non-operative treatment can relieve muscle spasm, nerve root adhesion and enlarge intervertebral space; It can also regulate endogenous pain-causing system, reduce the content of inflammatory factors in serum, and reduce stimulation to vascular receptors, thus relieving pain. Research has shown that 78.2% to 89.7% of patients have significant relief or resolution of clinical symptoms with conservative treatment. Although these conservative treatments have proven to have some effectiveness, they are not always effective and even have some side effects.Lumbar disc herniation (LDH) is a clinical degenerative spinal disease with corresponding clinical manifestations, which is caused by stimulation or compression of nerve roots due to rupture of annulus fibrosus and nucleus pulposus. It has been widely used as early as the Spring and Autumn and Warring States period. Thunder–Fire Moxibustion is a new moxibustion method that improves the original formula and usage. It is based on the meridian theory of Chinese medicine, combining the idea of acupuncture and moxibustion with the action of a drug, using moxa and herbs to make medicinal moxa strips. Compared to ordinary moxa strips, it has a thicker form, stronger potency, more substantial penetration, and a wider area of action. Thunder-fire moxibustion is commonly utilized in China to treat various pain-related conditions, including ENT (ear-nose-throat), bone and joint, gynecological, and internal diseases.–22 Thunder–Fire moxibustion uses the heat generated by the burning of the drug, infrared radiation, and medicinal and physical factors to reach the treatment area through the meridian and acupuncture point sensory transmission. The chemical substances produced by it promote the material exchange of tissue cells, so it has the functions of warming the meridians, promoting blood circulation and removing blood stasis, dispelling wind and dispelling cold. It is fully recognized by patients in clinical operations because of its simple usage, painless treatment, and few adverse reactions.As a traditional therapy capable of preventing and treating diseases, moxibustion has been applied for thousands of years.Although the benefits of Thunder–Fire moxibustion for LDH have been widely reported, only individual studies have been conducted. None have systematically evaluated the use of thunder-fire moxibustion alone or in combination with other therapies for LDH. Therefore, this paper analyses the efficacy and safety of Thunder–Fire moxibustion in treating LDH to provide Medical evidence-based for the cure of LDH in Chinese medicine.The International Prospective Register of Systematic Reviews recorded this work (CRD42022312569). We write this paper based on the preferred reporting items for systematic reviews and meta-analyses guide.We included all randomized controlled trials of Thunder–Fire moxibustion for LDH. There were no restrictions on the country and language.Adults diagnosed with LDH are not restricted by gender, ethnicity, or region. However, studies with specific or systemic diseases will be excluded .The intervention group was treated with either single thunder-fire moxibustion or in combination with other therapies for LDH. Still, thunder-fire moxibustion was required to be the only treatment variable. In contrast, the control group was treated with other therapies other than Thunder–Fire moxibustion, such as acupuncture, massage, western medicine, fire cupping, etc. Pain scores include the Numerical rating scale or the visual analogue scale (VAS), with lower scores indicating less pain. The ODI assesses the patient’s return to socially active functioning, with lower scores indicating less severe disease. The SF-36 assesses the patient’s quality of life before and after treatment, with higher scores indicating better quality of life.We selected the total effective rate, Japanese orthopaedic association (JOA) score, pain score, Oswestry disability index (ODI), and 36-item short-form health survey (SF-36) as outcome indicators. The overall effectiveness of each study included relief of signs and symptoms of low back pain, lower limb numbness, lower limb motor function, and lumbar spine range of motion. Although the definition of “overall effectiveness” differs from study to study, all refer to remission of disease and recovery of daily living and working abilities. The JOA score for lower back pain consists of 4 components: subjective symptoms , clinical signs , limitation of daily activities and bladder function, with a total score of 29 points, the higher the score, the better the patient’s lumbar function.We searched 8 databases in English and Chinese, including Cochrane Library, Web of Science, Springer, PubMed, Wanfang digital periodicals database, China national knowledge infrastructure database, Chinese biological medicine database, and VIP Database. These databases were searched from their inception to March 2022.The search terms: Intervertebral Disc Displacement  and Tunder-fire Moxibustion . These search terms are suitable for searching these databases. Table Two trained literature screeners searched the database to obtain the required literature according to the proposed search formula. In the event of a dispute, a third researcher engaged in the conversation and negotiated the decision. Firstly, they imported the selected literature into NoteExpress X9 and removed duplicates. Secondly, the 2 researchers (Luo Zongxiu and Liu Mingda) read the titles and abstracts and then excluded the literature that did not fit the study. Finally, the full text of the literature that matched the study was downloaded and read in detail.Two researchers extracted relevant information from the included literature and managed the registration using an Excel sheet. The data extracted included the name of the researcher, year of publication, the sample size of the treatment and control groups, interventions, duration of treatment, and outcome indicators. If important information was missing, we called the author to get information about the research. to assess the risk of bias. The risk of bias assessment tool included 7 items: random sequence generation, allocation concealment, blinding of researchers, subject and outcome assessment, incomplete outcome information, selective result reporting, and other sources of bias. A third researcher was involved in the discussion and consultation in case of disagreement.Two researchers used Cochrane’s risk of bias (ROB)χ2 test and the I2 test to determine heterogeneity. When P ≥ .1, I2 ≤ 50%, we consider the data homogeneous and select the fixed effect model. If P < .1, I2 > 50%, the data were supposed to be heterogeneous, and the source of heterogeneity was speculated using sensitivity analysis or subgroup analysis. Descriptive analysis or the random-effects model is chosen when we cannot find the cause of the heterogeneity.Meta-analysis of the data was performed using Review Manager (Version 5.5). The results of dichotomous variables were expressed as relative risk (RR), mean difference (MD) or standardized mean difference (SMD) for continuous variables, all with 95% confidence intervals (CI). We chose the  GRADE’s 5 factors may reduce the quality of evidence in systematic interventional reviews: risk of bias, inconsistency, imprecision, indirectness, and publication bias. The quality of the evidence was categorized into the following 4 levels: high quality, moderate quality, low quality, and very low quality, representing the strength of the evidence.We analyzed the evidence level with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE).One hundred forty-six trials were searched in the database, 28 from China national knowledge infrastructure, 33 from VIP, 49 from Wanfang digital periodicals database, 36 from Chinese biomedical literature database, 0 from Cochrane Library, 0 from Web of Science, 0 from Springer, and 0 from PubMed. Eighty-eight papers were excluded due to duplication. After reading the titles and abstracts, 10 irrelevant trials were excluded. Forty-eight articles that remained were read in full. After further reading, 10 papers were excluded because the treatment group did not include thunder-fire moxibustion. Twelve were excluded for complex interventions. Nine were excluded from the disease diagnosis. The last 17 studies were included in the meta-analysis . Five studies–36 reported treatment duration less than or equal to 10 days, 11 studies–47 reported treatment durations more than 10 days, and 1 study did not report treatment duration. Fifteen studies,35,37–48 used the total effective rate, 8 studies,43,44,46 used the JOA score, 6 studies,43,44,46 used the pain score, 2 studies,35 used the ODI,and 1 study used the SF-36. The clinical characteristics of the specific literature are shown in Table The total sample size of the 17 included papers was 1344 cases, including 673 cases in the trial group and 671 cases in the control group. These studies described comparable baseline information between the treatment and control groups, with no statistically significant difference . There was no heterogeneity in the total effective rate  . The total effective rate (more than 10 days) had statistical significance  with no heterogeneity. The total effective rate (not reported treatment duration) had statistical significance . According to the findings, thunder-fire moxibustion had a better effect than the control group , indicating that Thunder–Fire moxibustion was more effective than the control group. However, there was substantial heterogeneity (I2 = 93%). Because of the heterogeneity, we used a random-effects model and did a subgroup analysis based on treatment duration. JOA score  had statistical significance  with heterogeneity. JOA score (more than 10 days) had statistical significance  with heterogeneity , which is more effective than the control group, but there is obvious heterogeneity (I2 = 89%). To find the causes of heterogeneity, we used a sensitivity analysis. After removing the study of Zou Yanfang, the heterogeneity dropped to 36%. We speculate that this study has a longer single treatment time than other studies, which may be the main reason. Pain score  was statistically significant . Pain score  was statistically significant  . One study reported the comparison of thunder-fire moxibustion combined with manipulative therapeutics and manipulative therapeutics alone, and the results showed that the experimental group was more effective than the control group .Two studies used the SF-36 scale to evaluate the quality of life. Based on acupuncture combined with thunder-fire moxibustion, the results showed that the experimental group could effectively improve the quality of life  had the highest frequency of use, followed by BL40 , BL23 , GV3 . Other acupoints appeared less frequently  was assessed. The following 5 factors can reduce the level of evidence: risk of bias, inconsistency, imprecision, indirectness, and publication bias. All included studies reported outcomes directly. Some studies did not state the specific randomization method. None of the studies mentioned the specific implementation process of blinding and allocation concealment. It was not possible to judge the selectively reported outcomes. There may be some heterogeneity in JOA and pain scores depending on the duration of treatment. From the efficient funnel plot analysis, the asymmetry on both sides indicates the existence of publication bias. All of the above contribute to the lowered level of evidence. The quality of evidence for all comparisons was low or very low Table .Until now, no researchers have discussed a systematic review and meta-analysis of thunder-fire moxibustion in the treatment of LDH. This is the first study to evaluate the efficacy and safety of Thunder–Fire moxibustion in patients with LDH. This study found that Thunder–Fire moxibustion was superior to the control group in improving the total effective rate, JOA score, pain score, ODI score, and SF-36 scale, with statistically significant differences. Thunder–Fire moxibustion can alleviate low back pain, lower extremity numbness, and other symptoms, but there is heterogeneity in tests of JOA score and pain score. By observing the subgroup analysis of the forest plot, we found that it may be related to the treatment time and the duration of the disease. Still, this conclusion needs to be verified by further clinical trials or network meta-analyses. Because the intervention measures  are too complicated, it is difficult to objectively reflect the therapeutic effect of Thunder–Fire moxibustion in the treatment of LDH.Only 2 of the studies reported no adverse events in terms of safety summaries, and the remaining 15 were not recorded. Therefore, there isn’t enough evidence to prove the safety of Thunder–Fire moxibustion for LDH. which makes it hard to explain the efficacy of Thunder–Fire moxibustion in treating LDH.In this meta-analysis, although some data show that Thunder–Fire moxibustion can improve the symptoms of LDH patients, many factors affect the efficacy of Thunder–Fire moxibustion. The quality of the included literature is low. The sample size is small. The production technology and level of Thunder–Fire moxibustion are different. The evaluation index is subjective. As a result of the above, getting high-quality evidence is difficult, shows that thunder-fire moxibustion is extensively used for pain caused by various diseases, which can successfully prolong alleviation, reduce pain duration, minimize recurrence rate, and prevent harmful effects. Thunder–Fire moxibustion has been found to minimize inflammatory exudation, decrease the release of inflammatory factors including Tumor Necrosis Factor (TNF) and interleukin-1 (IL1), and promote the absorption of inflammatory exudates. Therefore, it has anti-inflammatory, analgesic, and immune-enhancing effects.,52 It’s essential to look into Thunder–Fire moxibustion’s mechanism, effectiveness, and safety.ResearchThis study has the following shortcomings. The included literature did not describe whether allocation concealment was implemented or not. If it was not implemented or was not implemented sufficiently, the concealed grouping would exaggerate the efficacy. Outcome measures are subjective. Due to the specificity of the intervention, blinding was not possible. The operation of Thunder–Fire moxibustion in each study is different: treatment time, differences in acupoints, control of Thunder–Fire moxibustion temperature and distance, etc. The above factors will affect the effect. Although we searched databases in both Chinese and English, the final included articles were Chinese, which may lead to publication bias. These studies did not address follow-up, resulting in an inability to evaluate long-term efficacy accurately. This study graded the evidence for a single outcome measure using the GRADE system tool. The quality of the evidence for the included studies was low or very low, indicating that the real situation may be significantly different from the conclusions of the systematic review. Because of the above shortcomings, we should cautiously explain the efficacy of thunder-fire moxibustion for LDH. Investigators should follow up with patients regularly and strengthen monitoring and reporting of adverse events. In conclusion, we should further enhance the authenticity and reliability of the research results to guide the clinical practice better.We suggest the following strategies for future researchers. They should use internationally agreed diagnostic criteria and report the specific methods of random sequence generation and allocation concealment in detail. Due to the highly subjective nature of pain scales, studies have suggested that a reduction of 20% or more in the VAS score is more meaningful.This study shows that thunder-fire moxibustion can improve patients’ symptoms in the treatment of LDH. At the same time, it has the advantages of convenient operation, convenient nursing and fewer adverse reactions. However, based on the quality of the current clinical trials, we cannot conclude the efficacy of Thunder–Fire moxibustion in treating LDH. To provide higher-level evidence support for the treatment of LDH with Thunder–Fire moxibustion, it is also necessary to conduct more high-quality randomized controlled studies and identify more complete outcome indicators.TCM Clinical Research Center for Bone diseases of Jilin Province (Grant No. 20180623048TC). Research on medication rules and clinical experience of Professor Liu Bailing, a master of traditional Chinese med icine based on data mining  (No. 2022153).Conceptualization: Zongxiu Luo, Fusheng Wang.Data curation: Zongxiu Luo, Mingda Liu.Formal analysis: Jianye Chen, Yuyan Jia.Investigation: Mingda Liu, Rui Zhou, Ying Wang.Methodology: Yuyan Jia, Fusheng Wang.Software: Jianye Chen, Zongxiu Luo, Mingda Liu.Writing – original draft: Rui Zhou, Ying Wang, Jianye Chen.Writing – review & editing: Xukai Wang, Xiangyang Leng.


First responders are faced with stressful and traumatic events in their work that may affect their psychological health. The current review examined the effectiveness of psychological interventions to treat posttraumatic stress disorder (PTSD), anxiety, depression, stress and burnout in first responders.Four databases were searched to identify controlled studies that examined the efficacy of psychological interventions to reduce PTSD symptoms (primary outcome) in first responders . Secondary outcomes were anxiety, depression, burnout, and stress.15 studies were identified, including 10 studies that measured PTSD, 7 studies for anxiety, 10 studies for depression, 7 studies for stress and 1 for burnout. Interventions were associated with a significant reduction in PTSD , depression , and anxiety  but not stress . CBT-based and clinician-delivered interventions were associated with significantly greater reductions in PTSD than other types of interventions and non-clinician interventions, but no differences were found for depression. There was evidence of moderate to high risk of bias across all studies.Psychological interventions are effective in reducing PTSD, depression and anxiety symptoms but not stress in first responders. Further research is needed using high quality randomised designs over longer periods of follow-up. The term first responders has been used extensively in the literature to refer to a range of professions and occupations such as firefighters, police officers and paramedics –3. TheseAlthough the specific roles of different groups of first responders varies, they all face multiple potentially psychologically traumatic incidents in their daily work which puts them at heightened risk of experiencing mental health difficulties and disorders including posttraumatic stress disorder (PTSD), depression, anxiety and burnout –10. In pIn the last two decades, five systematic reviews have attempted to synthesize the effectiveness of interventions for reducing psychological distress among first responders, especially PTSD , 18–21. Overall, three limitations are evident in the existing literature into interventions for psychological distress among first responders. First, controversy about the importance and effectiveness of interventions remains. While some studies and reviews have suggested that interventions are highly effective, others have reported no significant benefit of interventions , 23, 24.The first aim of the current review was to synthesise the evidence for the effectiveness of psychological interventions for improving mental health symptoms in first responders. Our primary outcome of interest was PTSD symptoms; secondary outcomes were depression, anxiety, stress, and burnout. Our second aim was to compare the effectiveness of different types and formats of interventions  for reducing symptoms of PTSD, depression, anxiety, stress, and burnout.https://www.crd.york.ac.uk/prospero/display_record.php?ID=MASKED. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines that can be found in This systematic review was registered in advance on PROSPERO, after specifying the inclusion criteria and analytical methods: CRD4MASKED. nd 2019, updated to September 8th 2021. The search strategy was performed by using three key blocks of terms: “interventions”, “first responders” and “posttraumatic stress disorder” or “depression” or “anxiety” or “burnout” or “stress”. Also, MeSH and keyword terms were examined based on terms usually used within previous reviews in the fields of first responders and PTSD  and non-clinicians .Comparison: Any type of control group  was included.Outcomes: The primary outcome was PTSD symptoms as rated by an observer  using validated scales such as PTSD checklist  or self-Design: Studies that used randomized controlled trial (RCTs) designs or controlled before-after designs (CBAs), as defined in the Cochrane handbook, were included .Context: Studies that investigated any treatment effects of psychological interventions in the first responders that were published in the English language were included.We excluded studies conducted on other types of first responders, such as in-hospital health care workers  or military first responders . Also, all studies that used different types of interventions, such as physical or pharmacological interventions rather than psychological interventions were excluded, as were non-English language studies and gray literature.All search results from each database were exported to Endnote version X8.2  and all duplicates were removed. The study selection consisted of two stages. In the first stage, titles and abstracts were screened based on the above criteria by one author (KA). A second author (JJ) checked and reviewed 10% of included studies. To estimate the level of agreement we calculated the Kappa score which indicated good agreement (k = 0.845). In the second stage all full texts were screened by one reviewer (KA) with a second independent reviewer (AP) screening 20% of full texts, with 100% agreement.We used Excel 2016  to organize a data extraction form. We extracted quantitative data for the meta-analysis on a separate Excel file. All data extraction was undertaken by KA. The first 10% of eligible articles were independently extracted by AP to check for agreement. Any discrepancies were resolved by discussion. The following descriptive information was extracted from eligible studies:Study: country, research design, recruitment method and content of the control condition.Participants: sample size, age, gender, discipline, setting.Intervention: content of the intervention, measurement time points.Outcomes: PTSD, stress, anxiety, depression and burnout.We used the Effective Practice and Organisation of Care (EPOC) risk of bias tool  to carryComprehensive Meta-Analysis software version 3 (CMA)  was usedWe calculated the effect sizes using standardised difference of means (SDM) and associated 95% confidence intervals for PTSD, anxiety, depression, and stress outcomes in all included studies. We used post-treatment means, standard deviations (SD), and sample sizes to calculate the effect sizes between treatments and control groups. When means and SD values were not provided in the original studies, we used the available sample sizes and p-values to impute missing SDM . For studies that had two types of interventions compared to a waiting list control group, we divided the sample size of the control group in half in each type to reduce the variance related with each effect size and to avoid double counting of participants . If studFor comparison groups, we identified the most common type of intervention used for each outcome and compared with all other interventions. If there was no common intervention for an outcome, then the outcome was not included in subsequent analyses. In addition, we also compared between interventions according to whether they were provided by clinicians versus non-clinicians (providers) and whether they were group-based versus individual-based interventions (format).2 statistic [2 values indicate 25% as low, 50% as moderate, and 75% as high heterogeneity. In addition, between-study heterogeneity was assessed by Cochran’s Q-statistic (measure of weighted squared deviations) [p < 0.05) was used to compare between types of interventions. Specifically, the Qbetween statistic was used to examine if the SDM was significantly different between groups of interventions. Moreover, meta-regressions were used to examine the impact of any potential moderating variables on the overall effect size for different outcomes. Meta-regression follows similar principles to regression or multiple regression in primary studies, except that in meta-analyses the variables are at the level of the study and not the participant [To account for heterogeneity, a random effects model was used in all analyses and assessed with Itatistic . I2 valuiations) . The Cocticipant . Six modticipant , and furticipant .A total of 4572 papers were identified by our searches. In addition, 13 papers were discovered by manual reference list scanning see . We remoAcross the 15 papers, the total sample size was 928 . 10 studies measured PTSD, 7 studies measured anxiety, 10 studies measured depression, and 7 studies assessed stress. One study evaluated burnout . In terms of participants, 6 studies were conducted with police officers, 3 studies were conducted with firefighters, 2 studies were conducted with ambulance personnel, and 4 studies were conducted in a mix of disaster workers that included police officers, firefighters, and paramedics. 4 out of 15 studies were conducted in the USA, 3 in Australia, 3 in the Netherlands and one study each in England, Saudi Arabia, Iran, Thailand and Mexico.A range of different types of interventions was used. Cognitive behaviour therapy (CBT) was the most frequent with 4 different types of CBT used in 3 studies, then critical incident stress debriefing (CISD) and resilience training were used in 3 studies each, while eye movement desensitization and reprocessing (EMDR) was used in 2 studies, and 1 study each used brief eclectic psychotherapy, eclectic group counselling, written emotional expression, and mental agility and psychological strength. One study had more than one intervention that used 2 types of cognitive behaviour therapy (the long type (CBT-L) and brief type (CBT-B)) compared to a waiting list control group . The meaThe risk of bias was calculated using the EPOC 9 criteria. 8 studies were considered low risk, 6 studies were scored as moderate risk, and 1 study was high risk .The main meta-analysis results found psychological interventions led to a significant reduction in PTSD and depression at p<0.01 level , but this was not found for depression, where the difference was non-significant . Interventions delivered by clinicians were associated with greater reductions in PTSD compared with those delivered by non-clinicians , but interventions delivered individually were not associated with greater reductions in PTSD than group interventions . For depression, however, there were no differences between clinician compared with non-clinician delivery , or individual compared with group format . See Cognitive behaviour therapy was the most common intervention (4 comparisons from 3 studies) used to treat PTSD, anxiety and depression. However, across the 7 anxiety studies, CBT was used only once, therefore, we were only able to compare CBT with all other interventions for the outcomes of PTSD and depression. We also compared interventions delivered by clinicians (8 studies) against those delivered by non-clinicians (6 studies) and the interventions that were delivered individually (8 studies) versus those provided in a group format (6 studies) for PTSD and depression outcomes. In terms of comparing between CBT and other interventions, the results showed that there were statistically significant differences between the standardised difference in means between the CBT and all other interventions for PTSD symptoms, such that CBT was more effective , such that studies with low risk was reported to have higher SDMs. However, there were no moderating effect of risk of bias for anxiety , depression  and stress outcomes  (see p = 0.001), such that studies with more intervention sessions was found to have larger SDMs. For anxiety, only mean age was found to be a significant moderator on the outcome, such that studies with a higher mean age had a larger SDM . For depression and stress there were no significant moderators. Moreover, gender was found to have no moderating effects on any of the outcomes.The moderate risk (n = 6) and high risk (n = 1) studies were combined and compared with the low risk (n = 8) studies using meta-regression. The results showed that there was moderating effect of risk of bias for only PTSD  see . We also.81) see . For PTSEgger’s regression coefficients found evidence of publication bias in the depression studies , but not for PTSD , anxiety  and stress   included in the review. The results of the meta-analysis showed that psychological interventions were associated with a significant reduction in PTSD symptoms, depression, and anxiety, but not stress. Moreover, the analyses also revealed that CBT was significantly more effective than other interventions for PTSD only, not for depression symptoms. Interventions delivered by clinicians were found to be more effective for PTSD outcomes but not for depression outcomes.Subgroup analyses also indicated that interventions were more effective in studies that were classified as having low risk of bias contrasted to the moderate-to-high risk of bias studies. The number of sessions was found to be a significant moderator for interventions for PTSD, such that more sessions were associated with greater intervention effectiveness. For anxiety outcomes, only the mean age was found to be a significant moderator of intervention effectiveness, such that higher mean age was associated with greater intervention effectiveness. For depression and stress, no significant moderating variables were found.The main finding of this meta-analytic review is in line with most previous systematic reviews , 18–22 tHowever, the current review differs in three important ways from previous reviews. Firstly, this is the first meta-analysis to compare between the effectiveness of intervention types. Secondly, unlike other reviews , 18, 21 There are several similarities between our current review and a recently published meta-analysis . HoweverMoreover, our review was the first to test whether there was any difference in the effectiveness of different types of psychological interventions in first responders, and the first to report that CBT was significantly more effective than other types of psychological interventions for reducing PTSD only, not for depression. This pattern of findings is consistent with findings from previous meta-analyses in non-first responder groups. Researchers have reported that several psychological treatments are effective for reducing PTSD in adults , 61. ForWe also found that the number of sessions was a significant moderator in PTSD studies such that psychological interventions were more effective in studies with a higher number of treatment sessions. This finding is consistent with some previous reviews , 67. AnoSurprisingly, the current systematic review and meta-analysis only identified a small number of RCT studies conducted in paramedics. It is now established that the prevalence of PTSD is higher in paramedics than other first responders. Therefore, there is an urgent need to investigate the effectiveness of psychological interventions in paramedics group. Yet, we only found 2 studies in paramedics compared with 6 in police officers, 3 in firefighters, and 4 in mixed disaster workers. Also, there is a clear lack of studies that treat burnout among the same population, and this is concerning as the burnout prevalence rate among paramedics has been found to range from 16% to 56% . TherefoAll included studies were from 8 different countries, and most of them (11 out of 15 studies) were from the USA, Australia, England, and the Netherlands, which limits the generalisability of the current findings. Differences between developing and developed countries in terms of prevalence of PTSD have been reported . Also, tThe present systematic review and meta-analysis has a number of strengths. The design of this systematic review followed the guidance of the Cochrane handbook for systematic reviews of interventions  and the Nevertheless, we are aware that there are also some limitations that ought to be acknowledged. The findings are based on a relatively small number of studies and there was a high level of heterogeneity between studies due to differences in the included studies, such as being conducted in developed versus developing countries, outcome measures, sample sizes, and length of interventions. Even though the review attempted to account for the heterogeneity by conducting subgroup analysis and meta-regressions, the variance was still high. Another limitation was that many of the studies have relatively short follow-up periods, therefore, we are unable to draw firm conclusions about the longer-term effects of interventions . This isThe current systematic review and meta-analysis found that psychological interventions were effective for reducing PTSD, depression, and anxiety symptoms but not for stress in first responders. Further research is needed to estimate the effectiveness of other types of interventions with high quality RCT designs over longer periods of follow-up.S1 Appendix(DOCX)Click here for additional data file.