Background: Tinnitus is a heterogeneous condition. The aim of this study as to compare the online and hospital responses to the Spanish version of European School for Interdisciplinary Tinnitus Research screening-questionnaire (ESIT-SQ) in tinnitus individuals by an unsupervised age clustering. Methods: A cross-sectional study was performed including 434 white Spanish patients with chronic tinnitus to assess the demographic and clinical profile through the ESIT-SQ, with 204 outpatients and 230 individuals from an online survey; a K-means clustering algorithm was used to classify both responses according to age. Results: Online survey showed a high proportion of Meniere’s disease (MD) patients compared to both the general population and the outpatient cohort. The responses showed statistically significant differences between groups regarding education level, tinnitus-related hearing disorders , sleep difficulties, dyslipidemia, and other tinnitus characteristics, including duration, type of onset, the report of mitigating factors and the use of treatments. However, these differences were partially confirmed after adjusting for age. Conclusions: Self-reported tinnitus surveys are a low confidence source for tinnitus phenotyping. Additional clinical evaluation is needed for tinnitus research to reach the diagnosis. Age-based cluster analysis might help to better define clinical profiles and to compare responses in ESIT-SQ among subgroups of patients with tinnitus. Tinnitus is the perception of subjective sound in the absence of external sound or any other sounds produced by the body itself. It is a prevalent condition that affects millions of patients in Europe . Around Although this is a common symptom, it can show different psychoacoustic characteristics, and it can be described as a ringing, beeping, buzzing, hissing, or whistling sound. In addition, it can present a different frequency or intensity, and can be perceived as a pure tone, as a narrow or broadband noise, or as consisting of different sounds (which could be considered a complex tinnitus) .According to the duration of the condition, tinnitus is considered chronic when it lasts for more than three months ,5, althoThe perceived impact of tinnitus can present a large interpersonal variability, and it can also vary over time. In addition, tinnitus can be considered as an annoying symptom in a small subgroup of patients . There aIn recent years, online surveys have increased and gained more importance, with the objective of creating large databases for epidemiological and clinical studies; however, the value of online surveys to predict responses in patients with tinnitus has seldom been investigated. Also, the COVID-19 pandemic has promoted teleconsultation, and the interaction with patients through online tools .Almost all studies based on online surveys share as main limitations the reliability of responses and the difficulty to extent the results obtained through these questionnaires to different populations . In addiThe application of these online questionnaires in patients with tinnitus has been also reported . A new tThe aim of this study is to perform a comparative analysis of the results obtained through the Spanish version of ESIT-SQ between two different groups of individuals, one recruited in the otorhinolaryngology clinics at two tertiary hospitals in Granada, Spain and another cohort obtained with the online version of the ESIT-SQ.A cross-sectional study was performed including a total of 434 patients with chronic tinnitus to assess the demographic and clinical profile by using the ESIT-SQ. The first group of individuals consisted of 204 outpatients visited at Departments of Otolaryngology at ‘Hospital Universitario Clínico San Cecilio’ and ‘Hospital Universitario Virgen de las Nieves’ from Granada (Spain). The second group included 230 individuals who were recruited through an online survey that was promoted in the hospital website and through social media.The inclusion criteria for all participants were: adult individuals (>18 years old) who had been suffering from tinnitus for at least six months, regardless of the hearing loss threshold. Exclusion criteria were restricted to major diseases that could influence the responses in the ESIT-SQ . Individuals unable to understand Spanish to complete ESIT-SQ and records with incomplete data were also excluded. Due to the demographic characteristics of our sample, the included population consisted primarily of the white Spanish population, although ethnicity was not considered an exclusion criterion itself.The ESIT-SQ consists of 39 closed, mainly multiple-choice, questions structured in two parts . Part A This questionnaire was designed by a multidisciplinary panel of epidemiologists, psychologists and otolaryngologists from ESIT to obtain a comprehensive assessment of tinnitus, other comorbid conditions, quality of life, sociodemographic data, and tinnitus characteristics .The ESIT-SQ includes three groups of variables: sociodemographic data, comorbid conditions and tinnitus characteristics. Sociodemographic data included age, sex, height, weight, studies level, smoking habits, and familiar’s member with tinnitus and dizziness.We categorized some variables such as hyperacusis, the number of relatives with dizziness or tinnitus, and the WHO classification for the body mass index . Other comorbid conditions included frequency of dizziness, otological disease, surgical history, hearing loss, hyperacusis, audiological devices, pain (including headache and earache), and medical history . Hyperacusis was also categorized into two groups according to whether it was considered severe or not by the respondent.The tinnitus characterization included the tinnitus frequency, duration , time since the onset of the tinnitus, duration of the disorder, number of different sounds, identifiable triggers, intensity fluctuation, rhythm, mitigating or aggravating circumstances, previous medical care, and previous treatments.First, we performed an exploratory statistical analysis for each group of participants (outpatients and online groups), separately. Since both groups had significant differences in sex and age distribution, we adjusted these variables to compare both groups in a second set of analyses. Since the online survey was distributed among members of the Spanish Association of patients with MD , a large proportion of respondents reported a diagnosis of MD. On account of this bias, a stratified analysis was also performed to compare tinnitus profile in patients with or without MD.The corresponding ordinal variables were handled as continuous variable in the analysis. Categorical variables were coded as dummy variables. For data analysis, a total of 205 variables from the baseline measurements were used.t-tests and χ2-tests for independent samples, including odds ratio with 95% confidence interval. Quantitative variables following normal distribution were expressed in mean +/− standard deviations (SD). On the other hand, variables not following normal distribution were summarized through medians and interquartile ranks (25–75%). Qualitative variables were summarized through absolute and relative frequencies. The p-values were adjusted for multiple testing using the Bonferroni correction. A significance level of p ≤ 0.05 was used for all statistical tests. All statistical analyses were performed using the software package SPSS v25.0 .Differences between groups were analyzed by contingency tables using Clustering is an “unsupervised” machine learning technique that aims to find groups in a dataset . This tep-value for an odd ratio (OR) < 1 means that outpatients more frequently reported this variable. The significance threshold for the p-value after Bonferroni correction was <0.00263.In our approach, responses from outpatients and the online survey were merged and clustered into two groups  following the k-means algorithm. Online and outpatient responses were compared for each variable in young and old individuals. A significant On the first part of the analysis, we describe raw data in both samples. A total of 434 patients with tinnitus were recruited; 204 (46.3%) were enlisted in the outpatient clinic at the Department of Otorhinolaryngology and 230 (53.7%) by online media.p-value < 0.001) between both surveys. The average age in the outpatient cohort was 55 (46–62) years old, while in online group it was 44 (37–53) years old. Female patients were 66% and 52% in the online and outpatients survey, respectively. Several differences were also observed among the clinical features both surveys. The reported frequencies of acoustic trauma, acute otitis media, and presbycusis they did not reach statistically significant differences (p > 0.05). On the other hand, sleep disorder (p < 0.001) and metabolic illnesses such as dyslipidemia (p < 0.001) were higher in the outpatient cohort. Of note, the reported frequency of Meniere’s disease (p < 0.001), vertigo (p < 0.001), and hyperacusis (p < 0.001) was different between both samples, with higher rates in the online survey (p < 0.001). Anxiety and depression were not different between both groups. There were significant differences in the distribution of age, sex, and level of education (p > 0.05). However, the tinnitus onset was different (p < 0.001), with a higher tendency to develop sudden onset in the online compared to the outpatient survey. According to influencing factors on tinnitus, there was a higher number of individuals reporting both aggravating and mitigating factors on tinnitus in the online group compared to the outpatient survey, although these differences were only statistically significant for the mitigating factors (p = 0.001) that was higher in the online group. Tinnitus increasing factors includes situations or conditions that could potentially worsen the tinnitus, such as lack of sleep, stress or alcohol/coffee consumption. On the other hand, tinnitus-reducing factors could decrease the intensity of tinnitus or improve its perception.The duration of tinnitus showed significant differences 72 (36–132) months in the online survey and 24 (12–96) months in the outpatient survey . Moreovep < 0.001), but there were no differences between all of the subgroups of treatment.In addition, the number of treatments used for tinnitus was analyzed, recording a higher proportion in the online survey . In this case, the average age was 52 (46–57.75) years old in the online group and 55 (46–62) years old in the outpatient cohort. Women represented 62% of the on-line group and 52.2% of the outpatient cohort.p < 0.001). The clinical profile was different in outpatients and online participants. MD , vertigo (p < 0.001) and hyperacusis  were more commonly reported in the online survey. However, hyperacusis was also frequently reported in outpatients (69%). The level of education was significantly higher in online respondents than in outpatients . There were also differences in the number of perceived sounds in both groups. Most of the outpatients reported that their tinnitus consisted of one sound, while most of the patients from the online survey reports two or more sounds (p < 0.001). No trigger associated with tinnitus was significantly different between both groups, the only exception being a change in hearing (p = 0.002), which was more frequently reported in the online survey. Aggravating factors were also more reported by the online group than by outpatients (p < 0.001).There were differences in the time since the onset of tinnitus 96 (36–180) months in the online survey and 24 (12–93) months in outpatient group, respectively . On the other hand, the tinnitus characteristics that were significantly different between both samples were the type of onset, mitigating factors and treatment necessity. However, when both groups were adjusted for age and sex, the differences were the duration of disturbing tinnitus, the number of sounds, changes in hearing, and aggravating factors.For the K-means clustering, the number of clusters k was set to 2, since this yielded clusters that were balanced in size, without outliers, and also resulted in clusters large enough to support most of the statistical comparisons performed. The ‘young’ cluster included 160 individuals, aged between 19 and 53, with a mean age of 44.77 ± 7.33, and a median age of 46. This group had 80 online participants and 79 outpatients visited at the hospital. One hundred fifty-two patients aged between 54 and 94 belonged to the ‘old’ cluster, with a mean age of 62.04 ± 6.62 and a median age of 61. This group had 52 online respondents and 98 outpatients. The fact that the mean and the median ages in each of the clusters is comparable shows that the process was not influenced by outliers.p-values for significance were adjusted for multiple comparisons using the Bonferroni correction, yielding the adjusted p-values for 0.1, 0.05 and 0.01 as 0.0053, 0.00263, and 0.0005, respectively. At the adjusted significance level of 0.00263, online and outpatient surveys in both the young and the old clusters were significantly different in the frequency of ear problems reported. The other variables that were different between the two groups were the occurrence of MD , which showed a significant difference between the online and outpatient cohorts in both clusters of young and old patients and was more likely to be reported among outpatients. On the other hand, hyperacusis showed a significant difference between online and outpatient cohorts only in the cluster of young patients, whereas the online group reported higher rates of this condition hyperacusis. However, after analyzing the intensity of hyperacusis, we found that the older respondents were more likely to report severe hyperacusis in the online survey (p = 0.001)  .t-tests or χ2-tests, accordingly. These analyses showed statistically significant differences between both groups in terms of age and sex, the history of acute otitis media, vertigo, and hyperacusis  and the description of tinnitus increasing factors for tinnitus  were reported most frequently in MD.The tinnitus profile was different in individuals with MD compared with non-MD participants . TinnituThe purpose of this study was to investigate the clinical profile of Spanish patients with chronic tinnitus by using the ESIT-SQ in two different groups of individuals, namely outpatients and online participants. Although the ESIT-SQ is a very detailed self-reported questionnaire, it records information on many diseases that should be supported by the diagnosis of a clinician, such as MD, hearing loss, or anxiety/depression. According to this, the ESIT-SQ should be used as a screening instrument and any disease or disorder must be confirmed by a clinical diagnosis. Despite these limitations, our study was able to identify a set of characteristics that are often present in participants with tinnitus.Although the ESIT-SQ was developed by Genitsaridi et al., only few studies have used it . There iMost individuals from the online survey were patients with chronic tinnitus and MD, a chronic inner ear disorder defined by episodes of vertigo associated with tinnitus and sensorineural hearing loss ,25. AlthRegarding the characteristics of each group, there are few studies that have investigated the effect of age on the responses obtained to assess comorbidities in patients with tinnitus. There are some studies where the average age was higher . HoweverThe ESIT-SQ recorded information about otological disorders such as acoustic trauma, infections, or different types of hearing loss. Hearing loss has shown a significant association with tinnitus in several studies ,29. HoweVertigo was more frequently reported in online survey. This could be explained by the higher prevalence of MD in this cohort. However, dizziness and vertigo are non-specific symptoms that could be explained by multiple causes including vestibular, brain, or heart disorders ,31,32,33Stress ,36, depr2 [2 could be related to higher rates of dyslipidemia and hypertension in tinnitus patients.We did not observe a higher prevalence of temporomandibular joint disorders, in contrast with other prevalence studies ,42. Hype2 ,44. NoneFinally, we also observed differences on hyperacusis between both cohorts, and it affected a significant percentage of patients with tinnitus. Hyperacusis was more frequent in the online survey. This could be explained due to a significantly higher proportion of patients of MD in this group. Other studies have also described a higher frequency of hyperacusis in patients with tinnitus than individuals without tinnitus. It is well known that tinnitus is particularly common in patients with hyperacusis, and they can co-occur in patients with severe tinnitus ,45. In aThere are multiple variables that may explain tinnitus heterogeneity, but there is a lack of studies focused on the characteristics of tinnitus. Genitsaridi et al. summarized in their systematic review what symptoms were more frequently recorded in the studies and which showed significant differences among different groups of patients. Among all of these characteristics, the most frequently reported were tinnitus severity, hearing ability, age, and depressive symptoms .Regarding duration of tinnitus, we find significantly differences between both groups, with a higher duration in online survey. Other studies showed similar results where the duration of tinnitus was reported as an important variable  .When we analyzed the differences between patients with MD, we observed that changes in hearing and triggers are associated with tinnitus in MD. Moreover, hyperacusis and worry about tinnitus were more prevalent in these patients. These findings were already reported in MD . In addiThere are controversies in the effect of different treatments on tinnitus, as their effectiveness is limited. Some studies reported the effect of several treatments in tinnitus, although there are limitations due to the heterogeneity of the results . Other sThere is a lack of literature on psychoacoustic characterization of tinnitus and there are no studies that compared two populations with tinnitus with different recorded way. New investigations with electro-acoustical devices are needed to standardize psychoacoustic measurements and to design and validate new tools for sound therapy to treat them.By using age clustering to improve clinical profiling, the separation between young and old patients confirmed some findings reported in the non-stratified comparative method. On the other hand, some other significant differences, such as level of education, presbycusis, and dyslipidemia were no longer replicated after age clustering. In addition, after Bonferroni correction, the differences in acoustic trauma in young patients from the online cohort and outpatients remained, while differences in hyperacusis and neck pain in old patients were not significant. The variables that were found to be significantly different between online participants and outpatients were ear problems, MD, hyperacusis for the younger group, and severe hyperacusis for the older cluster.Self-report questionnaires such as ESIT-SQ are useful to standardize clinical profiling in individuals with chronic tinnitus. However, these instruments should be used as screening and all medical or psychological conditions such as anxiety and depression, hearing loss, or MD, should be supported by a medical diagnosis.There are differences in the tinnitus profile in the online and outpatient surveys including the level education, hearing disorders associated with tinnitus (MD and hyperacusis), and difficulty to sleep. Moreover, tinnitus characteristics were different between samples, including the type of onset, tinnitus duration, the report of mitigating factors, and the use of treatments. When both groups were adjusted for age and sex, there were still differences in the tinnitus profile including the total duration of tinnitus, duration of debilitating tinnitus, number of perceived sounds, subjective changes in hearing, and factor increasing tinnitus. Age clustering indicates the role of acoustic trauma in young patients with tinnitus.


Patients with alcohol use disorders (AUD) have difficulties with certain aspects of higher-order language functions (HOLF) but there is no data on a wide range of these functions in this group. Therefore, the aim of this study was to compare different aspects of HOLF in patients with AUD and healthy controls (HC). A total of 31 patients with AUD and 44 HC took part in the study. We assessed HOLF with the Right Hemisphere Language Battery (RHLB) and measured control variables: depression using the Patient Health Questionnaire (PHQ) as well as the speed of processing and executive functions with the Color Trails Test (CTT). Patients with AUD had lower results on nine RHLB tests. Moreover, AUD patients had higher scores on PHQ and longer reaction times on CTT. The differences in most RHLB results remained significant after co-varying the control variables. Patients with AUD have difficulties with making inferences from the text, understanding the meaning of individual words, metaphorical content, and prosody, which may impede the comprehension and production of discourse in which linguistic elements must be integrated with non-verbal cues and contextual information. These disturbances may impact various spheres of everyday life and negatively influence social, private, and professional functioning. Language and communication abilities related to higher-level processing refer to the use of language in particular contexts, the communication of intentions, goals, thoughts and emotions, as well as the use of symbols to communicate. To understand an utterance that is rooted in such abilities requires drawing subtle inferences based on knowledge of the speaker, language, and context. A given utterance may be interpreted in any number of ways, depending on, for example, the identity of the speaker, physical context, or the preceding conversation . Among tBoth the linguistic and non-linguistic aspects of HOLF are supported by cortical areas in the left and right hemispheres, which has been confirmed by clinical and experimental data. These language processes appear to be linked with the temporoparietal, frontal, and cingular cortices; they are often bilateral in nature, although the right hemisphere appears to dominate ,12,13,14Chronic consumption of alcohol leads to neurotoxicity, causing changes in grey and white matter structure, as well as in the activation and functional connectivity of different brain areas ,18. The There is very little research into particular aspects of HOLF in AUD patients  and mostIndividuals with AUD reveal problems processing figurative content, such as understanding humor and detecting irony ,30. HoweTo our knowledge, no study to date has used the RHLB battery to assess a wide range of language and communication abilities in AUD patients. Moreover, most previous studies did not control for the effects of depression and executive functions when comparing some aspects of HOLF  between AUD patients and HC. Controlling these variables is important because other studies have demonstrated the existence of a relationship between them ,41,42, aA total of 75 participants took part in the study: 31  patients with AUD and 44 HC . All subjects were native speakers of Polish. Patients with AUD were selected based on medical history, consultation with psychiatrists, and a clinical interview based on the ICD-10 (WHO ) with thThe Polish version of the Right Hemisphere Language Battery (RHLB ) was useIn the Inference Test, the respondent answered questions about the information hidden in short narrative or conversational stories (scoring is between 0 to 16). The correct performance of the Lexical-Semantic Test requires understanding a heard word and indicating the corresponding picture (scoring is between 0 to 13). There are also 5 additional distraction pictures: 2 semantic, 1 functional, 1 phonological, and 1 visual control. The Humor Test consists of choosing an appropriate and humorous ending for a given story; there are 2 wrong endings: a neutral ending  and a surprising ending . The Commentary Test is the sum of points scored for comments made while performing the Inference Test and Humor Test (scoring is between 0 to 14). In the Written Metaphor test, the respondent is asked to identify a metaphorical answer from among 3 answer variants: the correct metaphorical answer, a literal answer, and an inappropriate meaning (scoring is between 0 to 10). In the Written Metaphor Explanation test, the subject gives their own interpretation of the metaphor from the previous test (scoring is between 0 to 10). The Picture Metaphor test requires indicating from among 4 pictures the one that reflects the correct meaning of the metaphor (scoring is between 0 to 10). The incorrect pictures consist of 1 showing the literal meaning and 2 other controls that correspond to some part of the sentence. In the Picture Metaphor Explanation test, the respondent again explains the metaphors in their own words (scoring is between 0 to 10). The Emotional Prosody Test is intended to assess the ability to understand emotional intonation . There are 16 nonsense phrases played from a recording; after each, participants are asked to indicate the appropriate tone of expression. The Linguistic Prosody test consists of a similar procedure. However, the subject hears recorded phrases with intonations expressing a statement, question, and an order (scoring is between 0 to 16). The last test is Discourse Analysis, which comprises 16 rating scales that assess the ability of the respondent to interact with another person and make a conversation (scoring is between 0 to 60).In the Polish population of HC and patients with right hemisphere damage, the psychometric properties of RHLB were validated by Łojek . The batA structured clinical interview was conducted with each participant. It included demographic data such as age, gender, years of education, and clinical data regarding AUD duration, length of stay in the treatment department, number of times in the therapeutic department, and number of times in the withdrawal department. Data were verified based on the patient’s medical history. The severity of depressive symptoms (occurring during the last 2 weeks) was assessed with the Polish version of the Patient Health Questionnaire-9  and standard deviations (SD). G-Power 3.1.9.7 software was used for sample size the calculation for the two-sample t-test. We assumed a power of 0.90 and α = 0.05 to detect a large effect size (0.80) for differences in HOLF between the 2 groups [t-tests. For significant differences in correct and incorrect RHLB answers between the 2 groups, an analysis of covariance (ANCOVA) was performed to control for the effect of depression (results on PHQ-9), and speed of processing and executive functions (results on both parts of the CTT), because these variables might be related to HOLF [d or ɳ2 [p-value correction was used for all statistical analyses due to multiple comparisons. The alpha criterion level was assumed at 0.05 and statistical power above 1-ꞵ = 0.80 for all statistical analyses [p < 0.10), which was recommended in the literature of biomedical sciences [Statistical analysis of the results was conducted using the IBM Statistical Package for the Social Sciences 26 . Continuous variables were presented as means  had higher scores on PHQ-9 (p < 0.001) and longer reaction times on CTT 1 (p = 0.012) and CTT 2 (p = 0.008).Demographic, clinical, and psychological characteristics are presented in p-value correction due to multiple comparisons) had worse results in terms of correct answers on 9 RHLB tests: Inferential Meaning (p < 0.001), Lexical-Semantic (p = 0.006), Commentary (p = 0.044), Picture Metaphor (p < 0.001), Picture Metaphor Explanation (p = 0.044), Written Metaphor Explanation (p < 0.001), Emotional Prosody (p = 0.025), Linguistic Prosody (p < 0.001), and Discourse Analysis (p < 0.001). Differences between groups on the Inferential Meaning Test, Lexical-Semantic Test, Picture Metaphor Test, Picture Metaphor Explanation, Written Metaphor Explanation, Linguistic Prosody Test, and Discourse Analysis (0.001 > p < 0.05) remained significant after co-varying for depression, speed of processing, and executive functions. In the case of results on the Commentary Test and Emotional Prosody Test, group differences were at the level of marginally significant (p < 0.01). The effect sizes (ɳ2) of the analyzed indices were found to be 0.04–0.21, indicating small to large effect sizes.As shown in p-value correction due to multiple comparisons) had worse results for two incorrect answers on the Picture Metaphor Test—Literal Answers (p < 0.001) and Written Metaphor Explanation—Abstract Incorrect (p < 0.001). Differences in both indices (0.01 > p < 0.001) remained significant after co-varying for depression, speed of processing, and executive functions. The effect sizes (ɳ2) of the analyzed indices were found to be 0.14–0.21, indicating large effect sizes.As shown in The aim of the present study was to investigate differences in HOLF between patients with AUD and HC. The results revealed disturbances in the ability to infer from context and understanding of lexical-semantic information  in patients with AUD. They had reduced capacity for abstract thinking based on visual-spatial analysis of information (picture metaphors) and problems with explaining metaphors. AUD patients had a greater tendency to make spontaneous inappropriate comments during the test. Impaired understanding of emotional and linguistic prosody was also observed. Moreover, patients with AUD were less effective at interpersonal communication. However, both groups had similar levels of comprehension of humor and written metaphor, represented by abstract thinking based on the processing of complex language material.In our study, we expected that patients with AUD would have decreased HOLF in comparison to HC, as measured by the RHLB. These assumptions were confirmed and are in-line with some previous research that studied selected aspects of language, communication, and social cognition ,40. In pAUD patients in our study also found it difficult to make inferences based on the texts they read. The stories were narrative or conversational. In the study of Cermak et al. , people Difficulties with comprehending narratives may be related to deficits interpreting lengthy, grammatically complex sentences and problems combining semantic and syntactic information . It shouFurthermore, we observed that AUD patients had difficulties comprehending conventional metaphors (which have not been studied in this group). These are a type of figurative expression that requires knowledge of semantic and syntactic rules, non-linguistic skills, and recollection of meaning . PatientFurthermore, our study showed that AUD patients do not differ from healthy controls in understanding humor. There is very little data about the processing of these functions and they are inconclusive. Some results are in line with our study but were obtained with other measurement tools . AlthougPatients with AUD presented a poorer ability to withhold inappropriate comments during the research procedure. Compared to the control group, they expressed more spontaneous comments related to the study situation and tests. Unfortunately, results concerning withholding inappropriate comments cannot be compared with other studies. These difficulties may be due to increased impulsivity observed in individuals with AUD and impairment of executive function ,63. In oDifficulties understanding the meaning of individual words, information implied in text, abstract, metaphorical content, and prosody may impede comprehension and production of discourse, in which linguistic elements must be integrated with non-verbal cues and contextual information . DisturbHowever, this study has some limitations. First, the group was small, thus it is worth conducting similar research on a larger number of people. In addition, craving scales or consumption scales were not used to quantify the severity of the substance use disorder. It would be worth measuring the quantity of alcohol consumed. Furthermore, we did not control for intelligence. However, we used executive functions as a covariate in the statistical analysis of group differences that may be related to HOLF. It is worth noting that the directionality of the effects cannot be established based on the current study. There is substantial evidence, as with many other substance use disorders, for genetic predispositions to AUD , and it In summary, our study found that patients with AUD have difficulties with different aspects of HOLF: the ability to infer from context, understanding of lexical-semantic information, comprehension of metaphors, prosody, and production of discourse. Moreover, patients had higher levels of depression, executive dysfunction, and a slower speed of processing. The differences in most HOLF remained significant after co-varying these control variables. These disturbances may impact various spheres of everyday life. Further studies should verify the results of our research.


Foodborne disease caused by foodborne pathogens is a very important issue in food safety. Therefore, the rapid screening and sensitive detection of foodborne pathogens is of great significance for ensuring food safety. At present, many research works have reported the application of biosensors and signal amplification technologies to achieve the rapid and sensitive detection of pathogenic bacteria. Thus, this review summarized the use of biosensors coupled with signal amplification technology for the detection of pathogenic bacteria, including (1) the development, concept, and principle of biosensors; (2) types of biosensors, such as electrochemical biosensors, optical biosensors, microfluidic biosensors, and so on; and (3) different kinds of signal amplification technologies applied in biosensors, such as enzyme catalysis, nucleic acid chain reaction, biotin-streptavidin, click chemistry, cascade reaction, nanomaterials, and so on. In addition, the challenges and future trends for pathogenic bacteria based on biosensor and signal amplification technology were also discussed and summarized. Escherichia coli, Salmonella typhimurium, Listeria monocytogenes, Vibrio parahaemolyticus, Vibrio cholerae, Staphylococcus aureus, and Bacillus cereus [In recent years, foodborne disease has become the most important food safety issue worldwide; it also poses a global threat to human beings. The outbreak of foodborne diseases is not only a threat to people’s health but also causes immeasurable economic losses. Most foodborne diseases are caused by different kinds of pathogenic microorganisms such as viruses, actinomycetes, fungi, parasites, and bacteria. Of these, bacteria are one of the most prevalent pathogens; as reported by Daniel Dewey, foodborne diseases caused by bacteria accounted for 47% of total foodborne diseases in 2009–2015 in the U.S. [s cereus ,4. It has cereus . TherefoTo date, different methods have been studied and employed to detect pathogenic bacteria, such as bacterial cultivation, polymerase chain reaction (PCR), loop-mediated isothermal amplification (LAMP), enzyme-linked immunosorbent assay (ELISA), and immunochromatographic assay (ICA). Culture counting, as the current gold standard for pathogenic bacteria detection, has the advantages of simple equipment, a low cost, easy operation, and high accuracy . HoweverIn 1962, an enzyme-based biosensor was reported for the first time by Professor Clark on the Annals of the New York Academy of Sciences . In thisThe concept of biosensors was defined by the International Union of Pure and Applied Chemistry (IUPAC) as follows: “a biosensor is an independent integrated device, which can directly combine a kind of transducer with a kind of biometric element, so that it can specifically analyze the target quantitatively or semi-quantitatively” . From thWith the development and application of sensors in multiple disciplines, many biosensors in different forms have been derived. At present, the biosensors can be classified according to its bio-sensitive element and transducer. Regarding the bio-sensitive element, it can be classified into enzyme, DNA, tissue, and immunosensor biosensors. According to the transducers used, we can classify biosensors into electrochemical, optical, piezoelectric, thermal, and acoustic sensors . At the Electrochemical biosensors are an important branch of biosensors with the longest history, the widest application range, and the best vitality. Electrochemical biosensor is a typical sensing device that transduces the biochemical events to electrical signals . General63-/4- is often used as an auxiliary probe for detection. When the electrode is modified with a biometric element with poor conductivity, it will hinder the diffusion of Fe(CN)63-/4- to the electrode surface, resulting in increasing impedance. When the target molecule reacts with the recognition element, it will lead to a further increase in impedance. Therefore, the quantities of the molecules to be measured can be calculated according to the change of impedance. In non-electrode modified impedimetric biosensors, an enzyme is often introduced for the enzymatic reaction, which leads to a change in the ion concentration in the detection solution, thus causing a change of impedance. A linear relationship can be established between the impedance change and the concentration of the target molecule to achieve the detection.Impedance in a circuit is used to measure the block level encountered by an alternating current. It is the general name for resistance, inductance, and capacitance. In an electrochemical system, impedance is an important parameter to describe the interfacial properties of electrode and electrolyte . An impeS. typhimurium on the electrode. The impedance change between the electrodes is used to detect the target bacteria. The procedure can be finished in 20 min, and the detection limit can be as low as 1 × 103 CFU/mL. Cimafone et al. (2020) reported a method for E. coli quantitative detection using an impedimetric biosensor based on a modified screen-printed electrode [E. coli antibody was fixed on the electrode by modifying where the bacteria was captured. By measuring the electrochemical impedance spectrum of Fe(CN)63−/4− after each modification and binding, amounts of E. coli in drinking water as low as 3 × 101 CFU/mL can be detected within 1 h  developed an amperometric immunosensor with high sensitivity for the detection of E. coli [E. coli O157:H7 was immobilized on the electrode surface. The bacteria become trapped on the surface and lead to redox reaction, whose peak can be determined by cyclic voltammetry. In this way, the concentration of the bacteria can be inferred. The method can detect E. coli O157:H7 at amounts as low as 30 CFU/mL  dissolved aptamer-modified nano-magnetic beads and colloidal gold particles in dark-red colloidal gold solution . Then, Sathogens A. Srisa-reaction . After b2 CFU/mL B. Chen eh urease . The ure2 CFU/mL C.A fluorescence biosensor is a biosensor based on the fluorescent properties of substances. At present, fluorescence spectroscopy and fluorescence energy resonance transfer methods are most commonly used. In brief, the principle of fluorescence spectroscopy is that different substances will emit different wavelengths of the fluorescence spectrum after absorbing the energy of light under UV irradiation, and the intensity is related to the concentration. Fluorescence spectrometry mainly uses this correspondence to determine the concentration of specific substances . In the E. coli [E. coli was captured, the Ag@Si core–shell nanoparticles were combined through the antibody. There was a positive correlation between the fluorescence intensity of dyes on nanoparticles and E. coli. By measuring the fluorescence intensity, amounts of E. coli as low as 5 CFU/mL could be detected. In the detection of foodborne pathogens, this method has the advantage of high sensitivity  used QDs with different emission wavelengths  to bind with aptamers of different target bacteria [E. coli O157:H7, S. aureus, L. monocytogenes, and S. typhimurium, and the detection limits are 8 × 101 CFU/mL, 102 CFU/mL, 4.7 × 101 CFU/mL, and 1.6 × 102 CFU/mL, respectively  developed a new fluorescent biosensor based on fluorescent dye and Ag@Si Core shell nanoparticles modified with antibodies against E. coli . The sensitivity A. In fluhimurium . The resbacteria . Then, cectively B.The microfluidic chip, also known as a lab-on-a-chip, is a technology that uses channels with sizes of tens to hundreds of microns to manipulate and process micro-volume samples. In recent years, the microfluidic biosensor has been developed by combining this technology with biochemical analysis technology. The sensor can integrate the analysis process  on a single microfluidic chip ,50. At pE. coli. Its detection limit can reach as low as 103 CFU/mL [E. coli was modified on the electrode. When the microfluid containing E. coli flows through the chip, the target bacteria are recognized and captured by the antibody on the electrode, resulting in the change of impedance. There is a linear correlation between the change of impedance and bacteria. The microfluidic biosensor can successfully detect amounts of E. coli as low as 3 × 102 CFU/mL and achieves rapid, sensitive, and automatic analysis. Kim et al. (2015) designed a microfluidic chip containing a sample inlet, reaction-binding region, and detection region. In the reaction-binding region, serpentine channels are used to increase the contact between samples to improve the reaction efficiency [3 CFU/mL for S. typhimurium , which raises strict requirements for the reaction conditions of fluorescent biosensors. The development of a microfluidic chip has led to great progress for biosensors in terms of miniaturization, automation, and integration, providing great help for the on-site detection of foodborne pathogens. However, due to the micro scale of microfluidic channels, there are challenges in the analysis of complex samples. For example, the channel’s non-specific adsorption of the sample and the blockage of the channel are problems that are difficult to solve. Therefore, to address current issues, we still need to develop biosensors in combination with more advanced technologies to improve their performance in practical detection.It is the basic principle of biosensors to quantitatively analyze the target by using the positive correlation between the target concentration and the detection signal. However, in practical detection applications, we often face the problem that the signal conversion and output cannot be triggered due to the low concentration of the target. If the concentration of the target remains unchanged, increasing the intensity of the corresponding output signal can deal with this problem. Therefore, the development of signal amplification technology to improve the detection sensitivity and detection range of biosensors has become a research hotspot. At present, the signal amplification technology used in biosensors is becoming increasingly diversified. In the same biosensor, multiple signal amplification techniques can be applied simultaneously . To dateAn enzyme is a kind of protein or RNA produced by living cells that has high selectivity and catalytic performance for substrates . Using tE. coli O157:H7 through electrostatic and hydrophobic interactions [E. coli O157:H7 can be carried out by measuring the color change with absorbance. Signal amplification technology based on enzyme catalysis can detect 12 CFU/mL E. coli O157:H7 in 30 min. This method proves that the urease catalytic technology can enable the signal amplification for the biosensor (S. aureus [2O2) to produce color changes to achieve target detection. This method could reach the detection limit of 5 × 102 CFU/mL in 90 min, and the rapid and sensitive detection of S. aureus was achieved  used magnetic nanoparticles labeled with antimicrobial peptides to capture ractions . Due to iosensor A, achiev. aureus . Other pachieved B. Luo etlabeling . The surfication C.It is the basic principle of PCR to amplify a target DNA fragment using complementary base pairing. Inspired by this technology, scientists have developed a signal amplification method based on DNA cycle amplification: in combination with immunology, the DNA fragment is labeled with a certain signal molecule to cause it to reach the maximum load and achieve the amplification of the output signal . This teS. aureus [S. aureus), the two hairpin probes are adsorbed by GO through π–π stacking, resulting in the quenching of the fluorescence signal. When there is a target nucleic acid, the two hairpin probes will trigger an HCR reaction and generate a double-stranded DNA complex. In this way, the fluorescent signal can be amplified by the interaction of fluorescent groups and fluorescent dyes on double-stranded DNA to achieve the sensitive quantification of the target fragment. Under optimal reaction conditions, the detection limit of the 16S rRNA fragment of S. aureus can reach 50 pM. Correspondingly, the lowest detectable concentration of S. aureus is 4 × 102 CFU/mL. Song et al. (2019) used two aptamers to capture and recognize V. parahaemolyticus [2-) oxidation, was generated by RCA-assisted cleavage technology. Its signal amplification effect enables the naked eye to identify the detection results. The amplification technology can detect amounts of V. parahaemolyticus as low as 10 CFU/mL without DNA extraction and expensive equipment, achieving ultra-sensitive detection  developed a signal amplification method for the sensitive detection of L. monocytogenes by combining ELISA with RCA technology [2 CFU/mL  Different protein or nucleic acid molecules can bind to biotin or SA, respectively. Since one SA can bind to four biotins, and one protein or nucleic acid molecule can bind to multiple biotins, the effect of multi-stage amplification can be achieved. (2) The binding ability of biotin and SA is very strong, at 105–106 times antigen antibody affinity. This strong combination can be formed in a very short time. (3) Various types of molecules, such as proteins, enzymes, DNA, and antibodies, can bind to biotin or SA. Their biological activities do not change after binding. Therefore, different biomolecules can be modified with biotin or SA according to the specific needs of detection to achieve the corresponding signal amplification effect [Biotin, also known as vitamin H or coenzyme R, is a water-soluble vitamin. Avidin is a glycoprotein composed of four subunits that can be extracted from egg white. Streptavidin (SA) is a protein secreted by n effect .E. coli O157:H7 was used to form a double antibody sandwich structure using two recognition antibodies. One side of the antibody was modified on the surface of colloidal gold particles. The colloidal gold particles were also labeled with HCR hairpin probes, and each hairpin probe was connected with HRP. When the HCR reaction was triggered, a large amount of HRP was loaded on the double antibody sandwich, which then catalyzed the color development of TMB to cause more obvious color changes. After that, the absorbance test could be implemented. The optical biosensor based on the signal amplification system can detect amounts of E. coli O157:H7 as low as 1.08 × 102 CFU/mL. Compared with the traditional ELISA method, the detection limit is nearly 185 times lower, and the sensitivity is improved  in 2001 . It is a2+ to Cu+ through the metabolic process [+ can trigger the click chemical reaction between the azides modified on the surface of colloidal gold particles and alkyne functional molecules. This leads to the aggregation of monodisperse colloidal gold particles, resulting in color changes. This method can detect 40 CFU/mL E. coli within 1 h, which verifies the signal amplification effect of click chemistry  triggering a cascade reaction on the basis of a signal generated by a single reaction can further enhance and amplify the signal; (2) converting a single reaction that cannot trigger signal conversion into a detectable signal through a cascade reaction; and (3) through the cascade reaction, the signal generated in the original single reaction mode is converted into another signal with higher sensitivity for output to achieve the purpose of signal amplification ,99. At p2O2. DNAzyme hydrogels with mimic enzyme properties can also transform ABTS- into ABTS2- in the presence of H2O2, resulting in color changes. This method allows the detection of lactose at levels less than 2 mM with the naked eye, which shows that multi-enzyme catalysis can achieve a good signal amplification effect. Zhang et al. (2014) applied the multi-enzyme catalytic system to a chemiluminescence biosensor for the signal amplification detection of E. coli O157:H7 [E. coli and GOx. The GOx on the complex can catalyze glucose to produce H2O2. H2O2 can be hydrolyzed by lactase to induce luminol luminescence to achieve the detection of E. coli O157:H7. The multi-enzyme catalytic system can avoid the influence of the accumulation of catalytic products on the enzyme activity. Thus, the sensitivity of the detection method can be further improved. Under optimal reaction conditions, the detection limit of the multi-enzyme catalytic system for E. coli O157:H7 was 1.2 × 103 CFU/mL  prepared DNAzyme hydrogel using the DNA structural unit of enzymatic polymerization. A mixed cascade enzymatic reaction system was constructed by encapsulated GOx and ß-Galactosidase  in the DNAzyme hydrogel . ß-Gal c O157:H7 . This us3 CFU/mL A. Gao etfunction B.2 nanosheets and mesoporous materials; (3) nanomaterials that can load and enhance the strength of many signal molecules, such as nanoflowers; (4) nanomaterials that have simulated enzyme catalytic activity and can load a large number of signal molecules, such as metal–organic frameworks. In this paper, the signal amplification function of nanoflowers, mesoporous materials, and metal–organic frameworks (MOFs) in biosensors is reviewed. The typical shapes of nanoflowers, mesoporous materials, and MOFs are presented in Nanomaterials refer to materials with at least one dimension in the nanometer scale (0.1–100 nm) in three-dimensional space or composed of these materials as basic units. This leads to unique functions and properties in terms of chemistry, biology, physics, mechanics, optics, magnetism, and electricity ,107. TheThe full name of nanoflowers is organic/inorganic hybrid nanoflowers (NFs). From the definition, it can be seen that this refers to a nanomaterial with a flower-shape, which is formed by the self-assembly of inorganic salt ions and organic ligands . The first successful preparation of nanoflowers was carried out in 2012 by Ge et al. (2012) . They usE. coli O157:H7 is immobilized on the ELISA plate, and the nanoflowers are added to the ELISA plate to detect the target bacteria. The concentration of E. coli O157:H7 as low as 101 CFU/mL could be detected by measuring the concentration of glucose produced by invertase transforming sucrose with a blood glucose meter  constructed an ELISA optical biosensor based on nanoflower signal amplification for the rapid and sensitive detection of E. coli O157:H7 [E. coli O157:H7 as low as 60 CFU/mL  prepared nanoflowers with ConA (which can recognize the target bacteria), sucrose invertase, and inorganic calcium ions . An antise meter A. Maaroueritidis . The doueniently B. This m O157:H7 . The nan0 CFU/mL C.2 nanosheets were used to block all the mesopores of MSNs. Finally, glutathione (GSH) was introduced to decompose the nanosheets to release glucose. The linear relationship between glucose concentration and GSH can be obtained by detecting glucose molecules with a blood glucose meter. The lowest detectable concentration of GSH was 34 nM/mL  prepared Cu-ZrMOF with high catalytic activity, which has mimic enzyme activity and can catalyze the decomposition of H2O2 [Pseudomonas aeruginosa was modified on the electrode surface to capture the target bacteria. The Cu-ZrMOF labeled with aptamer can combine with Pseudomonas spp. to form a complex. The Cu-ZrMOF on the complex can catalyze H2O2-induced electron transfer. Using cyclic voltammetry, the target bacteria can be quantified by the electric signal intensity. This method can detect concentrations of Pseudomonas spp. as low as 2 CFU/mL (E. coli O157:H7 was modified on the electrode. The antibody on CdS@ZIF-8 could recognize the target bacteria and form a double antibody sandwich complex. CdS@ZIF-8 was decomposed by adding hydrochloric acid solution to release a large amount of Cd (II) ions. By measuring the released Cd (II) ions by differential pulse voltammetry, E. coli O157:H7 can be quantitatively detected. The minimum detection limit of this method is 3 CFU/mL  usually refer to crystal materials with a grid structure formed by the self-assembly of inorganic metals and organic ligands . Comparelectrode . Subsequ of H2O2 . An anti2 CFU/mL A. Zhong 3 CFU/mL B.In summary, different kinds of signal amplification technologies have been widely used and studied in various fields. For food safety detection, the application of signal amplification technology in biosensors can improve stability, simplify the detection steps, and reduce costs. Further innovation and work on the basis of existing signal amplification technologies will occur in the future with the aim of building biosensor platforms with a high stability, convenience, and low cost and that are better able to solve the problems of food safety.Processing signals generated in the detection is an important part of biosensors. The signals can be in different forms, such as images or spectra, and the identification of foodborne pathogens is sometimes time consuming. In recent years, deep learning technology has begun to appear in biosensors for signal enrichment and rapid processing. For example, in the processing of spectra, deep learning has the potential to enhance the output of in-line, on-line, and at-line instrumentation used for process analytical technology in biosensing.Wang et al. (2020) presented a computational live bacteria detection system that periodically captures coherent microscopy images of bacterial growth inside a 60-mm-diameter agar plate . It analMaruthamuthu et al. (2020) developed a tool for detecting microbial contamination using Raman spectroscopy-based deep learning strategies . A RamanKukula et al. (2021) presented a deep learning-based approach to detect the identity of a bacteria class rapidly and accurately . The modYan et al. (2021) proposed a machine learning strategy based on fingerprint difference of Raman spectroscopy for the rapid diagnosis of pathogenic bacteria . In theiMaruthamuthu et al. (2020) summarized a series of process analytical technologies (PAT) that applied data-driven deep learning . PAT forE. coli [In order to better understand the advantages and disadvantages of the reported biosensors, a general comparison on incubation time, detection limit, and detection range for different types of biosensors and different signal amplification methods is summarized and shown in E. coli ,46. AmonE. coli ,125,126.Foodborne pathogens pose a great threat to the economy, environment, and human health. The early screening of foodborne pathogens is of great significance for food safety. This paper reviews current detection technologies, mainly regarding biosensors coupled with signal amplification technology. The advantages and disadvantages of different kinds of biosensors and signal amplification technologies were analyzed, providing a comprehensive reference for the sensitive and rapid detection of foodborne pathogens. In addition, the biosensors and signal amplification technologies introduced in this article have been affected by other factors , resulting in the detection time and sensitivity being different in different studies. Thus, the readers can choose the best suitable biosensors or signal amplification technologies according to their own needs without being limited by the detection sensitivity and time mentioned in this article.To date, many researchers have devoted efforts to the development and innovation of sensitive detection methods for pathogenic bacteria. However, the food background is usually complex and easily disrupted by other non-target substances, non-specific proteins, and so on. In addition, the concentration of bacteria in the screening samples is generally low, which brings great challenges to the screening of pathogenic bacteria. Thus, the pre-processing of large-volume and complex food samples is of great significance for the rapid and sensitive detection of bacteria. While applying biosensors and signal amplification technologies, the introduction of efficient bacteria separation and enrichment technology in large-volume samples will be an important trend of bacterial detection in the future.As a multidisciplinary high-tech field, the future development of the biosensor will have some new characteristics with the rapid development of biological sciences, information sciences, and materials sciences. First, biosensors may develop toward miniaturization and comprehensiveness. Future biosensors will further involve various fields of healthcare, food inspection, environmental monitoring, and the fermentation industry. With the advancement of micro-processing technology and nanotechnology, biosensors will continue to be miniaturized. Second, in the future, biosensors will be perfectly and closely integrated with computers, which can automatically collect and process data, providing more scientific and accurate results. At the same time, microfluidic technology will increasingly enter the field of biosensors to realize the integration and integration of detection systems.We believe that with the further improvement of some key technologies including signal enrichment and analysis, and with the continuous development of various disciplines, biosensors will surely be more powerful in the future.


Aims: Little information exists on the associations of cardiovascular health, a new metric proposed by the American Heart Association, and executive function, particularly in children. We aimed to explore this topic.Methods: We studied 3,798 children aged 6–12 years from 5 schools in Guangzhou, China. The executive function of children was evaluated using parent reports of the Behavioral Rating Inventory of Executive Function, which included 2 composite indexes and 8 subscale scores. We calculated the number of ideal cardiovascular health (range: 0–7) based on smoking, body mass index, physical activity (PA), diet, blood pressure, cholesterol, and glucose. A generalized linear mixed model was used to assess the association of the number of ideal cardiovascular health metrics and executive function.Results: Compared with children exhibiting 1–3 ideal cardiovascular health metrics, decreases of 1.37–2.63 points (indicating better performance) in metacognition index and its 5 subscale indexes  were observed in children who attained 5 or 6–7 ideal metrics . Ideal diet and ideal PA were independently associated with lower indexes of behavioral regulation and metacognition.Conclusions: The number of ideal cardiovascular health was positively associated with performance of executive function in children. A construct of ideal cardiovascular health, also referred as life's simple 7, is defined by the American Heart Association (AHA) in 2010 to track health status in relation to a 2020 strategic goal to improve cardiovascular health of Americans , with moAdditionally, cardiovascular health plays a critical role in brain health . ExecutiTherefore, the objective of this study was to investigate the associations between the AHA construct of ideal cardiovascular health metrics and executive function in the Chinese children. We hypothesized that a greater number of cardiovascular health metrics would be associated with executive performance. Furthermore, each metric included in the cardiovascular health would be related to executive function.This analysis was embedded on the baseline data from an ongoing population-based prospective cohort study in Guangzhou, China , previously described in detail . BrieflyThe above sampling strategy generated 8,324 eligible participants, of whom 5,788 children aged 6–12 years received anthropometric measurements and questionnaire survey. A total of 4,744 children provided voluntarily a blood sample. We additionally excluded 946 students without information on the Behavioral Rating Inventory of Executive Function (BRIEF) or important covariates . Finally, 3,798 participants were included in the data analysis. All participants and their parents/guardians gave their written informed consent before participation, and this study was approved by the Ethical Review Committee for Biomedical Research, Sun Yat-sen University, Guangzhou, China.via frequency food questionnaire, and we replaced grain and salt, two components proposed by the AHA, with milk, beans or dairy-or bean-products, and fried food consumption, respectively. The healthy diet score was defined to include the following 5 components: (1) fruits and vegetables (≥1 times/day); (2) fish or fish products (≥2 times/week); (3) milk, beans, or dairy-or bean-products (≥1 times/day), (4) fried food (≤ 2 times/week); and (5) sugar-sweetened beverages (SSB) (≤ 2 times/week). Ideal diet was defined as having 4 or 5 healthy components.We measured cardiovascular health metrics based on the definitions published by the AHA . Due to Blood samples were collected between 7 and 9 a.m. at physical examination with children being asked to fast for at least 10 h before the test. Additionally, parents or guardians were informed by head teachers to make sure their children to fast completely for 10 h. A venous blood sample (5 ml) was taken from the antecubital vein. Samples were stored in sterile blood collection tubes in refrigerated conditions (4–8°C) for not more than 4 h after collection and then sent to an analytical laboratory for testing. Fasting blood glucose concentrations were measured by the glucose oxidase method , and TC were analyzed by enzymatic assays . Ideal fasting blood glucose and TC concentrations were classified as <5.6 and <4.4 mmol/L, respectively.After 10 min rest, systolic BP (SBP) and diastolic BP (DBP) were measured with a validated electronic sphygmomanometer  with children seated. The average of 2 readings was used. Ideal BP was defined as SBP and DBP <90th percentile according to the age-, sex-, and height-specific standards for the Chinese children and adolescents .The number of simultaneous presence of ideal cardiovascular health components for each participant was summed, ranging from 0  to 7 .t-distribution [a mean of 50 and SD of 10]. A higher score is associated with more problems related to executive function.The execution function of children was evaluated using the parental form of BRIEF, which is designed to provide an assessment of behavioral executive difficulties in everyday life at 5 and 18 years of age . The BRIwww.dagitty.net) to identify the most parsimonious confounders set . Finally, the following variables were selected as confounders in the main model: age, sex, only child, parental education, monthly household income, and screen time. Parents also completed the Strengths and Difficulties Questionnaire (SDQ) about child behavioral problems  , sex (boys or girls), only child (no/yes), parental education , monthly household income , and screen time. Screen time was calculated based on the total time of child's TV viewing, video game play, and computer use over the preceding 7 days. Screen time was dichotomized (<2 h/day or ≥2 h/day) in accordance with the guidelines of the American Academy of Pediatrics . We haveders set   . Recommenalysis) .Due to the limited number of participants with lower or upper ideal heath scores, children scored 1–3 and 6–7 in ideal health metrics were combined to stabilize our estimates. Therefore, ideal cardiovascular health scores were divided into 4 categories: 1–3 points, 4 points, 5 points, and 6–7 points (no participants scored 0). Differences in basic characteristics according to the ideal health metrics classification were tested using one-way ANOVA and chi-square test for continuous and categorical variables, respectively.CIs. Age, sex, only child, parental education, monthly family income, and screen time were adjusted as covariates in the model, and school was considered as a random effect. In the sensitivity analyses, we used the standard to screen for overweight and obesity among school-age children and adolescents in 2018 to repeat the results. In addition, we used GLIMMIX to evaluate the associations between each of 7 cardiovascular health metrics individually  and 2 composite scores of BRIEF (BRI and MI). We further evaluated the potential effect modification of sex (boys or girls) and SDQ behavioral problems  through the addition of multiplicative interaction term between sex/behavioral problems and cardiovascular health scores into regression model.We evaluated the association of total number of ideal health metrics and executive function using generalized linear mixed models (GLIMMIX). Model estimates were presented as point estimates with 95% p < 0.05 was considered as statistically significant for a two-tailed test.All statistical analyses were performed using SAS version 9.4 . A p < 0.05). The prevalence of ideal health for the individual and total number of components are displayed in n = 3,978) did not differ by age, only child, parental education, monthly household income, or screen time from the excluded participants (n = 946)  . There wp for trend <0.001).The associations between the number of ideal cardiovascular health metrics and executive function are summarized in In the sensitivity analysis, the associations between the number of ideal cardiovascular health metrics and executive function remained robust when using the Screening for overweight and obesity among school-age children and adolescents in 2018 .CI: −2.67, −1.26) and 2.29  points reduction in BRI and MI, respectively, relative to the non-ideal levels  points lower in MI than the non-ideal MVPA.After additionally mutual adjustment for the remaining 6 health components, ideal diet was associated with 1.96 , which is consistent with the findings of previous studies , 4. In a.0%, whicThere is growing number of epidemiological studies to explore the associations between the individual or multiple components of the cardiovascular health and executive function in children. Poor diet, physical inactivity, obesity, and hypertension have each been shown to be associated with deficits in the executive function performance in children –11. The Physical activity and diet were positively associated with executive function performance in this study. Mounting evidence from prospective observational studies and randomized clinical trials have demonstrated the beneficial effects of PA on cognitive function in children and adolescents . The mecThe present study has some limitations. First, the cross-sectional study design prevented us from inferring the temporality of the ideal cardiovascular health metrics and executive function. Second, although we were able to adjust for several factors known to be important for the executive function of children, it is possible that the observed associations were biased by unmeasured confounding factors, such as pubertal status and parental cognitive status. Third, only the parental reports of behavioral executive function, a tool for ecological assessment, was used in the study, which could result in information bias. The computerized testing, a standard and systematic method for cognitive assessment, could be used with questionnaire together to complement each other's advantages and comprehensively assess executive function . Fourth,In conclusion, we found that the number of ideal cardiovascular health was positively associated with performance of executive function in children. Public health practitioners and parents should encourage children to maintain better cardiovascular health profiles to improve executive function.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethical Review Committee for Biomedical Research, Sun Yat-sen University. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.YC, LC, and ZG designed this study. ZG, YL, LL, and XZ contributed to the data collection. ZG analyzed the data and drafted the manuscript. YC, LC, YL, LL, and XZ critically reviewed the manuscript. All authors read and approved the final manuscript.The work was supported by the National Natural Science Foundation of China (Grant numbers 81673193).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 strongest predictors of EDs were as follows: preoccupation with the Internet, neglect of sleep in favor of Internet use, alleviation of negative feelings while online, higher mean number of hours spent online on weekends for academic and work-related purposes, extracurricular activity, lower height and higher BMI. An association has been demonstrated between problematic internet use and eating disorders. Somewhat surprisingly, our results suggest that people at risk of EDs use the Internet primarily to fulfill their routine duties. Nevertheless, further research is needed to establish the causality of EDs and PIU.The aims of this cross-sectional study were: (i) to establish the prevalence of problematic Internet use (PIU) and eating disorders (EDs) among Polish students; (ii) to investigate potential correlations between the two phenomena; and (iii) to identify predictors of eating disorders among socio-demographic and Internet use characteristics in this population. To this end, a total of 1008 Polish students aged 18–40, completed the Problematic Internet Use Test (TPIU22), the Eating Attitudes Test (EAT-26) and a self-designed Socio-demographic and Internet Use Survey. Men received more PIU scores ( Observations in recent years have made it clearer that the Internet is not only a helpful tool facilitating learning, work and entertainment, but also a source of threat and negative functional outcomes, assuming a form of addiction. In the literature, this very phenomenon is referred to in various ways as “compulsive Internet use”, “Internet related problems”, “pathological Internet use”, “Internet addiction”, or “excessive Internet use,” to name but a few. A quite compelling term emphasizing its negative consequences is “problematic Internet use” (PIU), understood as one that results in psychological, social, academic and occupational difficulties . EvidencResearchers distinguish two types of Internet addiction: generalized  and specExcessive preoccupation with the internet affects various aspects of life, including eating behaviors. Internet addiction has been associated with both excessive and too low body weight ,22, junkOf particular note are the psychological aspects of the relationship between PIU and EDs. For example, individuals with elevated levels of body image concerns and EDs may be more at risk of developing PIU, and PIU may be related to body image avoidance . PIU hasThe Internet, in turn, is an extraordinary medium not only of culture, but also of social interaction, especially during the SARS-CoV-2 pandemic. To this day, researchers have been struggling with establishing the causality of the PIU’s relationship with EDs. Perhaps those involved in excessive Internet use succumb to body images promoted in the mass media and, therefore, feel dissatisfied with their own appearance, which may subsequently lead to EDs . AlternaSo far, studies on the relationship between PIU and EDs have been conducted mainly among students, in Turkey, Spain, Taiwan, Egypt, Colombia, USA, China, on samples ranging from 314 to 2780 participants . Quite iTo establish the prevalence of PIU and ED among Polish students, taking into account sex of the participants. Based on previous literature reports, we expected greater severity of PIU in men relative to women ,12,13,14To investigate a potential correlation between PIU and Eds, we hypothesized that PIU scores would be higher in individuals with higher ED scores (as indicated in previous reports ).To identify which sociodemographic variables and characteristics of Internet use may serve as predictors of EDs.We assumed those could be excessive BMI, communication with others as the main purpose of Internet use, and greater number of hours spent online on non-work/study-related activities .Due to the reported higher risk for both PIU ,35 and EOur results will contribute to the existing body of evidence on the prevalence and comorbidity of PIU and EDs as well as identify predictors of EDs among the characteristics of computer use, such as the purpose, manner and duration of online activity. This will enrich the current state of knowledge about the relationship between PIU and EDs.This cross-sectional study was conducted in November and December 2018 at three universities of different profiles , located in different regions of Poland . Upon informed consent, the students were asked to complete provided questionnaire sets by a trained interviewer in the lecture hall, after a class. Participation was voluntary with each of the participants informed about the study purpose and the possibility of withdrawing at any stage. Participants were not rewarded for participation. The study was approved by the Bioethics Committee of the Pomeranian Medical University in Szczecin (decision no: KB-0012/188/05/17).A total of 1008 students of 1st cycle studies/years 1–3 of single-cycle programmes completed provided questionnaire sets. Such response rate allowed to obtain the statistical power of 1 (α = 0.05) in relation to H0, postulating no correlation between the results of the Problematic Internet Use Test and the Eating Attitudes Test, thus leaving a very low chance of type two error occurring.(1)Medical and health sciences (336 students: 174 women and 162 men);(2)Humanities and social sciences (336 students: 168 women and 168 men);(3)Technical sciences (336 students: 168 women and 168 men).The mean age of the participants was 21.3 years . The sample included 510 women (50.6%) aged 18–40 and 498 men (49.4%) aged 19–39. There were no statistical differences in the number of male and female students of:Enrollment in full-time, first-cycle studies or 1st, 2nd or 3rd year of single cycle studies . Sample selection was dictated by the particular risk of Internet addiction reported in this population .Student status at a medical, economic or technical university. The study included an equal number of students of three groups: medical and health sciences; humanities and social sciences and technical sciences. Sample selection was dictated by the aim to compare the risk of PIU and EDs depending on the selected major, as available literature indicates the existence of such a relationship in terms of PIU ,16.Sex of the participants. We intended to include an equal number of men and women at each university in order to make comparisons between the sexes in terms of the analyzed variables.TM 7.2.4.0 . The incidence of PIU was estimated at 10% based on available literature data .A total of 103 (10.22%) of the respondents met the criteria of Internet addiction (“high” or “very high risk of PIU”). Interestingly, there was a significant sex difference, as the addicted group was represented by only 18 (3.5%) women compared to as many as 85 men (17.0%) . The strongest predictor was Item 14: “I feel preoccupied with the Internet”. Each additional point for this item resulted in an increase in the EAT-26 overall score by 0.194 points (p < 0.001). Each point for item 13 “I sometimes neglect sleep …” contributed to the increase of EAT-26 score by 0.115 points (p < 0.001), and an increase in Item 20 score: “online activity allows me to relieve my negative feelings”, which entailed an increase in the EAT-26 score by 0.106 points (p = 0.004). As regards Internet use characteristics, a significant predictor of the EAT-26 score was the average number of hours spent online on weekends for study/work-related purposes , while among anthropometric variables—lower height  and higher BMI .Regression analysis of both the overall PIU score and its individual items demonstrated significant qualitative sex differences in terms of EAT predictors. Significant predictors of EAT-26 score in the entire sample were 3 PIU items and 3 additional variables , main Internet use device , age  or year of study .No correlation was found between EAT-26 score and type of study [F (2) = 0.485; Globalization and technological progress bring numerous benefits and greatly facilitate everyday life. Nevertheless, they are not devoid of certain threats, such as, e.g., imposing global patterns of the human body or excessive digitization of life. It, therefore, seems critical to explore how these problems may affect various aspects of the lives of contemporary young adults—a generation growing up with full and majorly unrestricted access to the Internet, whose task in the near future will be to shape the next generation to come. The aim of this study was to investigate the prevalence of PIU and EDs, potential correlations between the two phenomena and ED predictors among sociodemographic and Internet use characteristics in Polish students. To this end, we surveyed equal-numbered groups of male and female students from three different universities, majoring in science/technology, humanities/social sciences and medical/health sciences.Our pooled results suggest a 10.22% incidence of PIU in the investigated sample (18 women and 85 men). Much in line with our expectations, PIU criteria were significantly more prevalent in men. Similar prevalence rates of IA (Internet addiction) were reported in Turkey (10.1%)  and FranIn our study, we recorded an EAT-26 score of ≥20, considered indicative of high-risk state of EDs, in 9.23% of the investigated sample (55 women and 38 men). Contrary to expectations, we found no significant sex differences. However, analyses of raw scores still suggested their higher values in women compared to men. Higher EAT-26 rates (15.2%) were reported in Turkish youth (aged 14–20 years), with no significant sex differences . Asian rCertain behaviors are associated with the production of a short-term reward. Repeating these behaviors may be persistent  and leadp < 0.001). The hypothesized correlation between Internet addiction and EDs was confirmed by Hinojo-Lucena et al. in their meta-analysis conducted in 2019 [Our initial hypothesis was that PIU scores would be higher in individuals with EDs. In line with our expectations, we find a link between PIU and EDs, both in men and women. Although the strength of the observed correlation was low (rho = 0.212), it still proved statistically significant  reported significantly higher EAT-26 scores. Their results may, therefore, suggest the importance of striving for perfectionism, the need for external confirmation of competence or maintenance of control over their lives, often observed in the course of eating disorders, which may shed some new light on the relationship between PIU and EDs. These findings are consistent with reports by Casale et al., indicating that socially prescribed perfectionism may have an effect on problematic use of internet communication services . In turnHowever, we found no links between the selected university major and EDs. Similarly, no such relationships were reported either by Kamal and Kamal in their research on students of various faculties   or SpillIn conclusion, this research indicates that there indeed exists a relationship between PIU and EDs and that predictors of EDs can be found among the characteristics of Internet use. Our results also suggest that individuals at risk of EDs use the Internet as a means to fulfill their study/work-related duties rather than to move their social interactions to virtual reality. Nevertheless, these findings require further confirmation. Therefore, more research is warranted to disambiguate this issue, especially with an aim to establish the direction of the relationship between PIU and EDs and the role of perfectionism in the development of PIU.This study is not exempt from a number of limitations. The first limitation results from the very nature of cross-sectional research. This type of research excludes the possibility of a clear determination of the cause-and-effect relationship between ED and PIU. Another noteworthy limitation is the small sample size, i.e., the number of problematic Internet users exceeding the cut-off score in the EAT-26 test. We did not take sexual orientation into account in the research, due to the fact that disclosing one’s sexual orientation is not common in Poland. Asking about one’s orientation could lead to withdrawal from the survey as a question that is too intrusive into one’s intimate sphere. However, we will consider this variable in subsequent studies, especially considering reports on the role of sexual orientation in eating concerns and body image problems in men . FurtherThere is a correlation between eating disorders and problematic internet use both in the entire sample and in the male and female subgroups.Preoccupation with the Internet, neglect of sleep in favor of online activity, and relieving negative feelings while online seem to constitute significant predictors of eating disorders.Other predictors of eating disorders include a higher average number of hours spent online on weekends on study/work-related activities, extracurricular activity , lower height and higher BMI.Further research is needed to establish the causality of the relationship between problematic Internet use and eating disorders and the effect of perfectionism on this relationship.