The taxonomic backbone of the occurrence dataset follows the standardised GBIF checklist dataset to ensure correct cross-linking of the names.The dataset covers bird observation occurrences in Russia and neighbouring regions (ex-USSR countries and some other countries of Eastern and Western Europe) from 2001–2021. It is based on the internet platform “Online bird observation diaries” (Currently, the database contains 541,900 records of occurrences of 713 bird species, which makes it the largest dataset on birds of Russia and neighbouring regions published in GBIF.The occurrence dataset contributes to filling gaps in the bird distribution in Russia and Eastern Europe. It can be used for a deeper look at their populations, phenology and migrations over this area. The availability of special tools for verification of the entered information makes the database a valuable tool for analysing occurrences of non-native species, studying vagrancy, immigration, invasions and range dynamics.The dataset is regularly updated. Over the 11 months of 2021, it has increased by 98,165 occurrences. The accuracy of the analysis largely depends on the volume and accuracy of the original information . This isth century and earlier, the collection of ornithological data was the privilege of a limited number of professional researchers. During recent decades, the birdwatching movement has been gaining popularity, covering more and more countries across the world. That is why, in many countries, data collection on bird distribution, phenology, migrations and other similar work is being performed mainly by amateurs , species ranges, seasonal migrations;Providing an information basis for other ornithological programmes, such as preparation of the European Breeding Bird Atlas 2  and implFrom such a database, scientists can obtain extremely useful data on bird species distribution over time, detect species disappearing from a certain area, species invasions, migrations, occurrences of rare/endangered/non-indigenous species etc. Then they can use this information in scientific research or reports on national ecosystem services .The database was created on the Russian software “1C: Enterprise”, version 8.3 , a populOne of the important features of the database is an intuitive interface (different for PC and mobile devices), which allows users to easily upload their data and provides means for error control. The interface is provided with a map showing observation points. A user can set locations of occurrences directly on the map or manually, by entering coordinates in the text form, either by groups or one by one.It is possible to build and execute queries and produce a variety of reports. The reporting system allows users to make a selection for any period, region, species and observer and sort the output by a number of fields. Moreover, there is a possibility to manually outline the research area and obtain a query for it Fig. . Along wUseful functionality for ornithologists, ecologists and modellers include:various reports;a map with a wide range of data display functionality;possibility of data analysis in the context of 10 x 10 km squares according to European Russia (with the possibility of expanding to other types of grids and to other territories);data analysis for an arbitrary region within arbitrary boundaries ;displaying the nesting status of observed species;integration with GBIF, EBP.There are means for providing compatibility of the database with other ornithological projects. The first of them is the automatic import of data into the web GIS "Faunistics" . The secBeing created by an amateur ornithologist, the database is well adapted for birdwatchers and possesses a number of special means related to birding activity including:e-mail subscription to interesting occurrences by selected region or by lifers;formation of regional checklists with the possibility of testing one's observation for completeness;http://www.ru-birds.ru/mesta-nablyudenij.html) with automatically updated checklists;a map of interesting places for observing birds (providing of the competition “Big Year” and rating “Club – 300” (observers who collected more than 300 species in the territory of Northern Eurasia);ability to control access to your own data (data closed from other users);displaying observation points on the map together with the species range;automatic identification of rare species for the region by checklist.As an example of database analysis, let us consider the possibility of generating checklists. It is possible to generate a report for any region (both administrative and arbitrary), which presents a list of species in a given region, detailed by month. Different seasons are highlighted in colour Fig. .Russian Federation, 12 ex-USSR countries  and 12 more countries of Eastern and Western Europe .There are two different ways of user interaction with the database, either through a browser . Finally, some fields, such as date, can be also pre-filled automatically.All these greatly reduce the likelihood of an error.The dataset covers bird occurrences from 25 countries, including Russia, ex-USSR and some other European countries Fig. . Most of36.782 and 81.522 Latitude; 20.933 and -169.614 Longitude.Passeriformes, Charadriiformes, Anseriformes, Accipitriformes, Piciformes and Columbiformes This work is licensed under a Creative Commons Attribution Non-Commercial (CC-BY-NC) 4.0 Licence.RU-BIRDS.RU, Birds observations database from Russia and neighbouring regions. Zoological Museum of M.V. Lomonosov Moscow State University.https://www.gbif.org/dataset/ba19fc1d-670c-426b-b99d-49f003792ac4https://doi.org/10.15468/5cjx70, http://www.ru-birds.ru/temp/dwca-rubirds-ru.zip, 672abba8-f26b-4256-ae27-e820258f5c8a1RU-BIRDS.RU, Birds observations database from Russia and neighbouring regions. Zoological Museum of M.V. Lomonosov Moscow State University.Darwin Core331.4Ru-Birds.RU, Birds observations from Russia and neighbouгing regions.It is interesting to see which of the species in the dataset are most common and which are rarest. The ten most common and the 36 rarest species are presented in Table https://eurobirdportal.org). The dataset is actively used and cited in scientific publications (e.g. The project is continuously developing. The database is currently being integrated with EuroBirdPortal (ons e.g. . With thclarification of the boundaries of nesting and wintering areas and migration routes;geographical and biotopic analysis of ranges;phenological analysis of various events related to dispersal and migrations;analysis of long-term trends related to the population numbers of bird species, habitat change, the timing of migration etc.The database fills the information vacuum concerning the number and distribution of birds that exist on the territory of Russia and neighbouring countries. Placing a dataset on GBIF and publishing its description makes the database accessible to an international circle of specialists. At the same time, this expands the potential circle of project participants.We hope that, due to this, the volume of the database and its geographic coverage will continue to grow and, in the future, we will see new scientific papers using data from the “Online bird observation diaries” system.


Background: Primary trigeminal neuralgia (PTN) is known to reoccur following microvascular decompression (MVD) surgery. However, the rates and contributing factors related to PTN recurrence remain controversial. The purpose of this study was to explore the postoperative recurrence rates and related influencing factors of patients with PTN after MVD. Additionally, recurrence rates after different treatments were compared to provide guidelines for clinicians.Methods: We conducted systematic reviews and meta-analyses in accordance with the preferred reporting items of the PRISMA guidelines. We searched nine databases, namely, the PubMed, EMBASE, Cochrane Library, Web of Science, CINAHL, CBM, CNKI, VIP, and Wanfang databases, from establishment to July 13, 2020, selecting for studies about the long-term postoperative efficacy of MVD in the treatment of PTN. Factors associated with higher recurrence rates after MVD and long-term postoperative results of other treatments underwent formal meta-analysis, where odds ratios (ORs) with the corresponding 95% confidence intervals (CIs) were calculated. The dose-response model was used to inspect the associations between several factors and higher recurrence rates.Results: Seventy-four studies  were analyzed in our research. Overall, 956 out of 8,172 patients relapsed, and the pooled recurrence rate was 0.096 (0.080–0.113). Influencing factors of relatively higher recurrence rates included atypical trigeminal neuralgia symptoms, lack of nerve groove, non-arterial compression, patients who were 50–60 years old, and longer disease duration. Dose–response analysis showed that the recurrence rate had a significant trend with the published year and the follow-up time. Simultaneously, the recurrence rate of MVD treatment was much lower than that of conventional drug treatment, gamma knife surgery, percutaneous balloon compression, and radiofrequency thermocoagulation. When the surgical technique was improved or combined with partial sensory rhizotomy (PSR), the postoperative recurrence rates were significantly reduced.Conclusions: Even for PTN patients who have a successful operation, ~10% of them will still relapse. This research identifies several factors that can affect the recurrence rate. Compared with other operations, MVD has a relatively lower recurrence rate. Our analysis suggests that improved surgical techniques and combining PSR and MVD will yield better results.Systematic Review Registration:https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42020159276. Trigeminal neuralgia (TN), also called tic douloureux or Fothergill's disease, is rare, affecting 4–13 per 100,000 people . TN is aMicrovascular decompression (MVD) is generally recognized as the most effective way to treat PTN . AccordiAlthough there is great success in treating TN, some patients will experience varying degrees of recurrence during follow-up even if they have good results after surgery. One large-scale formal meta-analysis conducted by Holste pointed out that 76.0% of patients report being pain-free following MVD . NumerouWe conducted a comprehensive and formal meta-analysis to evaluate the recurrence rate of PTN patients and to identify its significantly related factors among the most commonly reported variables, including sex, tic side, clinical presentation of TN, presence of a nerve groove, types of offending vessels, and number of responsible vessels. In addition, we further compared the long-term prognosis of MVD with that of other treatments to provide better evidence-based guidance for clinicians.We conducted systematic reviews and meta-analyses in accordance with the preferred reporting items of the PRISMA guidelines . Our res*,” and Boolean operators “AND” or “OR” were also used to search. The detailed search strategy can be found in Nine databases, namely, PubMed, EMBASE, Cochrane Library, Web of Science, CINAHL, CBM, CNKI, VIP, and Wanfang databases, were searched from establishment to July 13, 2020. We also conducted manual retrieval to obtain additional relevant articles, and there was no language restriction. The main terms included “Trigeminal Neuralgia,” “Fothergill's neuralgia,” “Microvascular Decompression,” “Recurrence,” and “Risk factor.” The synonyms of Medical Subject Headings (MESH) terms, the wild card term “Two independent researchers (FYC and FM) first screened the literature according to the title and abstract. In this process, inclusion criteria and exclusion criteria were strictly followed. In the case of any dispute over the results, a third researcher (LW) was required to conduct arbitration. After excluding obviously irrelevant studies, the remaining studies were read for inclusion.We included studies if they met the following criteria: (i) patients with primary trigeminal neuralgia; (ii) the included literature had data related to patients' pain recurrence; and (iii) types of studies: case series studies or non-randomized controlled trials (NRCTs).Studies were excluded for the following characteristics: (i) studies did not state a clear follow-up time or the follow-up time was <1 year; (ii) patient loss at follow-up exceeded 20%; (iii) unknown or inaccurate data; (iv) multiple reports or repeated literature on the same population ; (v) no data of control or relapse-related influencing factors that we needed; and (vi) low-quality studies; the scores of case series studies were <6 points, and the NRCT scores were <16 points.Recurrence was defined as pain reappearing or worsening after a period of time when the pain completely disappeared or was relieved after MVD surgery. Therefore, those patients with unsuccessful surgery were outside the scope of our study. All the patients included in our study achieved favorable results after surgery.The quality of observational studies was independently evaluated using the National Institutes of Health (NIH) Quality Assessment Tool by two researchers (PX and FM) . The tooTwo researchers (FYC and PX) independently extracted relevant data from eligible studies. The extracted variables included (i) basic characteristics of studies ; (ii) number of patients and number of relapses; (iii) prognostic factors related to patients ; and (iv) postoperative recurrence rate of other treatments and MVD with other improvements.Our study was mainly divided into two parts: to explore the influence of risk factors on the recurrence rate after MVD and to explore the distinction in the recurrence rate between MVD and different treatments. All analyses were performed using Stata software .p-values. All statistical tests were two-tailed, and a p-value <0.05 represented significance. The pooled recurrence rate and 95% CIs were calculated using the Freeman–Tukey double arc-sine transformation  of the Q test was <0.1, or I2 was >50%, we chose the random effects model; otherwise, a fixed effects model was used  values with their 95% confidence intervals (CIs) and ormation . The fixwas used .Quantitative data in our study were analyzed by dose–response analysis. We used the non-linear robust error meta-regression (REMR) model to test the dose–response relationship between risk factors and the recurrence rate, which was mainly based on inverse variance-weighted least squares regression and cluster robust error variances for dealing with the synthesis of correlated dose–response data from different studies. Related methods and Stata codes that we used can be found in the paper of Xu and Doi . We wantp < 0.05.While researching the comparison of recurrence rates between different operations and MVD, we found that the treatment increased the risk of recurrence compared with MVD when OR > 1 and When there was significant heterogeneity, meta-regression analysis and sensitivity analysis would be conducted to explore the sources of heterogeneity from several aspects including the type of study (NRCTs vs. case series), the country of study (China and other countries), hospital grade , and preoperative treatment of the patients. We also conducted an extra meta-regression analysis of the publication year.The asymmetry of the funnel chart was examined visually and further examined by Egger's and Begg's tests by using the Stata software , 18. MorThe selection process is presented in the PRISMA flowchart in The study characteristics are presented in In the analysis of all 8,172 MVD patients, the proportion of female patients was much higher than that of males, with a ratio of approximately 1.336, and the incidence on the right side was much higher than that on the left side, with a ratio of approximately 1.278. The literature quality scores and potential bias in the included studies are also shown in As shown in t = −1.92, 95% CIs: −0.817 to 0.015, p = 0.059) bolstered this result. Galbraith plots  and mixed arteriovenous compression (p = 0.089) were significant, but the other four factors were not significant. For the weighted analysis with obvious heterogeneity, the Egger's test indicated no obvious publication bias, and sensitivity analysis confirmed the robustness of our research.The pooled results showed that there were no significant differences between the groups among factors including sex, tic side, and number of responsible vessels. However, factors including the clinical presentation, nerve groove, and type of offending vessel were significantly related to the recurrence rate.p = 0.001), “mixed arteriovenous compression” vs. “arterial compression” , “without nerve groove” vs. “with nerve groove” , and “atypical TN” vs. “typical TN” .As shown in We explored the association of publication year, follow-up time, duration of disease, and age with the recurrence rate by dose–response analysis . The relThe duration of disease and age were patient characteristics. With prolonged disease duration, the recurrence rate first increased and then stabilized. The rate of recurrence was positively correlated with disease duration. This indicated that patients would have a relatively lower recurrence rate when the surgery was performed in a timely manner. Taking 50–60 years old as a reference period, the recurrence rate of patients under 50 years old increased with age, but those over 60 years old showed a decrease in recurrence rates.Meta-regression model investigation of the “Population” and “Preoperative treatment” variable showed a significant influence on heterogeneity, while “Published year,” “Study type,” and “Hospital grade,” variables did not show a significant influence on heterogeneity.p = 0.011) and GKS (p = 0.089) were significant, but the other treatments were not significant. For the weighted analysis with obvious heterogeneity, the Egger's test indicated no obvious publication bias, and sensitivity analysis confirmed the robustness of our research. The pooled recurrence rate was 9.6% for MVD, 18.5% for traditional medical therapy, 12.4% for PSR, 20.9% for Gamma, 12.3% for PBC, and 11.9% for RFT. Meanwhile, the rate was 1.2% for improved MVD, 1% for MVD with PSR, and 2.3% for neuroendoscope-assisted MVD.We also conducted a meta-analysis between different types of treatment, and a significant difference in the incidence of recurrence was found between MVD and other treatments . The hetFrom the results, the recurrence rates of traditional medical therapy, GKS, PBC/PMC, and RFT were considered statistically higher than those of simple MVD, while MVD combined with PSR or improved surgical techniques had much better prognostic results than simple MVD.In the research including 74 studies with 8,172 MVD patients, we had a sufficient sample size to analyze the influence of various factors as well as different types of treatment on their recurrence rates. We showed that the recurrence rate was approximately 10%, and characteristics including atypical TN symptoms, no nerve groove, non-arterial compression, and longer disease duration were factors that contributed to a higher recurrence rate. In addition, patients who were 50–60 years old had a relatively higher recurrence rate. To our knowledge, this research is the first comprehensive meta-analysis of the recurrence rate and its related factors after MVD. In this regard, this meta-analysis provides the most current and convincing evidence of the recurrence rate and the factors related to the impact of relapse.The relapse rates reported were quite different –23. Our The research of Li pointed out that the reason for the better prognosis of MVD patients may be related to the shorter duration, older age of pain onset, limited distribution, arterial compression, and complete decompression . The resThe classification of typical and atypical TN was mainly based on the symptoms and clinical presentation of the patient. Atypical TN symptom as a high-risk factor related to recurrence were consistent with the previous literature. Tyler-Kabara reported that the prognosis of patients with typical TN was better than that of patients with atypical TN . Nunta-ASeveral previous studies had proven that venous compression was an important factor leading to recurrence , 29, whiSome scholars thought that arterial compression might be more likely to lead to nerve grooves, which caused the two factors to interact with each other . AdditioAlthough most of the patients with TN were female, and the affected side was mostly on the right , sex andIn our research, the more recent publications reported relatively lower recurrence rates, which may be due to the more modern technology of MVD. By observing the dose–response relationship between the recurrence rate and follow-up time, the recurrence rate increased rapidly in the first 2 years after surgery and basically had no increase in the fifth year or longer, which was similar to other series. Sun et al.  reportedIn the study of the duration of the disease, we found that the longer the illness, the worse was the long-term prognosis of the patient. Scholars speculated that during the process of nerve remyelination and repair, the probability of abnormal conduction reoccurring increased in patients who had been sick for a long time . AlternaWe performed a dose–response analysis on the age and duration of disease of the patients. In this study, we found that 50–60 years old was a period for a relatively higher recurrence rate. With age, the recurrence rate first rose and then fell. This result suggested that older people could also have a good long-term prognosis and that advanced age may act as a protective factor on the probability of recurrence. Most current studies have also shown that the postoperative prognosis of elderly patients is not worse than that of young patients. Phan et al.  concludeExperienced surgeons can modify the operation based on clinical findings, such as using the neuroendoscope to assist and change the size of the incision or approach. Most of the relevant clinical studies have demonstrated that these improvements could effectively reduce the postoperative recurrence rate –49. In tThe results of the subgroup analysis indicated that different types of research were not the source of heterogeneity. Meanwhile, the recurrence rate varies with the level of the hospital. We classified hospitals into three groups: grade 3A hospitals, non-grade 3A hospitals, and foreign hospitals. Patients treated in grade 3A hospitals had a lower recurrence rate than those treated in other hospitals. A nationwide study also proved that the type of hospital was a potential confounding and prognostic factor . It may There were several limitations of our research to consider. First, the heterogeneity of the studies was a limitation inherent to meta-analysis. This was inevitable in mass studies, and we tried our best to find the source of heterogeneity through subgroup analysis. Second, since the data of many original studies were not publicly available, we could not determine internal factors within the literature on recurrence. Research factors might interfere with each other. For example, we do not know what the sex ratio is in the study researching the impact of age. Therefore, we cannot tell whether age causes different recurrence rates or sex itself does. In addition, which surgical procedure the patient chooses depends on the judgment of the clinician of the clinical symptoms of the patient, which would introduce some bias; all NRCTs studies were subjected to potential selection bias related to control selection. Although we compared different treatments with MVD, we could not clearly point out the difference in recurrence rates among them. We hope that there will be related research in the future.Our comprehensive meta-analysis indicated that nearly 10% of the patients who had undergone successful MVD would still relapse. Several factors, including atypical TN symptoms, no nerve groove, non-arterial compression, and longer disease duration, could result in a higher recurrence rate. The recurrence rate of patients aged 50–60 years old could be relatively higher. Compared with conventional drug treatment, gamma knife, PBC, and RFT, MVD had correspondingly lower recurrence rates. Furthermore, improving surgical techniques or combining MVD with PSR would enable a better prognosis for PTN patients.The original contributions presented in the study are included in the article/FC, LW, and SW collaborated in the conception and design of the project, drafted the first draft, and modified the manuscript. LW and YN searched the databases to get relevant studies. FC and PX extracted data from eligible studies. FM, PX, and YX tested the data collection forms and evaluated the qualities of studies that were involved. LW, FC, and CZ conducted the analysis and interpreted the data. The final manuscript was read, modified, and approved by all authors. All authors had full access to all of the data in the study and took responsibility for the integrity of the data and the accuracy of the data analysis.This work was supported by the Cultivating Project for Young Scholar at Hubei University of Medicine (2016QDJZR23) and the Funding Project of Taihe Hospital (2019JJXM039).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.


N = 267). The Talent Development Environment Questionnaire (TDEQ) was administered, which in previous studies produced acceptable psychometric properties. Principal factor analysis, confirmatory factor analysis, Monte Carlo parallel simulation, MANOVA, and hierarchical regression were performed to analyze the data. The TDEQ was validated for the South African context and was found to measure four components, namely supportive and challenging environment, development fundamentals, support networks, and long-term development. Respondents in the various developmental categories of novice, advanced and elite student-athletes were not statistically significantly influenced by any of the four factors. Controlling for the talent developmental phase, the model proposed did not statistically significantly predict the development pathway of youth athletes. The results provide evidence with some practical significance as supportive and challenging environment and long-term development focus reported a small effect. Further research is warranted to develop a more suitable measuring instrument to measure the talent development pathway within the investigated athlete environment.The past two decades witnessed increased participation in professional as well as amateur sport, giving impetus to concomitant amplified interest in long-term athlete development (LTAD). LTAD has been described as the structured and progressive growth of an athlete through different stages of development resulting in some athletes achieving elite sport status. Furthermore, the interest in athletic career development from a holistic perspective has contributed to management approaches underscoring sustainable talent development and participation in sport. The current study investigated youth sports development pathways through both models of development within a South African context. A descriptive quantitative cross-sectional design was used to generate a convenient sample of athletes ( Internationally, early talent identification and development has become increasingly important within the context of youth sport structures and programs. In the quest to achieve international and elite levels of competition, national sport systems provide a blueprint for youth athlete development . Burnetttalent development perspective, other theoretical frameworks emerged focusing on a career transition stance  for the talent development pathway of athletes , learning to train , training to train , learning to compete , training to compete  and training to win  . The sixThe career transitioning model by Existing athletic career or talent development pathway models  emphasizAthletic-level talent development within a South African context in this study includes athletes between the ages of 18 and 25 years. During this stage, the athletes transition from junior to senior level during the progression from secondary to tertiary education . On the In general, first-year students move away from home to attend university and subsequently lose the support system comprising parents, friends and coaches resulting in a dramatically changed psychosocial context , 2017. IStudent-athletes often struggle to maintain a balance resulting in conflicting academic and training demands . Academiinter alia, athletic, psycho-social, and academic demands, experienced by athletes transitioning from secondary to tertiary education. The holistic developmental model supposes that for elite junior athletes used to the demands of competitive elite sport while at high school, with numerous hours of training, coaching regimes, competitions, and pressures, the progression from junior to senior level would be challenging  were distributed for data collection, of which 289 were returned questionnaires were returned rendering a response rate of 90%. Twenty-two questionnaires were incomplete and therefore data analysis was conducted on 267 complete questionnaires.Student-athletes from two universities within the Gauteng Province, South Africa comprised the sample frame from which data was collected. The sample frame was calculated according to the number of team members per sporting code, identified to be part of the study. Players from the rugby, netball, soccer, cricket, basketball, athletics, hockey, volleyball, and dance sporting codes from the two universities comprised the sample frame. However, students competing in any of the University Sport South Africa (USSA) sporting codes may have participated in the study (if they were to hear about the study). In order to gain an understanding of the talent development pathway of student-athletes, purposive sampling was used, where coaches of the identified sporting codes were contacted and asked to provide time during a training session for the researchers to recruit and administer the questionnaire voluntarily and anonymously. Coaches allowed the researcher time at the onset of a team training session at the university grounds, to inform students of the study purpose and administer the questionnaire in the presence of the coach. Three hundred and twenty questionnaires (n = 267) of student-athletes  participating at various levels of competition, for example university level , provincially  and nationally . A biographical profile of the sample indicated that the gender distribution was close to equal with 50.6% (n = 135) of the sample male and the remaining 49.4% (n = 132) female. As could be expected, 91.4% of the sample representing 244 respondents were between the ages of 18 and 25 years. Only 8.6% (n = 23) of the sample were in the 26 to 33 years’ age category. In terms of participation duration, the majority of the sample took part in the specific sport for more than 6 years , followed by respondents who participated for approximately a year , those who participated for 5 years , 6 years , 4 years , 2 years , 3 years  and less than a year . With reference to the study year of respondents, 29.8% representing 79 respondents were, respectively, in their first and second year of studies, followed by respondents in their third year of study , postgraduate students  and respondents who selected other (fifth year or more) . Categorization of student-athletes into the various developmental phases were confirmed by the researchers in accordance to years the student-athletes participated in a given sport. Student-athletes were categorized into groups, viz. novice (n = 44), advanced (n = 24), and elite athletes (n = 197). The categorization was in accordance with participation years in competitive sport where the novice group (16.5%) indicated that they have been competing for 0 to 2 years, advanced group (9.0%) between 3 and 4 years and the elites (74.4%) for 5 years or more.The research participants consisted of a convenient sample (n = 52) of the sample played rugby, 17.6% (n = 47) participated in soccer, 11.2% (n = 30) netball, 2.6% (n = 7) played cricket, 1.9% (n = 5) took part in athletics, 16.5% (n = 44) participated in basketball, 6.7% (n = 18) played volleyball, 2.2% (n = 6) did body building, 5.2% (n = 14) took part in dance, while the rest of the sample  selected other. In terms of training time, more than half the sample  indicated training time exceeding 6 h weekly, followed by 5 h per week , 4 h , 3 h , 2 h , and 1 h a week . Looking at the level respondents participated in the sport, 35.8% (n = 95) of the sample competed at university level, followed by inclusion in a provincial  and national  or USSA  team. Furthermore, 1.5% of the sample participated in a World Student Team, while 7.2% (n = 19) categorized themselves as professional and 1.1%, representing three respondents, selected other. Sequentially, 16.5% (n = 44) of the sample were categorized as novices, 9.0% (n = 24) advanced and the majority of the sample could be categorized as elites .When considering the type of sport respondents participated in, 19.5%  and student-athletes completed the paper-based questionnaires in the presence of the researcher. Standard ethical protocol was observed according to the institutions’ prescription at that time. Participants were informed about the purpose of the study and anonymity was ensured should they voluntarily participate. Participants were advised that they could withdraw from participation at any stage, and were assured of response confidentiality. Even though organizational permission was granted to conduct the study, participating universities requested to remain anonymous. Ethical review and approval was at the time of data collection not a requirement for the study on human participants in accordance with local legislation and institutional requirements at the time when study was conducted.Per se, the Cronbach Alpha coefficients of the TDEQ ranged from 0.616 to 0.978. Furthermore, the internal consistency for the total scale was 0.805, with seven-identified factors scoring 0.978, 0.616, 0.913, 0.730, 0.899, 0.618, and 0,618, respectively. Construct validity was computed by means of exploratory factor analysis reverting a seven-factor structure with eigenvalues ranging from 33.76 to 0.979, accounting for 64% of the total explained variance. Confirmatory factor analysis (CFA) was not computed in the study by Primary data was gathered by administering the original Talent Development Environment Questionnaire (TDEQ) by p = 0.000∗∗), indicative of sufficient correlation between variables to substantiate exploratory factor analysis. The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy returned a value of 0.892, providing evidence that the sample size was acceptable  rotation was computed. Principal component analysis was used as the method is deemed psychometrically sound avoiding potential factor indeterminacy associated with other approaches . The ratceptable . As factceptable . ResultsSubsequent to the confirmatory factor analysis, four underlying dimensions were identified see . Item loWithin the current sample, the TDEQ reported a Cronbach alpha coefficient of 0.94 for the total scale. All the sub-scales produced more than acceptable reliability estimates ranging from 0.805 to 0.941. Specifically, the supportive and challenging sub-scale had an alpha coefficient of 0.941, development fundamentals reverted the same at 0.824, support network reverted an alpha coefficient of 0.840 and long-term development focus had an internal consistency of 0.805.per se randomly generated data matrix with 1000 cases) were performed to validate the measuring instrument and to identify statistical significant dependent variables. Cronbach’s alpha coefficient was used to provide evidence for reliability. Inferentially, multivariate analysis of variance (MANOVA) was used to determine the influence of developmental phase on TDEQ components. Hierarchical multiple regression was computed controlling for developmental phase to construct a statistical model determining the individual contribution of each component in order to investigate the developmental pathway. Statistical significance  was set at either 0.01 or 0.05. Practical significance was set at the recommended levels of 0.2 , 0.5 (medium effect), and 0.8 (large effect) [see The Statistical Package for Social Sciences (SPSS) Version 26 was utilized to perform descriptive and inferential statistical analyses. Principal factor analysis and CFA based on a Monte Carlo parallel simulation (ect) see .Results will be presented in two sections, namely descriptive and inferential statistical results.In light of the developmental classifications elucidated in the methodology section, it is prudent to consider respondents’ year of study at university to gain insight into the duration student-athletes within the different talent developmental pathway categories have been competing in competitive sport after transitioning into tertiary education and the implications considering the two theoretical models. n = 43) of the sample could be deemed novice student-athletes who started competing in a new sport while at university or participated in a sport before entering university, but not at a competitive level . The advanced student-athlete development pathway group , indicated that they have been competing for 3 to 4 years competitively. The elite student-athlete talent development group consisting out of first year student-athletes , second years , third years , and fourth year or more  had more than 5 years’ experience in competitive junior sport.According to Descriptive statistics, including measure of central tendency are displayed in As can be seen from As a pre-requisite for the hierarchical regression modeling, a Pearson Product-moment correlation was computed to determine whether the TDEQ facets were statistically significantly correlated see .R-value of 0.677 and a p-value of 0.000∗∗. The strength of the relationship is large and as a two-tailed analysis was performed the correlation is positive. Thus as there is an increase in support network there will be a concomitant increase in support and challenging environment. Furthermore, there was a statistically significant negative correlation between support network and developmental fundamentals as seen from an R-value of −0.142 and a p-value of 0.02∗. The strength of the correlation is small and there is an inverse direction. Thus as there is an increase in support network there was a decrease in developmental fundamentals. Long-term development focus reverted statistically significant correlations with both support and challenging environment  and support networks . The effect size in both instances were strong and positive indicative of an increase in one variable will result in an increase in the other.The correlation analysis revealed a statistically significant correlation on the 99th percentile between support network and support and challenging environment as indicated by the MANOVA was used to determine whether the developmental phase statistically significantly influences the dependent variables viz. supportive and challenging environment, developmental fundamentals, support networks and long-term development focus. The results are illustrated in As can be deduced from Hierarchical multiple regression was performed to investigate the development pathway controlling for developmental phase. The results are displayed in p = 0.094) (see p = 0.110). The additional contribution of developmental fundamentals was 0.6%. In model 3, support networks were entered into the equation with no change to the model . In model 4, long-term developmental focus was entered. The model in totality explained 2% of the variance with the last mentioned contributing 0.03% to the model . None of the factors statistically significantly predicted the talent development pathway for the specific South African university athlete context. The South African context differs vastly in comparison to the same internationally. Ascribed to South Africa’s segregation history youths from rural areas are disadvantaged in terms of participation in and access to quality sports development opportunities  see . After etunities . Therefotunities .learning to compete as well as stage 5 of training to compete, between the ages of 15/16 and 19/20 years  , presumably these athletes were not exposed to previous high-level training and competitive practice. Novice development pathway student-athletes will be lagging behind in technical, tactical, physical and mental skills development  . During ctively) . As firselopment , since ielopment .According to the holistic perspective by Considering that the novice student-athlete category comprises 16.3% of the total group, the coaches are posed with practical challenges. In this regard, usually, where university coaches are expected to focus attention on attaining peak physical, technical, tactical and mental performance to maximize outputs at senior elite competitive level, they will have to spend a great deal of time to train and develop a small group of novice student-athletes’ skills to compensate for a lack in skills development within the team set-up. Even though it is commendable that students are willing to increase their sport participation and strive to engage at higher competitive levels when at university, the novice developmental category athlete is not up to the athletic standard needed at tertiary level and may influence the talent development environment of the particular university sport. The novice athlete may develop and progress during his/her university participation years, since newly attained exposure to skilled coaches, better training environments, competition opportunities, facilities and funding will facilitate development . Howevern = 24; 9.1%), indicated that they have been competing for 3 to 4 years competitively. This means that the first- and second-year students (n = 12) could have completed the learning to compete (LTAD stage 4) during their secondary education years, and have already developed sport-specific skills, maximized fitness and competed at higher junior competitive levels, before transitioning into university (training to compete (LTAD stage 5) stage as they transition into tertiary education. The total group of the advanced student-athlete category may possess more technical and physical skills compared to the novice category, since they have been competing a few more years within the specific sport. The advanced category group may also be able to cope better with the enhanced training routines, higher training hours, academic workload and competitive levels, since they already had exposure during secondary school within elite junior levels . Even though the advanced development group of student-athletes may have more experience and athletically increased development compared to the novice group, coaches will still need to spend a great deal of time to progress their athletic level from development to mastery stages for sport-specific physical, technical, tactical and mental skills according to the transitional model by The advanced student-athlete development pathway group  with the novice and advanced categories, it is evident that a large number of student-athletes transitioning into university sport have had more than 5 years’ experience in competitive junior sport. A total of n = 111 first- and second-year students in the elite category comprises 42% of the total student-athlete group with 5 years or more experience in competitive sport participation. The division of students into this category coincides with the athletes progressing through LTAD stages 4 and 5 at the desired ages (15–23 years), and are therefore ready to transition into tertiary sport according the model by n = 35) to first- and second-years, the elite category students totals 147 students (55%) in the total group, with 5 years or more experience. These athletes are likely to be closest to a standard late specializing talent development pathway. Elite group athletes possibly would be at a higher technical and physical developmental level, and coaches would be able to engage them at a higher level regarding skills development and mastery for the achievement of senior level success. This is indicative of the correct talent development pathway followed according to the prescribed ages according to LTAD and holistic development pathway models (n = 51), also had the opportunity to continuously train and compete at high competitive levels while at university, and a small number of them may have done so before they transitioned into tertiary education. The elite category student-athletes (n = 197) would be used to higher levels of training, physical conditioning, sport- and position-specific instruction, as well as accustomed to the pressures of higher levels of competition. In this regard, the coaches and staff will have to play a supporting role to facilitate the transition from elite junior to elite senior levels (Comparing the elite student-athlete talent development group (y models . Consider levels  and fromr levels , the mortraining to compete and training to win during their tertiary education. In order to determine the factors influencing the university talent development environment for the varying pathway category student-athletes, the Talent Development Environment Questionnaire was used as measuring instrument.The differences in years’ experience and exposure to competitive junior and senior elite sport were highlighted through the results in supportive and challenging environment, developmental fundamentals, support networks, and long-term development focus associated with the change from junior to senior competitive levels, coincide with the transition from secondary to tertiary education, and corresponds with previous research findings (Results pertaining to the factors influencing the talent development environment, namely findings .supportive and challenging environment, encompasses the support student-athletes require during and after transitioning. Primarily, student-athletes need emotional and psychological support within the new challenging and competitive athletic environment. The support also extends wider to include helping respondents cope with the increased academic workload, and adapting to psychococial changes regarding significant other relationships (The first identified factor, ionships . Studentionships . In thisionships . The lowionships  is indicdevelopmental fundamentals, refers to the guidance provided by coaches and support staff, which plays an instrumental role in the development of the fundamental skills for enhanced athletic performance (The second factor, formance . Therefoformance . The quaformance . Therefoformance . The lowformance  indicatesupport networks, elaborates on developmental fundamentals, where the coach has the responsibility to manage and control all support networks and resources available to student-athletes at universities (The third factor, ersities . Supportersities , while sersities . The negersities , points ersities . The supersities , and furlong-term development focus, identified in this study, is supported by the literature where The fourth factor, The student-athlete group within the South African university context has diverse development pathways as they transition from secondary to tertiary education. Almost half of the sample followed a normal late specialization pathway and completed the LTAD learning to compete stage and entered university with adequate skills and exposure to competitive junior sport. The remaining half of the participants followed an even later specialization development pathway, where students did not receive adequate training, development and competition exposure while in the learning to compete stage. The differentiation in skills and competitive participation levels of athletes as they enter university, create practical complications for coaches to manage the talent environment. Coaches may find it difficult to support the varied developmental levels of students as they transition into university sport and this is evident from the low satisfaction of student-athletes in terms of inadequate supportive and challenging environment, fundamental development aspects, support networks and long-term development focus.The TDEQ used to measure the talent environment created and managed by university coaches rendered four important factors, however, indicated that students did not perceive coaches to perform the functions effectively. The low model fit indicates that the four factors do not statistically significantly predict talent development pathways for the student-athletes within the various developmental pathways. The four factors are indicative of supportive actions, services and behavior from coaches and are therefore quite homogeneous. In this regard, the roles of the coaches within the development of student-athletes from diversified pathways are focused on support provided, which unfortunately seems to be insufficient. In contrast, a well-developed talent environment addresses a variety of aspects such as physical, mental, academic, psycho-social and sport-specific elements that enhance talent development. The low model fit indicates that the TDEQ is not comprehensive enough to measure the required talent development aspects for the South African student-athlete context. A different measuring instrument should be developed, context specifically, to ascertain the talent environment factors statistically significantly influencing the different developmental pathways of student-athletes.An acknowledged caveat in the research reported on subsume the use of non-probability sampling which could adversely influence the external validity of the results reported. Another caveat is that an international measuring instrument was used and had to be adapted to the South African context. It is recommended that future research be expanded to include a random sample of youth sport-athletes from secondary and tertiary educational institutions in all nine South African provinces. Furthermore, it is recommended that the influence of culture on youth sports development in the South African context be investigated. Future research endeavors could also underscore the development and validation of a South African TDEQ.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with local legislation and institutional requirements at the time when the study was conducted. The patients/participants provided their written informed consent to participate in this study.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.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 method of feeding (breastfeeding vs. feeding only expressed milk) also did not impact the nutritional value of DHM. Future research for the DHM should include a further cross-sectional observational study with the collection of detailed donor information and characteristics of milk expression and feeding practices to further evaluate the pooling processes and the effect on DHM composition.A primary role of Human Milk Banks (HMBs) is to provide human milk (HM) for preterm infants and to support the mothers of these infants as they establish their own milk supply. A better understanding of the variation in the energy and macronutrients contents of donor human milk (DHM) potentiates targeted nutrition for preterm babies. Therefore, the aim of this study was to assess the variability of energy and macronutrients content in DHM and to investigate the impact of maternal factors and feeding practices on the nutritional value of DHM. The study involved 49 donors registered in the HMB in the Holy Family Hospital in Warsaw, Poland. Samples from each donor were pooled within a maximum of two weeks. The composition of DHM, including energy content, protein, fat, and carbohydrate concentrations, was analyzed using the Miris Human Milk Analyzer. The analyses were performed before the pasteurization process. The mean time of milk donation to HMB was 13.2 ± 6.0 weeks. There were no significant differences in energy and macronutrients contents of DHM in the beginning and at the end of milk donation to HMB, however, HM fat concentration was positively correlated with afternoon feedings (r = 0.289,  World Health Organization , AmericaThe number of Human Milk Banks in Europe (HMBs) is increasing. Currently, there are 270 active HMB and 15 others are in various stages of planning and development. In Poland, there are 16 HMBs and the first one was opened in 2012 in cooperation with Human Milk Bank Foundation, which provided human milk banking standard, operational procedure and good manufacturing practice of donor milk acquisition and handling. Since there are no consistent European guidelines of HMBs, the consensus statement on established and operation have been published by the European Milk Bank Association. According to those recommendations, the screening process consists of a health questionnaire completed by a potential donor and a personal or telephone interview with the milk bank coordinator who reviews the health questions and assesses the mother’s suitability. Donor selection criteria include serological screening and requirements of healthy lifestyle and dietary habits. In most European HMBs, donors are allowed to donate milk from new-born’s birth, while the term of the end of donation is less specific in HM standard operational procedure [The composition of HM is not only dependent on the individual features of donors but is dynamic in nature, changing over the course of each feeding, over the course of a day, and the course of lactation ,9,10. FoConsidering the importance of DHM, we aimed to characterize the variability of energy and macronutrients content in DHM and investigate the impact of maternal factors on feeding practices (exclusive breastfeeding vs. feeding expressed milk) and HM expression pattern on the nutritional value of DHM.n = 123) included mothers of infants who have been admitted to the NICU and community donors. All registered donors were sent an e-mail containing the information about the research project, however, due to the lack of response or incorrectly completed questionnaires the final analysis was based on 49 participants (response rate was 40%). The questionnaire was conducted by Computer-Assisted Web Interview (CAWI) method and performed within a two-month period. The online questionnaire consisted of questions with two types of responses: close-ended and open-ended. Questions were about maternal anthropometric measurements , labour and infant-related factors. Information regarding feeding practices and method of milk expression  were collected on an ongoing basis, during the milk donation to HMB. Women were also asked about the number of HM expressions for HMB in four time periods  in the beginning and in the end of the milk donation to HMB.This was a retrospective, observational study of the energy and macronutrients composition of HM provided by donors to the HMB in Holy Family Hospital in Warsaw, Poland. Donors registered to the indicated HMB between January 2016 and September 2018 (The collection of DHM complied with the policies for HM collection established by the European Milk Bank Association (EMBA) and described in the literature . The milThe HM energy value and macronutrients contents  were determined using MIRIS human milk analyzer (HMA) . The HMA uses medium-infrared spectroscopy to detect the levels of macronutrients based on their respective wavelengths as a function of the intensity of the outgoing radiation . The anat-test or paired Wilcoxon test, depending on the distribution of the data. Paired tests were used when applicable. The hypothesis of the normal distribution of the variables was verified using the Shapiro–Wilk test. To evaluate the association between analyzed variables Pearson or Spearman coefficients correlation were computed. The analysis of length of milk donation to HBM was performed in terciles. Thus, analysis of variance and Kruskal–Wallis tests were used for comparisons, χ2 test also was used. To establish predictors of longer milk donation to HBM, a logistic regression model was created. The dependent variable in the models was coded as dichotomous using the value of the 2nd tercile of milk donation to HBM length as a threshold. The least absolute shrinkage and selection operator (LASSO) method was used for variable selection and regularization of the model. Results of logistic regression were presented as odds ratio (OR) with a 95% confidence interval (CI) for 1-unit increments of each variable. All computations were performed in R 4.0.5 , an environment for statistical programming.Mean, standard deviation, median and inter-quartile range were used to describe quantitative variables. Discrete variables are presented as the number followed by a percentage. Comparison of two groups was performed using n = 38, 78%; n = 33, 67%, respectively). Before pregnancy, six women were under-weight and five were overweight or obese. The majority of the donors delivered a girl  and 35% delivered a boy (n = 17). Most of the women were primiparous . Almost a quarter of the babies  were born preterm . About one in three mothers (n = 18) gave birth by cesarean section, 63% (n = 31) of babies were born vaginally.Mothers and infants’ characteristics are shown in n = 26), women declared exclusive breastfeeding, 37% of babies (n = 18) were feeding expressed milk and in 10% (n = 5) it was both. The donors were asked about the total number of HM expression for HMB at four different time points: 6.00–12.00, 12.00–18.00, 18.00–24.00, 24.00–6.00. The results are presented in p = 0.006; V = 61, p = 0.004; V = 129, p = 0.034; V = 57.5, p = 0.022, respectively). In the beginning and at the end of milk donation to HMB, the donors most often declared HM expressions at night .In 53% of cases . p = 0.054, p = 0.052, respectively).There were 98 donor milk samples, each analyzed in triplicate (p = 0.974), pre-pregnancy weight , pre-pregnancy BMI , current weight , current BMI  were found between these groups. However, higher pregnancy weight gain (15.1 ± 4.8 kg) in mothers exclusively breastfeeding was observed than in mothers who fed their children only with expressed milk (11.3 ± 5.3 kg), p = 0.021.HM samples from 18 women who fed their children only with expressed milk were compared with 26 HM samples received from mothers exclusively breastfeeding in the beginning and in the end of milk donation to HBM . The samConsidering the method of infants feeding, there were also no differences regarding babies’ weight, babies age at the beginning of the milk donation to HMB, or gestational age. No differences were also found according to the feeding pattern (breastfeeding vs. feeding expressed milk) or number of total HM expressions per day, both at the beginning and at the end of milk donation to HBM.p = 0.01; r = −0.316, p = 0.027, respectively). At the end of milk donation to HMB, fat concentration was positively correlated with the percentage of afternoons (12.00–18.00) HM expressions .Similarly to Khan et al. , we perfp = 0.026) at the beginning of milk donation to HMB  milk donation to HMB. Multiple factors presented in n to HMB .To the best of our knowledge, our study is the first Polish description of the association between maternal factors and HM expression pattern with DHM composition. We have shown that the expression pattern of milk donated to HMB may influence HM fat concentration. Moreover, we reported that the feeding method (breastfeeding vs. feeding only expressed milk) did not affect energy or macronutrient content in DHM.HM provides about 68 kcal/100 mL ,15. TherThe mean concentrations of fat in our DHM samples were 2.93 ± 1.04 and 3.19 ± 0.98 at the beginning and at the end of milk donation to HMB, respectively. We observed that HM fat content was positively associated with the number of afternoons HM expressions (12.00–18.00). Supporting these findings, Moran-Lev et al.  reportedThe largest study (1119 of HM samples)  providinp < 0.01). Both the ratios of breastfeeding and mixed feeding also rose to 23.8% and 55.3%, respectively. The composition and volume of expressed milk at the initial stage of lactation is highly dependent on breast emptying, the number of pumping sessions, and the length of each session [Considering the feeding method, we did not observe any differences in energy and macronutrients content of DHM, which is particularly important in feeding preterm new-borns who cannot be breastfed by their mothers, as well as other infants fed with expressed milk . There are a variety of indications for HM expression and the type and approach to milk expression may vary by particular indication. Most often, mothers of premature or critically ill babies are forced to initiate lactation by pumping because the babies are unable to suck. This may also be necessary for new-borns with a cleft palate, who may not be able to generate adequate negative pressure to feed directly from their mothers’ breast . Some wo session ,36. To oThe dataset represents the composition of mature milk, primarily donated by women who delivered at term. This study is limited because all milk samples came from Polish donors, so they may not necessarily be reflective of donor populations of HMBs serving specific communities. The sample size was relatively small, however, in our opinion, information coming from donors, especially those concerning HM expression pattern, are unique. Most researchers ,37,38,39Knowledge of factors that influence the composition of DHM and the routine analysis of expressed and donated milk have the potential to match an infant’s current energy and macronutrients requirements, which may reduce under- or over-fortification. Some researchers ,41 have Donor selection for HMBs is essential, both to ensure the safety and nutritional quality of the DHM, as well as to ensure that the future donor and her breastfeeding infant do not come to harm through the donation experience. In regard to results of our study, the development of guidelines and selection criteria for HM donors may influence DHM composition. Donor selection criteria should be more detailed and, except for currently valid recommendations, pattern of milk expression could be involved. Therefore, there is a window of opportunity to optimize the nutrition strategy for infants who are fed with DHM.We did not observe any significant differences in HM composition donated by mothers who exclusively breastfed their infants and those who fed expressed milk. However, we observed that HM expression patterns, such as the number of expressions at a different time of a day, may influence the fat concentration in HM. Owing to the fact that the present study has the limitation of small sample size, further research on a large scale, involving different populations to investigate factors connected with donors that are associated with DHM composition, are warranted. Hence, recruiting HM donors with a desirable profile and pattern of milk expression may contribute to the increase in the nutritional value of DHM, while reducing the need for HM fortifiers.


Background: Remimazolam is a new ultrashort-acting benzodiazepine. Remimazolam has been approved for procedural sedation by the US Food and Drug Administration in 2020. However, prior trials and the participants they enrolled were limited.Aim: In this meta-analysis, we investigated the effectiveness and adverse events (AEs) of remimazolam during procedural sedation.Materials and Methods: The study protocol was registered (doi: 10.37766/inplasy2020.8.0043), and six databases were searched. We performed meta-analysis, trial sequential analysis (TSA), and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for judging the certainty of evidence (CoE).Results: A total of five randomized controlled trials with 1,248 participants were included. Compared with the use of midazolam, the utilization of remimazolam resulted in an increase in procedure success rate , a reduction in the application of rescue medication , a decrease in time to recovery , and a better cognitive recovery of Hopkins Verbal Learning Test-Revised . No difference was found in completion of procedure  with inconclusive in TSA. Despite no difference of total AEs , more detailed analysis of AEs remained inconclusive in TSA. The GRADE assessment demonstrated low to very low CoE.Conclusion: Our analysis suggested that remimazolam may be a better choice for procedural sedation than midazolam. Nevertheless, further studies are warranted to conclusively establish its safety. Endoscopic procedures, such as colonoscopy and bronchoscopy, are common for diagnostic and intervention purposes, and more than 18 million endoscopic procedures take place annually in the United States . BenzodiRemimazolam is an ester-based benzodiazepine and can be rapidly hydrolyzed into inactive metabolites by tissue esterases . The onsTwo independent investigators  systematically searched PubMed, Web of Science, Embase, Airiti Library, Google Scholar, and Cochrane Library from inception to May 31, 2021, without language limitation. The keywords searched using free texts and medical subject headings included “remimazolam,” “midazolam,” “safety,” “adverse event,” “efficacy,” “procedure,” “sedation,” “endoscopy,” “bronchoscopy,” and “colonoscopy.” In addition, we searched ClinicalTrials.gov and European Union Drug Regulating Authorities Clinical Trials Database for any unpublished or ongoing trial and additional data from published trials. The final list of included studies was decided by discussion among all authors with full agreement required before inclusion. We also reviewed the reference lists from original manuscripts, published reviews, systematic reviews, and meta-analyses to identify trials that were not listed in the original database. Our search strategy aimed to include every RCT that investigated the effectiveness of remimazolam on procedural sedation.10.37766/inplasy2020.8.0043) and the protocol was updated and recorded the changes till June 13, 2021  . The repTitles and abstracts obtained from the initial literature search were screened independently by two authors . The authors also performed a full-text article review. Any discrepancy was resolved through group consensus. We enrolled the RCTs, in which interventions refer to subsequent or a single dose of remimazolam compared with midazolam groups on procedural sedation. We excluded studies with any of the following conditions: 1. review articles, case reports, or case series; 2. the included participants undergoing any endoscopic procedures with unclear anesthetics; 3. compared with any other anesthetics in the control group instead of midazolam; 4. unavailable data or without any relevant data for meta-analysis; 5. duplicated publications.Data were extracted and finalized from the eligible studies included by all authors. The data extracted from the eligible studies included demographic data, publication year, sample size, proportion of males, mean age, the American Society of Anesthesiologists physical (ASA) status, and funding sources. The primary outcomes included procedure success, completion of procedure, and no administration of rescue medication. Secondary outcomes were safety outcomes, including time to recovery, cognition recovery of Hopkins Verbal Learning Test-Revised (HVLT-R), and adverse events (AEs). Time to recovery was defined as time to first of three consecutive Modified Observer's Assessment of Alertness and Sedation (MOAA/S) scores of 5 after the end of the procedure. The MOAA/S scale is a measure of alertness/sedation and is derived from the original Observer's Assessment of Alertness/Sedation scale . The modI2) statistics. An I2 higher than 50% represented substantial heterogeneity. For each outcome, we performed further subgroup analysis according to different procedure. To determine the subgroup of AEs, we analyzed the AEs of cardiovascular events , respiratory events (decreased oxygen saturation), and neurological events (headache). As for the zero event, we further performed sensitivity analysis by Bayesian approach with Markov Chain Monte Carlo method (Dichotomous and continuous outcomes were presented as odds ratio (OR) and weighted mean difference (WMD), respectively, with 95% confidence intervals (CIs) . Statisto method . We usedo method . For pubo method . Values The TSA is used to approach and quantify the statistical reliability of data through repetitive and cumulative testing especially for meta-analyses . TSA wasgradepro.org).We assessed every result by using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology . AccordiClinicalTrials.gov, 31; International Clinical Trials Registry Platform (ICTRP), 39]. In the search of gray literature, 6 records identified via websites (n = 1), citation searching (n = 5). A total of 79 studies were excluded due to duplication, 148 studies due to non-RCT, 4 studies due to pharmacology studies, 6 studies due to animal studies, 7 studies with unavailable full text, 59 studies due to non-endoscopic procedures and 20 studies due to control group instead of midazolam. Finally, five articles were included in the meta-analysis. The results were demonstrated as PRISMA  flowchart , which remained statically significant.Based on the pooling of data from five trials with 1,093 participants, our analyses showed statistical difference between the use of remimazolam and midazolam on procedure success . Heterogeneity among all studies was high with 2 of 90% . We furt2 of 90% . Results2 of 90% . We furtI2 = 0%; Our analysis showed no statistically significant difference in the completion of procedure in the use of remimazolam compared with the use of midazolam  with low heterogeneity I2 = 0%; . The cumI2 = 89%; I2: 71%).Five trials demonstrated that the rescue medication usage in the remimazolam group was significantly reduced compared with that in the midazolam group .Five trials with 1,041 participants demonstrated that the time to recovery significantly reduced with the use of remimazolam compared with the use of midazolam  . These fIn this study, we performed some statistical methods for the further confirmation of precise results. We used the IVhet model for minimized the possibility or under- or over-estimate the heterogeneity by traditional random or fixed effect setting in meta-analyses with sparse studies . BesidesIn conclusion, this meta-analysis has systematically reviewed the RCTs to clarify the effects of remimazolam in procedural sedation. The pooled data show statistically significant differences in the outcome of procedure success. The use of remimazolam has resulted in less administration of rescue medication, less time to recovery, and better cognitive recovery compared with the use of midazolam during procedural sedation. We rated the evidence, in the main, as being of low to very low quality based on standard methodology of GRADE. Under the consideration the potential benefit and harm conclusively, we give a conditional recommendation for the use of remimazolam in procedural sedation based on the pooled estimates of good effect and acceptable safety. For determining the evidence of such a new drug, more RCTs with updated meta-analyses is warranted.Many of the limitations of this study were already examined in the discussion. The main limitations of this study were the limited numbers of studies and participants. Only five trials were included in this meta-analysis. Thus, the conclusion might not be definitive. Nevertheless, the results of TSA showed that several outcomes were with an adequate sample size and statistical significance.We clarified the effects of the newest benzodiazepine, namely, remimazolam, on procedural sedation via meta-analysis and TSA of RCTs. The pooled data showed that the use of remimazolam resulted in a higher rate of procedure success, lesser administration of rescue medication, shorter time to recovery, and better cognitive recovery than the use of midazolam during procedural sedation. However, this meta-analysis did not conclusively establish the safety of remimazolam. Despite there was no difference of total AEs between remimazolam and midazolam group, more detailed analysis of AEs yielded inconclusive results. Nevertheless, our study was the first to compare the utilization of remimazolam and midazolam for procedural sedation by pooling RCTs with small samples. The endpoints with statistical significance still demonstrated the potential clinical applications of remimazolam in procedural sedation.The original contributions presented in the study are included in the article/Y-TH and P-CL: conceptualization, validation, and formal analysis. B-JJ and B-HY: methodology, software, and writing of the original draft of the manuscript. P-CL: data curation, reviewing and editing of the manuscript, and supervision. Y-TH: visualization. All authors have read and agreed to the published version of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.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.


Behavioural addictions, such as compulsive buying (CB) and hoarding, are increasingly recognised in the current psychiatric nosology, particularly in developed countries. The prevalence of these disorders may not be static but possibly altered across different age groups. However, studies on this area are rare, and only few have focused on Chinese population. This epidemiological study employs population-based cross-sectional design and collects data in two regions, i.e., Hong Kong and Mainland China. A self-reported questionnaire is constructed based on carefully validated Chinese versions of Richmond Compulsive Buying Scale and Hoarding Rating Scale. A total of 2,439 valid samples are collected and divided into three age groups, i.e., emerging, early and middle adulthood. CB and hoarding behaviours have displayed an inverted u-shaped pattern across the above age groups. In addition, the strength of correlation between the two compulsive behaviours is consistent and maintained across different age groups. These results suggest that the compulsive behaviours vary among different stages of adulthood in major cities in China. This newly discovered pattern of compulsive disorders in Chinese population is different from those in American and European populations. Shopping is a common behaviour in modern life. People shop to buy their needs or relax and reward themselves. However, shopping can become a harmful and destructive behaviour to one’s life when it becomes extreme and unmanageable, which can lead to “compulsive buying” (CB). According to CB behaviour (CBB) has attracted research attention since 1990s in developed societies because of its significant personal and social effects. Evidence has shown that CB may lead to large debts (58.3%), guilt (45.8%), inability to meet payments (41.7%), criticism from acquaintances (33.3%), legal and financial consequences (8.3%) and criminal legal problems (8%) . In addiAlthough CBB has been proven to cause financial and psychological distress and can be considered as a type of behavioural addiction , CB is nThe tendency of CBB is found correlated to age. Specifically, young people seem to be prone to CBB. Research on the estimated prevalence of CBB in the United States has found that the identified compulsive buyers have a significantly lower mean age than other respondents . DittmarStudies on CB have consistently demonstrated that women are highly vulnerable to CBB. Women tend to consider shopping a positive leisure activity, whereas men perceive buying relatively negative and treat it as a task they have to finish . Women uThe relationship between compulsive hoarding (CH) and CB has attracted increasing research attention recently. Compulsive hoarding behaviours are described as obtaining a large number of possessions but failing to discard, which leads to substantial clutter that greatly affects the living space of an individual and his/her normal functioning . The preThis research examines CBB in China using a general community sample in Hong Kong and Mainland China and explores the relationships amongst CBB, CH behaviours, age and gender.This epidemiological study employed population-based cross-sectional design. The inclusion criteria were age of 18 years old or older, living in the studied regions, and able to understand Chinese. A sample of 2,305 Chinese participants   . He et a = 0.09) .2/df = 2.26, CFI = 0.99, NFI = 0.99, IFI = 0.99 and RMSEA = 0.049).The five-item self-reported CHRS contained items of clutter, difficulty discarding, excessive acquisition, distress and impairment . Each itPrevious study has adopted CHRS and RCBS-TC as measurement scales for self-reported correlational research and concluded that common method bias between compulsive hoarding and buying as measured by self-reported method is not demonstrated in obsessive-compulsive continuum, which hence provided satisfactory evidence that both scales is applicable in Chinese . SupplemDemographic items, such as age, gender, marital status, education level and monthly income, were also recorded for analysis.Electronic and paper-based data collections were used complementarily. Some participants were recruited from the general public in three districts of Hong Kong, i.e., Kowloon, Hong Kong Island and New Territories, thereby exhibiting a fair mix of people with different backgrounds. Research assistants invited pedestrians to complete self-administrated questionnaires . The paper-and-pencil method was also used for the data collection. Participants from Shenzhen were recruited online and completed the online survey voluntarily. Ethical approval was sought from the ethical committee of a local university and the collaborative organisation. Informed consent was obtained from the participants through appropriate method .n = 1,203), early adulthood  and middle adulthood . F = 30.98, p < 0.001, see Mearly = 20.16, SD = 8.09) and then dropped in the middle adulthood group , which was less severe than the emerging adulthood group . By using the value of 29 as the cut-off point to separate compulsive from non-compulsive buyers .A total of 2,439 valid samples (response rate = ∼38%) were collected. With regard to participants’ demographic characteristics, 47.8% (52.2%) were males  and their ages ranged from 18 to 59 years. The valid samples were divided into three age groups, i.e., emerging adulthood . However, the differences were not observed in the middle adulthood . As shown in Fearly = 4.92, p < 0.01; Fmiddle = 7.99, p < 0.001), whereas not in the emerging adulthood . Across three age groups, there was no significant effect of income on CBB.Females demonstrated more compulsive buying behaviours than males in all three age groups See . Thus, Hremerging = 0.47, rearly = 0.53, rmiddle = 0.47). To investigate further the salient predictors for CBB in each age group, binary logistic regressions were conducted with the probability to be a compulsive buyer as dependent measurement and compulsive hoarding and demographic variables as predictors. Because of the insignificant effect of income found across the three age groups, income was not included in the binary logistic regressions. As shown in Compulsive buying (CB) was found significantly and positively correlated with CH in all three age groups .” Thus, Chinese people in their thirties were expected to be accomplished and have acquired certain social status. Meanwhile, the unique concept of face  in Chinese culture could be used to explain the high prevalence of CB amongst online buyers who were found to shop more often to show off their social statuses and success  in the emerging adulthood, reach the peak at the early adulthood and drop slightly in the middle adulthood in these two major cities of China. This newly discovered pattern of compulsive disorders in Chinese population was quite different from the findings based on American and European population. By studying the data obtained from the United Kingdom,  success . TherefoConsistent with the findings of studies conducted in Western societies and as predicted in Hypothesis 2, Chinese females with ages between 18 and 39 years were more prone to CB and CH behaviours, which is consistent with the past findings. Both Chinese and Western studies suggested that young female compulsive buyers may use excessive shopping to cope with their stress and negative feelings . HoweverThe association between CB and CH was proven in this research (supported Hypothesis 3), which was consistent with existing literature. In a study conducted in Germany, two-thirds of the participants who were suffering from compulsive hoarding were also classified as compulsive buyers . SimilarThe findings of this study could potentially have important society and treatment implications. The inverted u-shaped pattern across the three age groups of CB and CH suggested that society should care about the mental health of individuals in the early adulthood. Establishing identity, one of the developmental tasks of young adults , togetheDespite of significant contributions of this study, some limitations should be observed. Firstly, we adopted two well validated scales for screening two compulsive behaviours. However, precluding response bias was difficult due to the nature of self-reported answers. Secondly, due to the limitation of funding, we were unable to recruit psychiatrists to perform the diagnosis of CB and CH that was regarded as gold standard for all 2,439 participants. Such shortcomings could affect the accuracy of categorisation of compulsive and non-compulsive group. Lastly, this study recruited large-scale participants to represent Chinese general population. However, the age distribution was uneven. The number of the participants composing the early and middle adulthood was half of that of the emerging adulthood.To the best of our knowledge, this study was one of the pioneers to explore the prevalence of CB and CH behaviours in a Chinese community sample. The prevalence of these compulsive behaviours was displayed in an inverted u-shaped pattern, which was different from those of western societies. Demographic variables, such as gender, marital status, income and education level, were found to affect these compulsive behaviours, especially in the emerging and early adulthood. These newly discovered Chinese findings could be explained by the unique Chinese culture. Thus, future research should further explore how culture influences existing understanding of CBB.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 Regarding Human Research, The Open University of Hong Kong (Ref no. HE20Jul2017-S&T2017/01). The patients/participants provided their written informed consent to participate in this study.SL and HH: conceptualization and funding acquisition. JY, SL, and HH: methodology and writing – review and editing. JY and SL: writing – original draft preparation. SL: project administration. All authors contributed to the article and approved the submitted version.The authors declare that this study received funding from three parties, including The Open University of Hong Kong, Wofoo Social Enterprises, Hong Kong, and National Natural Science Foundation of China. The funder was not involved in the study design, collection, analysis, interpretation of data, the writing of this article or the decision to submit it for publication.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.


We aimed to assess the association of the oxidative balance score (OBS) with metabolic syndrome (MetS) in adults. Setting. Health centers from five districts in Tehran, Iran.  A population-based cross-sectional study β-carotene, vitamin D, vitamin C, vitamin E, and folate), dietary prooxidants (iron and saturated and polyunsaturated fatty acids), and nondietary anti-  and prooxidants (smoking and obesity). The odds ratio (OR) and 95% confidence interval (CI) of the MetS and its components across tertiles of the OBS were calculated by logistic regression analysis, controlling for age, sex, energy intake, occupation, and educational level.  We recruited 847 participants with an age range of 18-65 years. Dietary intake was assessed by a semiquantitative food frequency questionnaire with 168 items. The OBS was calculated by using the following 13 dietary and nondietary anti- and prooxidant components: dietary antioxidants , after controlling for potential confounders. Higher OBS score was associated with a lower likelihood of abdominal obesity  and increased diastolic blood pressure . Higher OBS was not associated with other components of the MetS.  The range of OBS was between 16 and 39. Being in the top versus the bottom tertile of the OBS was not associated with the MetS (OR = 0.71, 95% CI 0.48-1.03;  Overall, the present study showed that there was no significant relationship between OBS and MetS in Tehranian adults. The metabolic syndrome (MetS) is a collection of several metabolic disorders including abdominal obesity, dyslipidemia, hypertension, hyperglycemia, inflammation, high body mass index (BMI), and insulin resistance . The incMetS is a consequence of a complex interaction between several factors such as unhealthy dietary patterns and lifestyle-related factors , 7. It hConsidering the role of oxidative stress in the development of MetS , this stThe sample size required for this study was calculated by considering the frequency of obesity as a dependent variable using the following formula. Taking into account the total prevalence of overweight and obesity of 68.5% in Tehran adults, with 95% confidence and a maximum estimation error of 5% and a value of 0.04 as the effect size, the sample size was 546. Due to the fact that cluster sampling is two-stage and the response of individuals in each health center may be correlated, the number of samples is multiplied by the effect factor of the cluster design selected as 1.5, and the total number of samples 819 is obtained, which we consider as 850, because this data is taken from the previous design and the effect of dietary pattern on obesity is more sensitive than its effect on cardiometabolic and inflammatory biomarkers; in the present study, the sample size of 850 is considered.Eight hundred fifty adult males and females referred to the health care centers in different zones of Tehran took part in the present cross-sectional study. Five zones including North, South, West, East, and the center of the city were selected. Next, a list of all health care centers that existed in each zone was provided. We randomly chose eight health centers from five districts  and then divided the total sample size (850) by the number of health centers (40) to obtain the number of participants in each health center. Inclusion criteria were apparently healthy male and female, aged between 20 and 59 years, living in Tehran city, who attended the local health care centers during the study period (2018-2019), and had a willingness to take part in the study.All participants gave written informed consent before their inclusion in the study. The study was performed in accordance with the Declaration of Helsinki, and the procedure of the study was approved by the Research Ethics Committee of Tehran University of Medical Science (Ethic Number: IR.TUMS.VCR.REC.1397.157). Detailed written information regarding the background and procedures of the study was presented to participants.At the first visit at each health center, data about gender , age, education , smoking status , occupation , and marital status (married or other) were collected by trained interviews through prespecified data extraction forms.The validated International Physical Activity Questionnaire (IPAQ) was utilized for determining physical activity levels . MetabolA wall stadiometer with a sensitivity of 0.1 cm  was used for measuring the participants' height. They were asked to take off their shoes for height measurement. Participants' weight was measured, without coat and jacket, by using an adult's digital scale  with 0.1 kg precision. BMI was calculated as weight in kilograms divided by height in meters squared. Waist circumference (WC) was measured with a tape measure to the nearest 0.1 cm between the iliac crest and the lowest rib during exhalation. After 10 to 15 minutes of rest and sitting, systolic (SBP) and diastolic (DBP) blood pressure was measured by a trained physician, on the right arm, with a digital barometer . For each participant, the mean of two blood pressure measurements was recorded. Fasting plasma glucose (FPG), serum triglyceride (TG), and high-density lipoprotein cholesterol (HDL-C) were measured after 10–12 hours of overnight fasting from a venous blood sample. Blood samples were measured by standard methods at the Nutrition and Biochemistry Laboratory of the School of Nutritional Sciences and Dietetics at Tehran University of Medical Sciences.A semiquantitative food frequency questionnaire with 168 items  was usedThe diagnostic criteria introduced by NCEP ATP III  was usedβ-carotene, vitamin D, vitamin C, vitamin E, and folate); (2) dietary prooxidants (iron and saturated (SFA) and polyunsaturated (PUFA) fatty acids); (3) nondietary antioxidant ; and (4) nondietary prooxidants (smoking and obesity). Dietary factors were ranked into tertiles. For dietary antioxidants and physical activity, the first to third tertiles were assigned scores of 1-3. An inverse scoring was used for dietary prooxidants. For obesity, we assigned 1: BMI ≥ 30 kg/m2 and WC ≥ 102 cm in males and ≥88 cm in females, 2: either BMI ≥ 30 kg/m2 or WC ≥ 102 cm in males or ≥88 cm in females, and 3: BMI < 30 kg/m2 and WC < 102 in males or <88 cm in females. For smoking, we assigned 1: current smoking, 2: former smoking, and 3: never smoking. The score of four components was then summed to calculate the OBS for each participant. The minimum and maximum scores possible are, respectively, 3 and 39.We used the method introduced by Goodman et al., to calculate the OBS of each participant. According to this method, a total of 13 dietary and nondietary pro- and antioxidant components, based on a priori knowledge about their association to oxidative stress, were selected . The comP value less than 0.05 was considered statistically significant.The OBS was categorized into tertiles, and then, the characteristics of the participants were presented accordingly. Continuous variables were presented as mean and standard deviation (SD) and categorical variables as frequency (number) across tertiles of the OBS and then compared by using the one-way analysis of variance (ANOVA) and the chi-square tests, respectively. The odds ratio (OR) and 95% confidence interval (CI) of MetS and its components were estimated through binary logistic regression analysis in two models. Model I adjusted for age, sex, and energy intakes as potential confounders. Model II was adjusted for confounders in Model I plus education and occupation status. All statistical analyses were done by the use of SPSS software version 24 . The initial sample size included 850 participants; of those, three participants were excluded due to lack of data for at least one variable. Therefore, 847 participants were included in the present study. Characteristics of the participants and dietary intake across tertiles of the OBS are indicated in P = 0.07) in the fully adjusted model. There were significant relationships between higher levels of OBS and abdominal obesity as assessed by WC  and increased DBP . There was no significant association between the OBS and other components of the MetS.Oxidative stress is associated with several health outcomes like diabetes, inflammation, different types of cancer, and other metabolic disorders , 15, 22.Current evidence regarding the association of a priori OBS and the risk of chronic diseases is inconsistent. Two prospective cohort studies showed that a balanced oxidative status was associated with a lower risk of all-cause and cause-specific mortality , 31. SomEvidence regarding the association of the OBS and the MetS is scarce. Our preliminary search found only one study that assessed the association of oxidant/antioxidant disequilibrium and MetS . A recenAnother cross-sectional study in Thailand showed that those with the MetS had lower circulating levels of superoxide dismutase, catalase, and vitamin C than those without the MetS . HoweverWe also found no association between the OBS and most components of the MetS. Exceptions were increased DBP and WC, for which inverse associations were found. Our results regarding the null association between the OBS and high fasting glucose and SBP and inverse associations with increased DBP and WC are consistent with those of the Korean cross-sectional study . Howeverα-carotene, β-carotene, β-cryptoxanthin, lutein, lycopene, selenium, iron, and PUFA, as well as nondietary factors including smoking history, alcohol drinking, and the use of aspirin and other nonsteroid anti-inflammatory drugs.Another cross-sectional evaluation within a prospective cohort study in the US found inverse associations between the OBS and increased WC and low-density lipoprotein cholesterol concentration, and no association for total cholesterol and TG . The dieAlthough we did not find a significant relation between OBS and the MetS, several biological pathways suggest a link between oxidative stress and cardiometabolic disorders . Recent One of the strengths of our study was the ability to include both dietary and lifestyle components into the score, so a comprehensive view of different determinants of oxidative stress was provided. Our study included a relatively large sample size involving both men and women. In addition, data was collected by expert dieticians with valid and reliable questionnaires. On the other hand, our study has some limitations which can affect the results. Because of cross-sectional design and the temporal sequence, as a result, a casual association cannot be concluded. Moreover, some items were missing in the OBS . Also, the known limitations of FFQ for dietary assessment, i.e., the error in recall and limited food choices, should be considered. Finally, we had a lack of information about genotypes that can affect OBS and components of the MetS . We alsoIn conclusion, no significant association between OBS and odds of MetS in adults was found. However, a significant inverse association was found between OBS and abdominal adiposity and DBP. Further studies, in particular those with prospective nature, need to confirm the present findings.