This study attempts to elucidate the prevalence and genetic factors associated with four angular hoof deviations in the Pura Raza Española horse: splay-footed forelimb (SFF), pigeon-toed forelimb (PTF), splay-footed rear limb (SFR), and pigeon-toed rear limb (PTR). From a total of 51,134 horses evaluated, only 15.75% did not have any of the four investigated angular hoof defects, while the rest presented varying degrees of defect. We identified the factors influencing these defects, including age, inbreeding coefficient, sex, and birth stud size, using a Bayesian multivariate animal model with the BLUPF90 software. The heritability estimates ranged from 0.11 (SFR) to 0.31 (PTR) for model A (three categories.), indicating the genetic influences of varying categories; and ranged from 0.11 (SFR) to 0.29 (PTR) for model B (two categories). Additionally, the study explored the genetic correlations between these defects and their relationship with the diameter of the superficial digital flexor tendon (SDFT) and the proportionality index (PI). The findings revealed that diameter of the SDFT is strongly correlated with inward-toe conditions (PTF and PTR), while PI is associated with outward defects (SFF and SFR). These results provide valuable insights into angular hoof deviations in PRE horses, shedding light on their prevalence, genetic factors, and associations with other anatomical features, which can have general implications for a horse’s health and performance.P≠0 ≥ 0.95), while PI is associated with outward toe defects .Abnormalities in hoof shape are usually connected with limb conformation defects. The role of angular hoof deviations is important for longevity in sports competitions and is increasingly recognized as a factor associated with lameness in performance horses. In this paper, we measured the prevalence of four defects related to the angulation of the hoof in the Pura Raza Española horse (PRE): splay-footed forelimb (SFF), pigeon-toed forelimb (PTF), splay-footed rear limb (SFR), and pigeon-toed rear limb (PTR). A total of 51,134 animals were studied, of which only 15.75% did not have any of the four angular hoof defects investigated, while 26.61%, 23.76%, 79.53%, and 3.86% presented SFF, PTF, SFR, and PTR, respectively. Angular defects were evaluated using two different models; model A was a linear scale composed of three categories, where 0 corresponded to the absence of defects, 1 to a minor presence of the defect and 2 to the highest degree of the defect. Model B was composed of two categories, where 0 corresponded to the absence of defects and 1 to the presence of defects, joining classes 1 and 2. We measured the factors influencing the appearance of these defects: age, inbreeding coefficient, sex, and birth stud size. The heritability of each defect was also estimated using a multivariate animal model, using the Gibbsf90+ software from the BLUPF90 family, resulting in heritability estimates of 0.18 (s.d. = 0.009), 0.20 (s.d. = 0.010), 0.11 (s.d. = 0.009), and 0.31 (s.d. = 0.010) for SFF, PTF, SFR, and PTR defects, respectively, for model A, and 0.17 (s.d. = 0.008), 0.19 (s.d. = 0.009), 0.11 (s.d. = 0.009), and 0.29 (s.d. = 0.009) for SFF, PTF, SFR, and PTR defects, respectively, for model B. Finally, the genetic correlation between the diameter of the superficial digital flexor tendon (SDFT) and the proportionality index (PI) in relation to the higher or lower prevalence of the defects was analyzed. We concluded that diameter of SDFT development is strongly correlated with inward toe conditions (PTF, PTR;  The hoof structure plays a critical role in locomotion, weight distribution, and shock absorption during movement in equines , and disAngular hoof deviations encompass a spectrum of abnormalities that involve the alignment and orientation of a horse’s hooves in relation to the limb axis. These deviations impact the biomechanics of the horse’s limbs and, consequently, influence the horse’s performance in various activities, including work and sports competitions, or simply its ability to move comfortably without pain. These areas’ defects are associated with a series of factors, such as injuries, inflammation, bio-mechanical imbalances, abnormal development during the horse’s growth, or even genetic factors. The main consequence is the effect on the horse’s ability to move correctly ,5. ThrouIn this context, although all the above-mentioned risks produce themselves financial losses and a lower quality of life for the horse, from a population management point of view, knowledge about the genetic implications is of great interest. The identification and study of limb defects are essential for implementing the appropriate selection measures to reduce their incidence and improve the health and athletic performance of the breed, especially when considering sport competition horses such as the Pura Raza Española (PRE) horse. The PRE is a native Spanish breed, one of the oldest in Europe and one of the most important at the international level. This breed has gained international recognition in the field of Classical Dressage, taking part annually in a significant number of competitions, both in Spain and worldwide . In geneThis study aims to provide a more comprehensive understanding of the factors affecting hoof health in PRE horses, with potential implications for the breeding program, management practices, and overall well-being of this equine breed. In this study, the incidence of hoof defects in the PRE horse population was estimated and the potential influencing risk factors in the presentation of angular hoof deviation were analyzed. Additionally, genetic parameters related to these defects were examined to determine if there is a genetic basis contributing to their occurrence. Finally, the relationship between the presence of hoof defects and morphological variables, specifically the diameter of the superficial digital flexor tendon (SDFT) and the proportionality index (PI), were explored.In our study, we analyzed hoof conformational data from 51,134 Pura Raza Española (PRE) horses . The sample encompassed a variety of hoof conformational defects : hoof deDefects of the ‘splay-footed forelimb’ (SFF) and ‘pigeon-toed forelimb’ (PTF). These defects are related to the direction of the front hooves when seen from the front. An individual exhibits these defects when the hoof points either inwards or outwards, respectively, in relation to the vertical plumb line, as measured from the outer edge of the shoulder joint and the humero-cubital joint to the ground.Defects of the ‘splay-footed rear’ limb (SFR) and ‘pigeon-toed rear limb’ (PTR). These defects are related to the direction of the rear hooves when seen from the back. An individual has an SFR or PTR defect when the hoof tips either inwards or outwards, respectively, in relation to the vertical plumb line, as measured from the point of the hip and tibia-fibula joint to the ground, when seen from the rear.The four analyzed defects were as follows:The estimation of genetic parameters was performed with two different models:For model A, the four conformational hoof defects were recorded on a linear scale from 0 to 2. Category 0: represents a lack of the defect, the hooves are vertical, or slightly turned outwards (SFF or SFR) or inwards (PTF or PTR), with, at most, 5 degrees of angulation. Category 1: a minor presence of the defect, the hooves are turned outwards (SFF or SFR) or inwards (PTF or PTR) between 5 and 20 degrees of angulation. Category 2: the most significant level of the defect, the hooves are turned outwards (SFF or SFR) or inwards (PTF or PTR) with more than 20 degrees of angulation.For model B, the four conformational hoof defects were recorded as a dichotomous model. Category 0: represents a lack of the defect, the hooves are vertical, or slightly turned outwards (SFF or SFR) or inwards (PTF or PTR), with, at most, 5 degrees of angulation. Category 1: presence of the defect, the hooves are turned outwards (SFF or SFR) or inwards (PTF or PTR), with more than 5 degrees of angulation.In PRE horses, SFF and SFR defects are considered to be severe when they are in category 2, and PTR and PTF defects are considered to be very severe when they are in category 2. When a PRE horse, in any part of its body, has more than 2 very severe defects or more than 4 severe defects, the horse cannot be registered as a breeder of the PRE breed.The covariates analyzed were the evaluation age  and the classical inbreeding coefficient . The F value, following Wright , definedAdditionally, heritabilities and genetic correlations between the hoof defects and two morphological variables, the diameter of the superficial digital flexor tendon (SDFT), and the proportionality index (PI) were analyzed. The SDFT extends from the elbow region to the distal interphalangeal joint in the forelimb or from the hock region in the hind limb. The diameter of the SDFT was measured on a linear scale from 1 to 9, depending on the thickness of the tendon of the four limbs as a whole, where 1 is very thin and 9 is highly developed (larger diameter); the evaluation is unique, grouping, in a single evaluation, both forelimb and rear limb diameter. This tendon is a fundamental part of the connective system that allows for the function of hoof flexion in the horse’s limbs. The PI was defined as the height at the withers * 100 divided by the scapular-ischial length (distance of the straight segment from the union of the scapular-humerus joint to the point of the buttock). The PI is a variable widely used in equine breed characterization , and alsA multivariate Generalized Non-linear Model (GLZ), with a multinomial logit distribution, was used to examine associations between the conformational hoof defects and their potential factors. All the statistical analyses were conducted using Statistica 11 for Windows software .y is the vector of observations, X is the incidence matrix of fixed effects, Z is the incidence matrix of the animal genetic effect, b is the vector of fixed effects, u is the vector of the direct animal genetic effect, e is the vector of residuals, I is an identity matrix, and A is the numerator relationship matrix.For the genetic evaluations, the genealogical information was obtained from the PRE StudBook managed by ANCCE , ensurinThe genetic parameters were estimated using the Blupf90 software . A BayesThe basic statistical results for angular hoof deviations in the PRE horses are shown in The percentage of affected animals (category 1 or 2) for each hoof defect can be observed in In the analysis of angular hoof deviations in PRE horses, multiple effects were evaluated, including age, inbreeding, sex, and birth stud size . A GenerThe evolution of the four defects studied in the PRE horses over the last 20 years based on the horses’ birth year is shown in The variance components and heritability values for the four hoof defects studied in PRE horses are shown in P≠0 ≥ 0.95). On the other hand, for model B, the genetic correlations between SFF-PTR, SFF-SFR, and PTF-PTR were positive, with values of 0.14 (s.d. = 0.031), 0.35 (s.d. = 0.054) and 0.30 (s.d. = 0.030) for the three genetics correlations with a P≠0 = 1. The genetic correlation between PTF-SFR was small, with a value of −0.05 (s.d. = 0.055), and not different from zero, as indicated by the symmetric HPD at 95% that included zero (ranged from −0.053 to 0.159) and the low probability of being different from zero (P≠0 = 0.17).The genetic correlations among the four hoof defects are presented in P≠0 = 1.00) In model B, for the SFF and SFR defects, there was no evidence of a relationship between these factors .P≠0 = 0.87 in model A and P≠0 = 0.54 in model B). In model B, for the SFR defects, there was no evidence of a relationship between these factors, not different from zero, as indicated by its symmetric HPD at 95% that included zero and the probability to be lesser than zero (P≠0 = 0.94).Regarding the proportionality index (PI), opposite correlations were observed compared to the SDFT. For model A, the defects SFF and SFR displayed low to moderate positive correlations of 0.212 (s.d. = 0.030) and 0.124 (s.d. = 0.041), respectively. For model B, the defect SFF displayed low to moderate positive correlation of 0.222 (s.d. = 0.031). In both models, for the PTF defect, there was no evidence of a relationship between these factors, not different from zero, as indicated by the symmetric HPD at 95% that included zero and the low probability to be lesser than zero  in the PRE horses. The SFR defect exhibited the highest mean value and a wider confidence interval, indicating greater data dispersion compared to the PTR defect, which had the lowest mean value and the smallest confidence interval . These iIn the PRE horse, the outward deviation hoof defect can vary in severity and may appear in the forelimbs and/or rear limbs, although it is more common in the rear limbs (SFR) . Horses,In each of the four hoof deviation defects, categories 1 and 2 represented the individuals affected, with significantly different percentages being observed among the defects . This inTo achieve an accurate, comprehensive understanding of the patterns in hoof deviation defects, we need to consider that both environmental and genetic factors can influence the occurrence and severity of conformational defects. Although most widely published works have addressed the clinical perspective, no detailed genetic analyses for hoof deviation defects in PRE horses have been extensively conducted until now. In our study, we examined not only the influence of sex and age, but also the individual coefficient of inbreeding and the breeding stud size . OverallHoof variations depend not only on the constant movements made during work  and the Regarding sex, males exhibited a higher incidence of hoof deviation defects compared to females, which aligns with the findings in the lameness study conducted by Ross . This seAn association between the size of the breeding stud and the percentage of affected horses was also observed. Large-scale birth studs primarily focus on breeding, while smaller and medium-sized ones are mainly dedicated to competition. This distinction is crucial, because the type of livestock management significantly influences aspects such as the type of exercise horses undergo, the management regimen, the intensity of training, and other related factors. In this context, it has been documented that foals raised in large herds with extensive management may develop limb conformation irregularities due to uneven load patterns during grazing , as horsRegarding the evolution of defects related to consanguinity levels b, it is Conformation defects have been evaluated in numerous equine breeds using a linear scale that usually ranges from 5 classes ,58 or 9–Regarding the genetic correlations between different hoof deviation defects, our results support that different sets of genes are involved in coordinating hoof deviation defects, depending on whether they occur in an outward or inward position . In a stThe equine limb behaves like a large system of springs due to the extension of the metacarpophalangeal joint and the elastic recoil in tendons ,64; specOn the other hand, the PI in horses seems to be a determining factor that influences movement and, consequently, plays an essential role in maintaining proper balance and hoof conformation . This peIt is possible that there may be limitations in this work, as it was not possible to stan-dardize the age of all the animals since the animals were not evaluated at the same age. Additionally, the presence of animals assessed both with and without horseshoes, as well as their participation in competitions, could have introduced biases in the assessment of angular defects, as footwear and exercise can impact the correction of these issues. Another limitation of phenotyping in the study is the assessment by a single evaluator, rather than using consensus from multiple evaluators for each horse, and variability between horses since there were different single evaluators across the large dataset. Despite this, this work had a significant representation of active PRE horses and it demonstrated that the angular hoof deviations affect limb biomechanics, influencing the horse’s ability to perform, which may also have genetic implications, justifying the implementation of sui-table selection measures to reduce their incidence and improve both the breed and equine sports performance. All these findings emphasize the importance of breeding programs that not only focus on the quality of movements and functionality in dressage, but also place a fundamental emphasis on conformational defects of the horses’ limbs.A high prevalence of angular hoof defects was found in the PRE population, with a higher occurrence in males and significant variations with an increasing inbreeding coe-fficient and breeder herd size. It was demonstrated that genetic factors play a role in the occurrence of these defects, with moderate heritability values. Furthermore, we observed genetic correlations between the defects analyzed, pointing to the existence of specific genes related to the presence of particular defects. Our study also underscored the signi-ficance of taking into account factors such as the proportionality index (PI) and development of the superficial digital flexor tendon (SDFT). It revealed correlations between these factors and the direction of angular hoof defects, with the SDFT being associated with inward defects and the PI with outward defects. Breeders and veterinarians should take into account, when organizing the mating of the stud, the genetic values of the breeding animals for each of the angular hoof deviation defects , along with the genetic values of the rest of the morphological defects of the breed, both in the limbs and other areas of the body. From a reproductive perspective, breeders should prioritize horses whose genetic values, for each of the conformation defects analyzed in the breed , have a high probability of not being transmitted to the offspring. Well-organized horse pairings based on the genetic value of the offspring will reduce defects in the population.


Futsal is a discipline with high training and nutritional requirements. Despite growing research interest in athletes’ diet and nutritional status, no studies have examined Polish male futsal players. Therefore, the aim of this descriptive study was an assessment of the dietary intake and nutritional status in a selected group of futsal players. The study comprised 11 members of a top Polish futsal team (aged 26 ± 3.62 years). Dietary intake was assessed using a standardized 3-day food record. Body composition, total energy expenditure, physical fitness level, and concentrations of the biochemical indices of each participant were estimated. The energy availability in the diet was lower than recommended. Moreover, low consumption of carbohydrates was stated, as well as an inadequate intake of Vitamins E and D. Higher protein and cholesterol intake than recommended were also observed. To conclude, our results point to the need for educating athletes and coaches, particularly teaching about proper food choices, promoting quality foods, and, in some cases, using individual dietary plans to meet energy and nutrient needs. Nutrition education would help to improve their dietary and health habits and optimize their performance in sports training. TTaking all this into account, futsal players have high nutritional requirements in terms of both energy expenditure and fluid and electrolyte loss during training and matches . An effeThe nutritional recommendations published by international sports organizations, such as the International Olympic Committee (IOC), the American College of Sports Medicine (ACSM), and the International Society of Sports Nutrition (ISSN), are therefore important, primarily to support the physical demands of training and optimize performance, improve recovery, and support the nutritionists working with athletes to meet individual nutritional needs . HoweverRecently, there has also been growing interest in the role of Vitamin D in the human body ,17,18, eIn recent years, body composition analysis has become part of athletes’ assessments as an important determinant of health and performance . DiffereDespite growing research interest in athletes’ diet and nutritional status, no studies have examined Polish male futsal players. Therefore, the present study aimed to investigate the diet and nutritional status of professional futsal players.Initially, the study group consisted of 12 men, who were members of a top Polish futsal team. Due to a problem with blood collection, the number of athletes participating in the research decreased to 11 men. The mean age of athletes was 26 ± 3.62 years, and the average training experience was 7 ± 2.38 years. All subjects were free from injury and illness, and declared that they had not introduced any changes in their lifestyles, training elements, nutrition, and/or supplementation. The characteristics of the participants are presented in The study protocol was reviewed and approved by the Bioethics Committee of the Poznan University of Medical Sciences . Participation in the study was voluntary; athletes were informed about the purpose of the study and could withdraw at any time. All study participants gave written informed consent. All procedures were carried out in accordance with the ethical standards of the Helsinki Declaration of 1975.All procedures were conducted at the end of the preparatory period (September 2021), which lasted six weeks.All anthropometric measurements were conducted in the morning, in a fasting state, by the same specialist (a certified nutritionist). Body mass and height were measured using a certified digital medical-grade scale and a mechanical measuring rod  with an accuracy of 0.1 kg for weight and 0.5 cm for height, respectively. Body composition was assessed by the bioimpedance method, using the TANITA BC-420 analyzer  with GMON Professional software version 3.4.2 . Body composition was measured strictly following the recommended measurement conditions , as descThe assessment of dietary intake was conducted using a standardized 3-day food record. The participants were asked to express the size of their meals in common measurement units . The information thus obtained was adjusted using the album of photographs of food products and dishes elaborated by the National Food and Nutrition Institute in Warsaw (Poland) . QuantitExercise energy expenditure (EEE) was assessed over three days, in which athletes collected their dietary data. EEE was measured during team training sessions, which included futsal practice and control matches. During the training, the Polar Team2 System with software version 1.4  was used to record the players’ heart rate. Energy expenditure was calculated using proprietary algorithms.Energy availability (EA) is defined as the amount of dietary energy remaining after exercise training for all other metabolic processes, normalized to fat-free mass (FFM) (or lean body mass) . The con2max) was calculated using the following formula [The futsal players performed the Yo-Yo Intermittent Recovery Test Level 2 (YYIR2) according to established procedures . The tes formula :VO2max . The samples were collected following all safety standards into serum-separating tubes  and centrifuged at 2000× In the serum, the total cholesterol (Cat. No. 7-204), high-density lipoprotein , low-density lipoprotein , triglycerides (Cat. No. 7-253), total protein (Cat. No. 7-236), albumin (Cat. No. 7-238), and glucose (Cat. No. 7-201) concentrations were analyzed. All measurements were performed using the Accent 220S automatic biochemical analyzer  and PZ Cormay S.A. Company reagents . The serum concentration of 25-hydroxyvitamin D was determined using an IDS EIA kit .1–Q3), and minimum–maximum (Min–Max). The Shapiro–Wilk test was used to check the data for a normal distribution. The level of statistical significance was set at p < 0.05. Spearman’s rank analysis was used to calculate the correlation coefficients.All analyses were performed using the Statistica 13.0 software package . Data are presented as the means, standard deviations (SD), medians (Me), quartiles (Q2max of 59.7 ± 2.07 (mL·min−1·kg−1).The basic characteristics of the examined players are presented in As shown in −1 and met the requirements for this sporting discipline. However, an imbalance in the intake of macronutrients was found. The futsal players’ diet was characterized by a lower than recommended content of carbohydrates and a slightly higher protein content. Higher cholesterol intake than recommended was also observed. The consumption of fatty acids was sufficient, except for saturated fatty acids , which exceeded the recommended standards.The average energy value of the diet and the intake of selected nutrients in futsal players are presented in The athletes consumed too high an intake of sodium and potassium. The average daily food rations were also characterized by a high intake of calcium, phosphorus, magnesium, iron, zinc, Vitamin A, Vitamin C, Vitamin B1, Vitamin B6, and Vitamin B12. On the other hand, values lower than recommended were noted in the consumption of Vitamins D and E .2max and the percentage of fat content  and insufficient amounts of carbohydrate compared with their estimated requirements. Although the average energy intake of the athletes studied was in line with sports associations’ recommendations, the energy provided in the study group’s usual rations varied and was sometimes insufficient to meet the daily energy requirements. More than 2500 kcal, the minimum recommended by the ACSM , was proa et al. , Japanesa et al. , in theiGiven that the majority of available studies indicate that carbohydrates are the preferred macronutrient in the diets of team game players , the lowOur subjects did not consume adequate amounts of energy and carbohydrates, and the intake of other macronutrients in their diets exceeded the current recommended daily intake, which could indicate that athletes did not make quality nutritional choices.In our study, a slightly higher protein intake than recommended ,47 was oHowever, despite the overall proportion of fats in the diet of the studied athletes (32.7%) being in line with the recommendations, only one of the athletes (9%) had an acceptable cholesterol intake. In contrast, the intake of saturated fatty acids was too high in 100% of cases. This fact is explained by the increased intake of meat products and eggs in the daily rations. Parallel biochemical blood tests showed that some athletes had too high total cholesterol and triglyceride levels , and others (27%) had total cholesterol levels close to the upper limit of the reference level.The diet of our athletes was characterized by an insufficient intake of Vitamin E. This may be related to a lack of knowledge, as September, the month of the study, is rich in tocopherol-rich fruits and vegetables such as tomatoes, broccoli, brussels sprouts, spinach, peaches, and blackcurrants. Respondents should also include olive oil, sunflower oil, almonds, hazelnuts, sprouts, and cereal seed germ in their diets.Although the dietary intake of Vitamin D was deficient, the serum levels of all tested subjects were high. Vitamin D is synthesized in the skin and produced in the body following exposure to Ultraviolet B (UVB) radiation from the sun  or from + and K+) can lead to painful, sudden, and involuntary skeletal muscle contractions during or after training [It is very likely that an inadequate intake of fruit and vegetables, with a predominance of processed products high in salt, also led to excess sodium in the athletes’ diets. Given the high losses of this component in sweat, these values are not worrying. However, from a practical point of view, the observed high potassium intake could be considered significant, as an imbalance in electrolyte concentrations , which is simple, quick, and non-invasive. However, it should be noted that the obtained results depend on BIA-based predictive equations. The study was conducted once, in September, when Polish seasonal fruit and vegetables were available. Repeating this research at other times of the year would be interesting. With these limitations in mind, this study provides information on professional Polish futsal players’ diet and nutritional status, drawing attention to the need for effective strategies in this area.To conclude, our results point to the need to educate athletes and coaches, particularly teaching about proper food choices, the promotion of quality foods, and, in some cases, the use of individual dietary plans to meet energy and nutrient needs. Nutrition education would help to improve their dietary and health habits and optimize their performance in sports training.


The main objective of this study is to assess moderation effects of online behaviors between personality traits and addiction to Internet. To this end, four instruments were validated for Portuguese version through confirmatory factor analysis and exploratory factor analysis (Study 1) Multiple regression analysis was applied to examine the personality predictors of specific online behaviors while controlling for gender and age; and moderation effects were assessed (Study 2). Results showed good psychometric properties for the four validated scales. Machiavellianism is positively associated with all the dimensions of this study. Psychopathy is positively associated with total Cyberstalking, Cyberstalking Control, Flaming and Trolling. Narcissism is positively associated with all the dimensions, except Online Harassment and Flaming. Machiavellianism is positively associated with Addiction to Internet through Cyberstalking, Flaming and Trolling. Psychopathy is positively associated with Addiction to Internet through Cyberstalking Control and Flaming. Narcissism is also positively associated with Addiction to Internet through Cyberstalking and Trolling. This study demonstrates that dimensions of the dark triad of personality play an important role in Internet addiction through online behaviors. The results of this study have theoretical and practical implications: on the one hand, they reinforces the findings of other studies showing that dimensions of the dark personality triad play an important role in Internet and social network addition, contributing to the literature; and, on the other hand, on a practical level, they allow to conduct awareness campaigns in communities, schools, and work to understand that one can be exposed to unpleasant situations due to behaviors that some people with personality traits of Machiavellianism, narcissism and/or psychopathy that may cause problems affecting the mental, emotional and psychological health of others. It is almost impossible to live nowadays without the Internet and hundreds of online applications . AlthougThe addition to the Internet is an extensive concept that encompasses a multiplicity of behaviors and impulse control problems in its use , with chCyberstalking, also known in the literature as electronic or virtual stalking, includes the use of the Internet (or other computerized device), to harassing or chasing other persons, by systematic and undesirable actions, causing suffering to the targets of these behaviors . CyberstLiterature has reported a number of harmful consequences for mental health of victims of cyberstalking and/or harassment. The negative psychological impact of the cyberstalking and/or online harassment manifests itself through psychopathological symptoms such as anxiety, depression, posttraumatic stress disorder and panic attacks; through negative emotions such as sadness, anger, fear, shame, embarrassment, isolation and low self-esteem; through physical symptoms such as stomach pains and heart palpitation; and even through inappropriate behaviors such as harmful self-behavior ,14.In turn, Trolling can be considered a type of online harassment ; this beIt is possible to classify the above-mentioned behaviors  as anti-social behavior and online; according to Moor and Anderson , antisocIt should be noted that online antisocial behavior represents a more complex phenomenon and with more serious consequences because it is practiced online or through any technological devices. Thus, the possible anonymity of the perpetrator, the public potential to become uncontrollable, the constant nature of victimization through the permanent presence of information and communications technology (ICT) in everyday life, the increased difficulty in identifying the perpetrator and the power imbalance created by anonymity are perceived by victims as weakening and strengthening the perpetrators ,18.Research has shown that the personality traits that make up dark triad play a crucial role in adding to the Internet and social networks ,20,21. TThe dark triad assesses aversive personality traits: Machiavellianism, psychopathy and narcissism ,23. ThesSeveral researches reveal that dark triad’s personality traits seem to be positively associated with the problematic addition to the Internet  and withSindermann et al.  stated tSmoker and March  examinedIn the study by Lopes and Yu , 135 parThe main objective of this study is to assess the moderation effects of online behaviors between personality traits and addiction to Internet through two studies. To achieve this objective, specific objectives were outlined: (1) to evaluate the psychometric qualities of the instruments used in this study through (1a) assessment of the adjustment to our sample of instruments previously validated for the Portuguese population (Internet Addiction Test and Dirty Dozen Dark Triad); (1b) and the validation for the Portuguese population of the Cyberstalking scale, Online Harassment scale, Flaming scale and Trolling scale; (2) to establish associations between Internet addiction, Machiavellianism, psychopathy and narcissism, cyberstalking, online harassment, flaming and trolling, on the one hand, and the sociodemographic variables, o the another; (3) to establish associations between personality and online behaviors; and (4) to understand if online behaviors moderates the relation between the dark triad of personality and Internet addiction.All procedures followed the Declaration of Helsinki and later amendments or comparable ethical standards. Also, the Scientific Committee of Universidade Católica Portuguesa approved this study that was conducted from July to September 2022. Participants were recruited through social media and assessed through Google Forms, having been informed about the study’s purpose and assured of confidentiality and anonymity of the data. All participants signed the informed consent. The criteria used to select participants were: to be 18 years old or older, and have Portuguese nationality and residence. Exclusion criteria include being fewer than 18, not understanding the content of the questions asked and not using social media. The translation of the four instruments  was performed according to the International Test Commission (ITC) guidelines for translating and adapting tests  and the The sociodemographic questionnaire includes questions related to gender , age, years of education and if participants are in a romantic relationship .The Internet Addiction Test (IAT) was conceived by Young  to measuJonason and Webster  developeSilva Santos et al.  developeLewis et al.  conceiveThe items used to measure flaming behavior were based on scales developed by Turnage . AggressHoward et al.  developeData analysis includes procedures related to descriptive statistics: for continuous data, measures of centrality (mean), dispersion (standard deviation and range) and shape (skewness and kurtosis) were used; frequencies and percentages are also displayed. The normality of the items was assessed by skewness (SI < 3) and kurtosis (KI < 10) indexes suggesting non-severe violations of normality , utilizi2, shows that the model fits the data acceptably; the higher the probability related to χ2, the closer the fit to the perfect one. A value of the parsimony-corrected index Steiger–Lind root mean square error of approximation (RMSEA) close to 0 and non-significant at the 0.05 level represents a good fit. Values of incremental fit index (IFI), Tucker–Lewis index (TLI) and the Bentler incremental comparative fit index (CFI), close to 1 (0.95 or better), are indicators of best fit, as well as goodness of fit index (GFI). Re-specification of the models allows to analyzing path estimates, standardized residuals of items, and the modification indices. Regarding construct validity, items with low individual standardized factor loadings (regression weights below 0.50) may eventually be removal. The modifications indices (MI) provide information about potential cross-loadings and error term correlations . Concerning the parsimony-adjusted index Akaike Information Criterion (AIC) and the standardized root mean square residual (SRMR) (over 0.10 suggests fit problems), the smallest the values the most parsimonious is the model, they allow to compare the fit across models.A Confirmatory Factor Analysis (CFA) with Maximum Likelihood Estimation (MLE) was carried out to confirm the models proposed by the authors of the original versions of the instruments. The model fit evaluation was based on Kline’s  thresholConcerning Cyberstalking scale, it was not possible to confirm the model proposed by the authors through the CFA. Therefore, it was decided to carry out an exploratory factor analysis (EFA) with maximum likelihood factoring. Parallel analysis—principal components analysis with raw data permutation —was perfTo assess the model reliability, convergent and discriminant validity, Cronbach’s alpha coefficients, composite reliability , average variance extracted  and square root of AVE (higher than the highest correlation with any other latent variable) were used; if AVE is less than 0.50 and CR higher than 0.60, the convergent validity of the model is adequate . Cronbach’s alpha coefficients (0.90) composite reliability (0.91), average variance extracted  and square root of AVE (0.74) were calculated, being the values within the reference range. Mean (1.78) and standard deviation (0.64) were also calculated.The Internet Addiction Test was validated for the Portuguese population as being unifactorial. We proceeded to carry out a confirmatory factorial analysis to evaluate the model in our population, but the fit was unacceptable. After consulting the modification indices, two correlations between errors were established until a good model was found . Cronbach’s alpha coefficients ; composite reliability ; average variance extracted (AVE) ; square root of AVE ; mean and standard deviation were calculated . All the values were within the reference range.The Dirty Dozen Dark Triad was validated for the Portuguese population as tri-factorial. We proceeded to carry out a confirmatory factorial analysis to evaluate the model in our sample, but the fit was not good. After consulting the modification indices, two correlations between errors were established until a good model was found ; the estimated values of standardized regression weights are within the reference values (between 0.44 and 0.70). Cronbach’s alpha of the total is 0.84 and no item, if removed, increases Cronbach’s alpha. After consulting the modification indices, several correlations between errors were established but, in spite of that, a good model was not found. The authors decided to perform an Exploratory Factorial Analysis (EFA). To this end, the sample was randomly divided into two groups with almost the same number of participants: one group assigned to EFA (N = 387) and the other to subsequent CFA (N = 386). Factors were extracted by the maximum likelihood method and rotated by varimax rotation. The number of factors was decided in consideration of the parallel analysis, scree-plot, cumulative variance explained, interpretability, and Kaiser’s criterion. In the parallel analysis, 3 components had eigenvalues that were above the 95th percentile of eigenvalues of 1000 random datasets of the same dimension. The EFA resulted in a solution with ten items distributed by three factors (2(31) = 2.54; IFI = 0.963; TLI = 0.946; CFI = 0.963; GFI = 0.959; SRMR = 0.083; RMSEA = 0.063 (0.046–0.081); AIC = 126.73]. Cronbach’s alpha  was carried out  to confirm the unidimensional model proposed by the original authors. However, the model was not good ; the estimated values of standardized regression weights are within the reference values (between 0.54 and 0.71). Cronbach’s alpha of the total is 0.83 and no item, if removed, increases Cronbach’s alpha. Also, in the parallel analysis, only 1 component had an eigenvalue above the 95th percentile of eigenvalues of 1000 random datasets of the same dimension. After consulting the modification indices, three correlations between errors were suggested and established and a very good model was found . Cronbach’s alpha coefficients (0.83) composite reliability (0.88), average variance extracted  and square root of AVE (0.71) were calculated, being the values within the reference range. Mean (1.85) and standard deviation (0.87) were also calculated.A confirmatory factor analysis (CFA) was carried out (N = 773) to confirm the unidimensional model proposed by the original authors. However, the model was not good ; the estimated values of standardized regression weights are within the reference values (between 0.65 and 0.83). Cronbach’s alpha of the total is 0.87 and no item, if removed, increases Cronbach’s alpha. Also, in the parallel analysis, only 1 component had an eigenvalue above the 95th percentile of eigenvalues of 1000 random datasets of the same dimension. After consulting the modification indices, two correlations between errors were suggested and established and a very good model was found . Cronbach’s alpha coefficients (0.87) composite reliability (0.91), average variance extracted  and square root of AVE (0.82) were calculated, being the values within the reference range. Mean (2.10) and standard deviation (1.25) were also calculated.A confirmatory factor analysis (CFA) was carried out (N = 773) to confirm the unidimensional model proposed by the original authors. It was found a very good model ; the estimated values of standardized regression weights are within the reference values (between 0.70 and 0.75). Cronbach’s alpha of the total is 0.76 and no item, if removed, increases Cronbach’s alpha. Also, in the parallel analysis, only 1 component had an eigenvalue above the 95th percentile of eigenvalues of 1000 random datasets of the same dimension. Composite reliability (0.86), average variance extracted  and square root of AVE (0.82) were calculated, being the values within the reference range. Mean (1.56) and standard deviation (0.82) were also calculated.A confirmatory factor analysis (CFA) was carried out  and 0.535 (between Flaming and Trolling); besides, all variables have a normal distribution and absence of multicollinearity .r = −0.420; p < 0.001), Dirty Dozen Dark Triad Machiavellianism , psychopathy , narcisism , cyberstalking total , cyberstalking justification , cyberstalking time , online harassment , flaming behaviors , and trolling behaviors . Years of education correlate positively and significantly with Dirty Dozen Dark Triad narcisism  and with cyberstalking justification .Age correlates negatively and significantly with almost all the psychological variables: Internet Addiction  = 2.30; IFI = 0.997; TLI = 0.984; CFI = 0.997; GFI = 0.998; SRMR = 0.013; RMSEA = 0.041 (0.000–0.092); AIC = 30.60]. Also, Machiavellianism, Psychopathy and Narcissism were indirectly associated with addiction to Internet through online behaviors.To achieve this moderation, an index of online behaviors  was developed. The results of the moderation  showed tThe main objective of this study was to assess the moderation effects of online behaviors between personality traits and Internet addiction. Thus, several specific objectives were delimited. The first objective was to evaluate the psychometric qualities of the instruments used in this study by assessing the fit to our sample of instruments previously validated for the Portuguese population (Internet Addiction Test and Dirty Dozen Dark Triad), and the validation for the Portuguese population of the Cyberstalking scale, Online Harassment scale, Flaming scale and Trolling scale. The results reveal good psychometric properties for the four validated scales, which allowed us to continue with our objectives.As for the Cyberstalking scale, in the present study the one-dimensional structure was not verified, and it was found three factors were named cyberstalking control (includes items that monitor the other’s online behavior); cyberstalking justification  and cyberstalking time . The alpha values found are close to the original scale. One of the advantages of this scale is that it considered not only romantic relationships , but also included persecution of acquaintances and people that the perpetrator suspects/dislikes .Relatively to the Online Harassment scale model found, it is in line with the proposal of the original authors . As for The adaptation of these instruments may constitute a contribution to research in the context of these online antisocial behaviors  in a Portuguese context; the results that individuals obtain in the analyzed behavior can be related to other variables that help to understand the complexity of it.The second objective was to establish associations between the variables under study and the sociodemographic variables. The results show that age correlates negatively and significantly with most of the psychological variables, namely: Internet addiction, Dirty Dozen Dark Triad Machiavellianism, psychopathy, narcissism, cyberbullying total, cyberbullying justification, cyberbullying time, online harassment, flaming behaviors, and trolling behaviors. That is, as a person age they exhibit fewer problematic online behaviors. This can be explained due to exposure to technology from a very young age, it may be that older people have less technical competencies to use the Internet and especially social networks. In this sense, most investigations indicate that younger individuals tend to be more Internet addicts , with agConcerning the years of education, they are positively and significantly correlated with the Dirty Dozen Dark Triad narcissism and with the justification of cyberbullying. With respect to the sex variable, Machiavellianism, psychopathy and narcissism are significantly higher in men than in women. The same is true for flaming and trolling. Cyberstalking justification and time, as well as online harassment show higher values in women than in men. These results contrast with other results that find similar values for men and women . AlthougThe third objective was to search for relationships between personality traits and online behaviors. The results of our study show that Machiavellianism is positively associated with all dimensions of the studied variables. Psychopathy is positively associated with cyberbullying total, cyberbullying control, flaming and trolling; and narcissism was positively associated with most dimensions, except with online harassment and flaming. These results are in agreement with other studies showing similar results ,16,20. FFor its part, narcissism is associated with online self-promotion behaviors and trying to be more popular, which can cause problematic Internet use ,32,38,39Psychopathy has been associated with cyberbullying, trolling, intimate partner cyberbullying, and violent gaming ,20,32. TAnd finally, the last objective was to determine whether dimensions of the dark triad of personality explain online behaviors and these last moderates the relation between dak traid and Internet addiction. Our results reveal that Machiavellianism, Psychopathy and Narcissism are associated with Internet addiction through online behaviors. These associations reinforce the behavioral characteristics of these individuals and how they may behave on the Internet, allowing us to suggest that dimensions of the dark triad of personality explain online behaviors ,38,39,63The results of this study have theoretical and practical implications, since, on the one hand, they reinforces the findings of other studies showing that dimensions of the dark personality triad play an important role in Internet and social network addition ,21, contDespite these results, some limitations should be addressed, namely, the use of self-report instruments that may somehow influence the data obtained, being susceptible to arbitrariness of responses, subjectivity of participants in the perception of content and tendency to give socially desirable answers. Additionally, the cross-sectional nature of the study is highlighted, which leads to the impossibility of establishing cause and effect relationships between the variables.Future studies may investigate the issue of Internet dependencies versus Internet dependency, to understand whether the addition, when occurs, is originated in relation to activities on the Internet  or if it is in relation to the Internet itself. Future investigations should continue to study the addition to the Internet and online antisocial behavior including specific samples of clinical/forensic context, involving individuals with diagnoses of personality disorders that constitute the Dark Triad.


The research indicated that skipping breakfast was considered a risk factor for obesity . After adjusting for age, gender, area, and grade and continuing to adjust for sleep duration and physical activity, the results showed that consuming fried food at least once a day increased the risk of obesity . This study found that the frequency of breakfast and the consumption of fried food, fresh vegetables, and fruits were not significantly associated with being overweight (p > 0.05). Conclusions: This study indicated that dietary behavior was related to overweight and obesity among Ningbo students. Further studies and more government support are required to confirm this study’s findings and address the current overweight/obesity problems.Objectives: To investigate the prevalence of overweight and obesity among Ningbo students and explore the association between students’ dietary behavior and overweight and obesity. Materials and Methods: A total of 7299 students were recruited, including 3755 males and 3544 females. A questionnaire on student health status and influencing factors was used to investigate dietary behavior. Logistic regression analysis investigated the relationship between dietary behavior and overweight and obesity. Age, gender, area, grade, sleep duration, and physical activity were adjusted in the multivariate regression models. Results: This study revealed that the prevalence of overweight and obesity in Ningbo students was 16.14% and 9.88%, respectively. The logistic regression analysis results showed that regular consumption of sugary beverages was associated with a higher risk of being overweight (OR = 1.256, 95% CI: 1.023–1.542,  Obesity is a complex, multifactorial, noncommunicable disease defined by excessive adiposity . Over thWith the increasing burden of childhood OW/OB, there is an urgent need for early identification and control of its occurrence and development, which is the key to prevention and control. OW/OB results from a combination of several factors, including genetics , environOur study was based on the National Monitoring and Intervention Project on Common Diseases and Health Influencing Factors among Students and explored the association between students’ diet and OW/OB. This study aimed to provide a scientific basis for dietary habit-related interventions to prevent OW/OB in schoolchildren.This study was a population-based and cross-sectional study based in Ningbo, Zhejiang, China, from 2019 to 2021, using multistage stratified cluster random sampling. One urban and one rural area were randomly selected in 2019 and 2020, respectively. Two urban areas and one county were selected in 2021. Five schools  from the urban area and three (two middle schools and two high schools) from the rural area were randomly selected. Then, classes were randomly selected in the school, and investigations were conducted on the whole class, with at least 80 students selected from each grade. A total of 7299 students were enrolled in our study. All participants’ parents or legally authorized representatives signed informed consent forms, and the Ethics Committee of Ningbo Centers for Disease Control and Prevention approved this study .The survey was based on the National Monitoring and Intervention Project on Common Diseases and Health Influencing Factors among Students. A self-reported questionnaire estimated the students’ dietary behavior. The School Health Center of China Center for Disease Control and Prevention drafted, validated, and distributed the questionnaire. The questionnaire investigation was conducted with the class as a whole by professionally trained investigators, including the students’ basic information ; eating habits ; and life behavior . The consumption of sweetened beverages, fried food, fresh fruits, and vegetables was identified by asking the students, “How many times have you consumed sweetened beverages/fried food/fresh fruits/vegetables in the past seven days?”. The frequency of breakfast eating was identified by asking the students “Do you have breakfast every day in the past seven days?”.Students’ physical examinations were scheduled on an empty stomach in the morning. In the daily examination, the retested objects were randomly selected in a proportion of 5%. The original examiner retested the physical examinations to test the error, and the allowable range of the test error was 0.5 cm for height and 0.1 kg for weight. OW/OB was distinguished according to the “Body mass index reference norm for screening overweight and obesity in Chinese children and adolescents” ,24.p value of <0.05 was considered statistically significant.The data of this study were established using EpiData 3.1 and analyzed by SPSS 19.0. The characteristics of the study subjects were described by the mean and standard deviation for continuous variables and by numbers and percentages for categorical variables. Logistic regression models were used in this study to investigate the association of the frequency of breakfast eating , the consumption of sweetened beverages , fried food , fruit , and vegetables  with OW/OB. The odds ratios (ORs) and 95% confidence intervals (95% CIs) were used to assess the risk of OW/OB. Multivariable-adjusted Model 1 was adjusted for age, sex, area, and grade, and Model 2 was further adjusted for sleep duration and physical activity based on Model 1. GraphPad Prism 8 was used to draw the forest plot. A The general characteristics of the study participants are shown in p < 0.001), more likely to be males (p < 0.001), junior middle school students (p < 0.001), and had physical activity between 1 and 2 h a day (p = 0.040).There were 1178 students with OW and 721 students with OB, and the OW and OB rates were 16.14% and 9.88%, respectively. Students with OW/OB were younger (p = 0.197), breakfast skipper (p = 0.422), and regular breakfast eater (p > 0.05). Then, we studied the association between the frequency of consumption of sugary beverages and OW (p > 0.05). However, regular drinkers were at a higher risk of OW than nondrinkers , which remained statistically significant after adjusting for age, sex, area, and grade  and further adjusting for sleep duration and physical activity .st eater A. Similast eater B, fresh st eater C, and frst eater D, it wass and OW E. The rep = 0.675). However, the OB rate of breakfast skippers was significantly higher than those of regular breakfast eaters . In multivariable-adjusted models, breakfast skippers still reported a higher risk of OB . In the analysis of the association between eating fried food and OB (p = 0.026). After continuing to adjust for sleep timing and exercise , the students who ate fried food at least once a day continued to have a higher risk of OB. Then, this study analyzed the frequency of eating vegetables (p > 0.05). Finally, in the relationship between the frequency of consumption of sugary beverages and OB (p = 0.308). However, regular drinkers were at a higher risk of OB than nondrinkers , which remained statistically significant after adjusting for the variables .In d and OB B, after getables C and fregetables D and thes and OB E, the reThe World Health Organization has defined OW/OB as an epidemic . Childhop < 0.001), which was consistent with our research [Our study also observed gender differences in the prevalence of OW/OB in students, with a higher proportion of boys with OW/OB than girls. According to Chen et al.’s research in Chongqing, China, the overweight and obesity rates of boys in children (aged 6–12 years) were higher than those of girls (15.97% vs. 10.51%, 12.33% vs. 4.53%, research . The samresearch ,43. Thisresearch . Compareresearch . Unlike Dietary factors are another vital factor affecting OW/OB in children and adolescents . In thisThe strengths of this study were that it included a relatively large number of research subjects from several different schools and years and adjusted for possible confounding factors. However, this study still has certain limitations. First, as this is a cross-sectional study, it is essential to note that the associations observed may be bidirectional, and there is no clear evidence of the results. Second, in this study, dietary factors were estimated using a questionnaire to investigate the frequency of consumption, which may be affected by recall bias. The specific dietary intake such as other sugary foods that play an important role in overweight and obesity, was not considered in this study, which may cause some errors in evaluating the results. Moreover, different definitions of overweight and obesity in children and adolescents have been used in China and other countries, which add complexities to making comparisons across studies . TherefoIn summary, the rate of children and adolescents with OW/OB in Ningbo is relatively high despite the government implementing a health education program and issuing dietary guidelines to counter the threat of OW/OB. These measures aim to increase people’s knowledge of nutrition, promote the development of healthy dietary patterns, and maintain a healthy lifestyle. Despite progress in preventing OW/OB in children and adolescents, key factors that must be addressed remain uncertain. Among students, we should pay attention to boys and junior high school students, especially those with frequent consumption of sugary drinks, skipping breakfast, and regular fried food. Health education for children and adolescents should be strengthened, and healthy dietary habits should be developed. At the same time, nutrition knowledge for parents should also be emphasized to control the risk of OW/OB in children and adolescents.The prevalence of overweight and obesity among children and adolescents in Ningbo was relatively high, and the frequency of consumption of breakfast, fried foods, and sugary beverages was related to overweight/obesity. Further studies and more government support are required to confirm the findings of this study and address current overweight/obesity problems. Health education should be strengthened for students, parents, and schools to change their dietary habits and prevent and control the occurrence and development of OW/OB.


The study population included pediatric patients with anaphylaxis. This population was stratified based on whether they had asthma. (3) Results: The number of hospital admissions was stable from 2016 to 2019, dropping in 2020 and raising to the highest number in 2021. A total of 60.63% of hospitalizations occurred in boys and the most common anaphylactic reactions were due to food consumption (67.28%), increasing over time. The in-hospital mortality (IHM) remained stable and under 1% in all the years studied. The incidence of anaphylaxis was 2.14 times higher in children with asthma than in those without asthma . Furthermore, it was 1.79 times higher in boys with asthma than in those without asthma  and 2.68 times higher in girls with asthma than in those without asthma . Asthma was not associated with severe anaphylaxis . (4) Conclusions: The number of hospitalizations for anaphylaxis in children remained stable from 2016 to 2019, dropping in 2020 and recovering in 2021. IHM was low and remained stable during the study period. The incidence of hospitalizations for anaphylaxis was higher in asthmatic children than in non-asthmatics, but there were no differences in the occurrence of severe anaphylaxis among them. Anaphylaxis is a serious, potentially life threatening, allergic reaction that is triggered suddenly by exposure to specific allergen substances ,2,3,4. IEpidemiological factors associated with anaphylaxis vary with age, culture and lifestyle . Food haBetween 11% and 38% of children who experienced anaphylaxis have a history of asthma or recurrent wheezing . HoweverDespite the substantial burden that this problem produces in the pediatric population, data concerning the characteristics of anaphylaxis in children in Spain are spare and they are not updated ,15. StudAn observational, retrospective study (from 1 January 2016 to 31 December 2021) was conducted using a population-based database, the Minimum Basic Data Set of Specialized Care Activity Registry (RAE-CMBD in Spanish). The RAE-CMBD, owned by the Spanish Ministry of Health (SMH), records individual information of all patients admitted to Spanish hospitals. The collected information includes sex, age, admission date, discharge date, diagnoses (up to 20), procedures (up to 20), and discharge destination  [The study population included pediatric patients (17 years old or younger) with an ICD-10 code for anaphylaxis in any diagnostic position within the RAE-CMBD. Subsequently, this population was stratified based on whether they had an asthma code in any diagnostic position within the RAE-CMBD. Hospitalized patients with lacking data for age, sex, dates of admission and/or discharge and discharge destination were excluded.Different types of anaphylactic reaction triggers were recorded: food, drugs, serum, or unspecified, according to the ICD-10 coding methodology.The use of mechanical ventilation (invasive and non-invasive), codified in any position in the RAE-CMBD procedure field, was also analyzed .Admission to the ICU refers to being admitted to the intensive care unit during hospitalization with anaphylaxis for at least 24 h. In-hospital mortality (IHM) was the proportion of deaths during hospitalization. A child with severe anaphylaxis was defined as someone who required admission to the ICU and/or died during hospitalization.The incidence of hospitalization with anaphylaxis per 100,000 children with and without asthma was calculated for each of the six years analyzed. Incidence rates were calculated based on the Spanish pediatric population with asthma, grouped by age and sex, according to the National Health Survey of 2016/2017 [A descriptive statistical analysis was conducted, categorical variables were expressed as frequencies and percentages, and for quantitative variables, mean and standard deviation were provided.t-test or Jonckheere-Terpstra test for continuous variables.Temporal trends were analyzed using Cochran–Mantel–Haenszel statistics or the Cochran–Armitage test for categorical variables, and linear regression t-test or Mann–Whitney test, as necessary.Categorical variables were compared using Fisher’s exact test, and continuous variables were compared using Multivariable logistic regression was used to identify variables associated with severe anaphylaxis among children with anaphylaxis according to asthma status. The models were constructed, including sex, age, year, reaction triggers and use of mechanical ventilation. The results of these models are presented as odds ratios (OR) with 95% CI.p-value of <0.05 (two-tailed) was considered significant.Statistical analysis was performed using Stata version 14 software . A According to Spanish legislation, written consent from patients or evaluation by an ethics committee is not required since the RAE-CMBD is an administrative, mandatory, ammonized registry, and its data can be requested online to the SMH . The SMHAs can be seen in Of all the hospital admissions, 60.63% occurred in boys, with a mean age of the study population of 6.77 years.The most common anaphylactic reactions were due to food consumption (67.28%), followed by drug consumption (12.98%) and serum consumption (3.03%). Unspecified reactions were codified in 16.95% of the cases.The need for mechanical ventilation was infrequent, with overall values of 2.68% for invasive and 1.32% for noninvasive, respectively.Among the children diagnosed with anaphylaxis from 2016 to 2021, 10.57% were admitted to the ICU, and the IHM rate was 0.66%. Severe anaphylaxis, defined as either admission to the ICU or IHM, occurred in 10.77% of the children.As indicated in p < 0.001) and reactions associated with drug consumption . However, non-specific reactions decreased over the study period . Between 2016 and 2021, there was a significant increase in reactions associated with food consumption , as observed in The use of non-invasive mechanical ventilation increased in children with anaphylactic reactions between 2016 and 2021  of cases and remained stable overtime .p < 0.001) and a similar sex distribution.Children with asthma had a higher mean age than children without asthma  were more frequent among children with asthma, but fewer reactions due to drug consumption  were found, as shown in Anaphylactic reactions due to food consumption . Reactions associated with drug consumption increased in the group of non-asthmatic children (8.36% in 2016 vs. 12.01% in 2021). However, non-specific anaphylactic reactions decreased in both asthmatic children  and non-asthmatic children . Both in children with and without asthma, reactions associated with food consumption significantly increased over the study period  in the group of non-asthmatic children between 2016 and 2021, as indicated in The use of non-invasive mechanical ventilation significantly increased (p = 0.004). However, the frequency of severe anaphylaxis decreased (p = 0.006). In children with asthma, over the study period, ICU admissions, in-hospital mortality, and the frequency of severe anaphylaxis remained stable, as shown in In non-asthmatic children, the frequency of ICU admissions increased over the study bperiod , whereas in patients without asthma, it was in the age group between 0 and 5 years (45.48). After using the Poisson regression model, adjusted for age and sex, it was found that the incidence of anaphylaxis for the period 2016–2021 was 2.14 times higher among children with asthma than among those without asthma .p < 0.001) compared to the other age groups (0–5 years old and 6–11 years old). Additionally, they had more admissions to the ICU (p = 0.001) and more severe anaphylactic reactions (p = 0.002), as indicated in When comparing the characteristics of anaphylaxis admission based on age groups, patients without asthma, aged between 12 and 17 years, had fewer reactions associated with food consumption and more reactions associated with drug consumption and non-specific reactions  and 2.68 times higher in girls with asthma than in those without asthma .p = 0.004). Additionally, girls had significantly fewer reactions associated with food consumption . In patients with asthma, only the use of non-invasive mechanical ventilation was higher in boys than in girls (p = 0.035). The rest of the study variables presented similar values between boys and girls, as indicated in When comparing admission characteristics by sex, it was observed that in those without asthma, the mean age of girls was higher than that of boys  were risk factors associated tor severe anaphylaxis.After adjustment, severe anaphylaxis was significantly higher in the study population in years 2017, 2018, 2019, and 2020 compared to the year 2016.Finally, when using the non-asthma status as the reference category, the analysis of the entire database revealed that the presence of asthma was not associated with severe anaphylaxis .Our study provides new data regarding anaphylaxis among children. We reported that the number of hospital admissions for anaphylaxis in children remained stable from 2016 to 2021. Previous studies investigating trends in anaphylaxis hospitalization among children have reported conflicting results. Agreeing with us, Robinson et al.  found thDeclining trends have been reported by Motosue et al.  who showFinally, increments in hospitalizations have been published by Dyer et al. , who desThe underlying reasons for the stable trends in anaphylaxis hospitalizations in children obtained in our study are not known. We do not believe that our findings are due to a decline in prevalence of anaphylaxis. In fact, recent studies on the trends in prevalence of anaphylaxis and food allergy support a rising prevalence . It is lWe also found a drop in the number of hospital admissions for anaphylaxis in 2020, coinciding with the start of the COVID pandemic, which was recovered in 2021. The decrease in the frequency of anaphylaxis at the start of the pandemic has been described by other authors , as wellOur data showed that anaphylaxis hospitalization was more likely in male than in female children. These results are consistent with those reported by the majority of previous studies ,29. RegaSevere anaphylaxis requiring ICU admission is a rare event and difficult to study since the number of affected patients is usually small . We idenConsistent with other studies , we founAsthma seems to be associated with the risk of anaphylaxis. In the current study, the incidence of hospitalizations for anaphylaxis was higher in asthmatic children than in non-asthmatic children. González–Pérez et al.  also demThe relationship between asthma and severe anaphylaxis is controversial. Despite asthma having been identified as a risk factor for severe anaphylaxis ,39,40,41This study has several potential limitations. First, we used administrative data, which are susceptible to coding errors and diagnostic misclassification. Therefore, we lack detailed information on the clinical criteria for diagnosing anaphylaxis. However, in Spain the medical societies recommend using the Guidelines of the European Academy of Allergy and Clinical Immunology . Second,The strengths of this study include the use of a large, nationally representative database, with a 6-year study period, which provides the ability to study trends of anaphylaxis in Spain over time. In addition, we used rigorous methods to select the study population and meticulous data analysis to measure outcomes.In summary, using nationally representative data, we found that the number of hospitalizations for anaphylaxis in children remained stable from 2016 to 2019, with a drop in 2020 and recovery in 2021. Anaphylaxis hospitalization was more likely in male children, and food was the most common cause, increasing over time. IHM was low and remained stable during the study period. On the other hand, the incidence of hospitalizations for anaphylaxis was higher in asthmatic children than in non-asthmatics, but there were no differences in the occurrence of severe anaphylaxis among them. Increased knowledge regarding the epidemiology of pediatric anaphylaxis in children may contribute to improve its management.


Acute pancreatitis (AP) is associated with a high incidence of acute kidney injury (AKI). This study aimed to develop a nomogram for predicting the early onset of AKI in AP patients admitted to the intensive care unit.Clinical data for 799 patients diagnosed with AP were extracted from the Medical Information Mart for Intensive Care IV database. Eligible AP patients were randomly divided into training and validation cohorts. The independent prognostic factors for the early development of AKI in AP patients were determined using the all-subsets regression method and multivariate logistic regression. A nomogram was constructed for predicting the early occurrence of AKI in AP patients. The performance of the nomogram was evaluated based on the area under the receiver operating characteristic curve (AUC), calibration curves and decision curve analysis (DCA).Seven independent prognostic factors were identified as predictive factors for early onset AKI in AP patients. The AUC of the nomogram in the training and validation cohorts were 0.795  and 0.772 , respectively. The AUC of the nomogram was higher compared with that of the BISAP, Ranson, APACHE II scores. Further, the calibration curve revealed that the predicted outcome was in agreement with the actual observations. Finally, the DCA curves showed that the nomogram had a good clinical applicability value.The constructed nomogram showed a good predictive ability for the early occurrence of AKI in AP patients. Acute pancreatitis (AP) is a common disease of sudden onset. The disease has a diverse clinical course that ranges from mild, to moderate to severe acute pancreatitis (SAP), with a high mortality rate of 36–50% . The patAP patients were obtained from the Medical Information Mart for Intensive Care-IV 1.0 (MIMIC-IV v1.0) database . The MIMThe use of data from the MIMIC-IV database was approved by the Institutional Review Board of the Beth Israel Deaconess Medical Center and Massachusetts Institute of Technology. Since the data were deidentified, there was no requirement for informed consent. To access the database, we first completed the required online courses and an examination (Record ID: 42039823).https://github.com/MIT-LCP/mimic-code/tree/main/mimic-iv) [Data were extracted using Structured Query Language (SQL) programming in PostgreSQL (version 14.0), and the SQL script codes used to extract patients' information were obtained from the GitHub website (imic-iv) .Using the International Classification of Diseases (ICD), ninth revision  and tenth revision , we identified the patients diagnosed with AP from the MIMIC-IV v1.0 database. The exclusion criteria were age less than 18 years old and intensive care unit (ICU) stay < 24 h and patients with a history of chronic renal failure, including a previous history of a kidney transplant. For patients who had multiple admissions to the ICU, data were only obtained from the first admission.After identifying eligible patients, we collected AP patient’s baseline parameters immediately after admission to the ICU, including demographic information, previous medical history, vital signs, laboratory indicators, injury factors, interventions, and disease severity scores. The vital signs and laboratory indicators are the first value within the first 24 h after ICU, and intervention measures and the severity scores of the disease are evaluated within the first 24 h after ICU.The outcome measure was determined as the development of AKI within seven days of admission to the ICU. A diagnosis of AKI was based on the 2012 Kidney Disease: Improving Global Outcomes (KIDGO) guidelines as follows: elevated serum creatinine (SCr) after 48 h by ≥26.5 μmol/L (0.3 mg/dl); or ≥50% of the baseline SCr value (increased by 1.5 times), or a urine output of more than six hours of <0.5 mL/kg/h . BaselinMissing data were common in the MIMIC database. In this study, variables with a deletion rate greater than 20% were excluded. The extracted variables and missing proportions of variables are shown in The patients were randomly assigned to the training cohort (70%) and validation cohort (30%). Subsequently, a nomogram was established based on the training cohort and validated in the validation cohort.t-test was used to compare data between groups with unequal variances. Data with skewed distribution were expressed as median and quartiles and were compared using the Mann–Whitney U test. Furthermore, categorical variables were presented with count (%) and were compared using the 2χ test.Measurement data conforming to the normal distribution and homogeneity of variance were expressed as the mean ± standard deviation. Data between groups were compared using the independent t-test. The unequal variance Due to a large number of variables, the independent prognostic factors were filtered through two steps. First, a preliminary screening was conducted to identify possible predictors using the all-subsets regression method to avoid overfitting and increase the degree of the model. Subsequently, multivariate logistic regression was carried out. A nomogram was then constructed using all the independent prognostic factors.p-value <0.05 was considered statistically significant. Data were analyzed using the Stata software (version 15.1) and R software (version 4.1.0), including tidyverse, mice, caret, leaps, glmnet, rms, pROC, and ggDCA.The nomogram was validated using multiple metrics. The discriminative ability of the nomogram was evaluated using the area under the receiver operating characteristic curve (AUC). The obtained AUC values were compared with AUC values of the bedside index for the severity in acute pancreatitis (BISAP) scores, Ranson scores, and acute physiology and chronic health evaluation (APACHE) II scores. Further, a calibration curve was plotted to evaluate the calibrating ability of the nomogram. Moreover, Decision curve analysis (DCA) was used to assess the clinical significance of the nomogram. A n = 560) and the validation cohort (n = 239). Patients were screened for acute pancreatitis as shown in A total of 799 patients with acute pancreatitis were identified from the MIMIC-IV database. The patients were randomly assigned to the training cohort . See Clinical data of patients in the AKI group were compared to that of patients in the non-AKI group. The results revealed that patients in the AKI group were older, with higher mortality rates and APACHE II, BISAP, and Ranson scores compared with the non-AKI group. In addition, patients in the AKI group were more likely to require mechanical ventilation and renal replacement therapy, use vasoactive drugs, and had longer ICU and hospital stays than those in the non-AKI group. Differences between the AKI and non-AKI groups were statistically significant , need for mechanical ventilation, use of vasoactive drugs, and sepsis as the potential predictors of AKI in AP, after adjusting for the maximum value of R2 (adjR2). See Variables in the training cohort with a Multivariate logistic regression was performed on the seven variables identified in the all-subsets regression. The results showed that age, ethnicity, total bilirubin, activated partial thromboplastin time, need for mechanical ventilation, use of vasoactive drugs, and sepsis were all independent risk factors for early development of AKI in AP patients as shown in Further, a nomogram was constructed based on the results of the multivariate logistic regression. The risk scores for each factor included in the nomogram are shown in D = 5.217, 3.094, 2.109, p < 0.05). The validation cohort had AUC values of 0.772 . In addition, the BISAP, Ranson, and APACHE II showed AUC values of 0.645, 0.680, and 0.717, respectively. The difference was not statistically significant . In the training cohort, the AUC value was 0.795 . Further, the BISAP, Ranson, and APACHE II scores showed AUC values of 0.638, 0.706, and 0.734, respectively. The differences were statistically significant  predicted AKI in AP, which was consistent with findings from a previous study by Shi et al. . StudiesUp to one-third of patients with necrotizing pancreatitis develop necrotic infection . The incCurrently, the APACHE II, BISAP, and Ranson scores are clinically used to predict the prognosis of AP patients in the ICU . there iHowever, this study had some limitations. First, this study was retrospective, and single-centered. Therefore, future studies should be conducted prospectively in multiple centres to improve clinical utility and external validation, respectively. In addition, the nomogram did not include novel biomarkers or imaging results, which could hinder the performance of the model. The model did not include other factors, such as causes of acute pancreatitis, classification of acute pancreatitis, intra-abdominal hypertension and abdominal compartment syndrome that could potentially affect the development of AKI in AP. Third, the sample size of this study is not large, and only internal verification is used to evaluate the accuracy and effectiveness of the model. Future studies should employ large sample sizes, and include more variables to validate our findings.