The prevalence of feline retroviruses in San Mateo County, California was unknown in 2004. Published prevalence in studies worldwide has varied widely, and veterinary guidelines for management of retrovirus-positive cats have not addressed feral cats. This study examined retrovirus prevalence in feral cats presented to a large humane society’s spay/neuter clinic over a 15-year period, in the setting of population trends in the shelter’s total and feral cat admissions, and numbers of cats presented for spay/neuter procedures. The prevalence differed from earlier studies in Florida and North Carolina (higher for one retrovirus and lower for another), even as feral cat and total cat presentations decreased in San Mateo County, suggesting that retrovirus surveillance should continue in this area.p = 0.29) from the first to third period; FeLV prevalence decreased significantly from 1.73% to 0.29% (p = 0.01). Significantly more FIV-positive males than females were identified each year and for each period (p < 0.01). The four largest SMC cities were the major source of feral cats to the Shelter, S/N Clinic, and of FIV- and FeLV-positive cats in the first two periods; in the third period, 50% of feral cats to the Shelter and of FeLV-positive cats were from these cities. Despite a 61.63% reduction in feral cat admissions to the S/N Clinic, the FIV prevalence for males remained similar and increased for females. The retrovirus prevalence suggests the need for continued testing and surveillance of FIV among SMC free-living cats.This study was initiated in 2004 because the prevalence of feline leukemia virus (FeLV) and feline immunodeficiency virus (FIV) infections in feral cats in San Mateo County (SMC) was not known. The cities attributed to the feral cat population presented to the Peninsula Humane Society & SPCA’s Spay/Neuter Clinic and to the Shelter itself were analyzed to examine potential geographic concentrations of feral cats with positive retroviral status. Trends in FIV and FeLV status were examined in three 3-year periods . Population trends over the 15 years of this study for feral cats admitted to the Shelter were also examined. In each study period, more female feral cats were presented to the S/N Clinic . FIV prevalence increased from 5.52% to 6.41% ( San Mateo County (SMC), the high socio-economic status area on the peninsula south of the city and county of San Francisco, California, is a mixed suburban and rural county with 20 incorporated towns and cities . In 2000One method to control the population of outdoor, presumably unsocialized or feral cats is trap-neuter-return or -release (TNR). TNR programs may include testing for feline leukemia virus (FeLV) and feline immunodeficiency virus (FIV), vaccination for upper respiratory viruses (FVRCP) and rabies virus, and microchipping. Ear-tipping has been adopted as a recognized sign to indicate association with established TNR colonies. Cats with ear-tips can be more easily identified, monitored, and released when found in traps without the need to transport them to clinics. TNR programs have been shown to decrease feral cat populations more successfully than wholesale euthanasia and vaccinations reduce the spread of infectious diseases inside and outside colonies and prevent the introduction of new infectious diseases ,6,7,8,9.Peninsula Humane Society & SPCA (PHS) is a large non-profit open-admission shelter that holds SMC’s animal control contract . PHS hasFeLV and FIV are feline retroviruses that vary in clinical presentation and clinical outcomes; over the time of this study, these have been studied and better understood, even as research continues ,17. BrieIn 1993, SMC created a program ,19, fundThis study was initiated in 2004 as the prevalence of FeLV and FIV infections in feral cats in SMC was not known. To elucidate the retroviral prevalence in feral cats in SMC, the cities attributed to the feral cat population presented to the S/N Clinic and to the Shelter itself were analyzed to examine potential geographic concentrations of feral cats with positive retroviral status. Trends in FIV and FeLV status among the feral cats presented to the S/N Clinic were examined in three 3-year periods . Population trends over the 15 years of this study for feral cats admitted to the Shelter were also examined.® SPSS® Statistics, Chicago, IL, USA). Cat information included date of presentation, sex, breed, FeLV and FIV status, color, prior neuter status, presence of tattoos, and medical comments such as pregnancy status and number of fetuses. Caretaker information included initials, zip code and city of residence, and ear-tip preference. Boxes containing the paper records were periodically sent to storage and were not later available to access for this study. Thus, this was a convenience study, based on the records that were available. During the time of this study, the shelter used the SNAP Combo FeLV Ag/FIV Ab test . Between 2001 and 2016, records for all live cats and feral cats presented to the Shelter were provided electronically; for cats identified as feral, information included dates of admission, disposition , and associated city. The Shelter information was obtained to compare feral cat admissions to the Shelter and to the S/N Clinic over the study periods.The S/N Clinic maintains paper records for owned cats, dogs, and other owned animals and for feral cats. From these records, information on feral cats for the three 3-year periods, 2001–2003, 2005–2007, and 2014–2016, was entered into a statistical database for analysis  to test for changes in admissions using Epi-Info  [2MH. The relationships between FeLV and FIV status and sex were compared using the χ2 statistic. Relationships between city of caretaker residents (for the S/N Clinic cats) and city of record (for Shelter cats) were compared for the study periods using the χ2 statistic. The temporal trend in feline admissions to the Shelter was evaluated by linear regression, using Excel . A p-value < 0.05 was considered to be statistically significant.Duplicate identification numbers and record entries for S/N Clinic feral cats were noted and reconciled through inspection, when possible. Because of incomplete records, inconsistencies remained in some of the data; therefore, numbers did not always sum to expected total numbers of cats in various categories. Trends of live cat intake, including feral cats, admitted to the Shelter between 2001 and 2016 and in the three-year periods and to the S/N Clinic were analyzed by the extended Mantel-Haenszel test (χGeorgia) . PrevaleBetween 2006 and 2008, PHS used a mobile van to provide spay/neuter services for dogs and cats in larger cities in SMC and surrounding counties . Feral cOverall numbers of cats presented to the S/N Clinic during the three periods of study were 10,989 (2001–2003); 9787 (2005–2007); and 3293 (2014–2016). The feral cats represented 16.82% (1848); 19.60% (1918); and 21.53% (709) of these cats during the three periods, respectively .p = 0.09 and 0.84, respectively). As 76 of 1848 (4.11%) feral cats had missing information for sex, further analysis was completed for 1772 cats  (p < 0.01 each year and across the period). Four cats, all males, tested positive for both retroviruses. Overall, 22 males, 31 females, and one cat of unknown sex had already been altered, and three cats had tattoos indicating prior spay procedure.Between 2001 to 2003, retroviral status was complete for all cats. For those with retroviral data, 32 (1.73%) and 102 (5.52%) feral cats tested positive for FeLV and FIV, respectively . The prefemales) . Twenty-p = 0.75 and 0.35, respectively). In this period, 816 males, 1098 females, and four cats of unknown sex were presented to the S/N Clinic (p = 0.02). There was a significant difference in FeLV prevalence between males and females in the second period (p = 0.04). FIV-positive prevalence significantly differed between males and females (p < 0.01 for each year and across the period)  and 47 cats (2.45%), respectively. For those with retroviral data, 22 of 1851 (1.19%) and 126 of 1871 (6.73%) feral cats tested positive for FeLV and FIV, respectively . No signN Clinic . FeLV pr period) . Betweenp = 0.52 and 0.85, respectively). In this third period, 318 males, 387 females, and four cats of unknown sex were presented to the S/N Clinic   and 45 of 702 (6.41%) feral cats tested positive for FeLV and FIV, respectively . Again, N Clinic . FeLV-po period) . Informap = 0.01), while the prevalence of FIV increased from 5.52% to 6.41% (p = 0.29)   . In eachor 2015) . Despitep < 0.01).During the three study periods, feral cats were presented to the S/N Clinic from the 15 cities and five towns in SMC and from unincorporated areas of the County, San Francisco International Airport , and several cities outside SMC . It was In the first 3-year period, 30 FeLV-positive cats were associated with nine SMC cities, one FeLV-positive cat from outside SMC, and 101 FIV-positive cats were associated with 17 SMC cities. In the second period, 21 FeLV-positive cats were associated with ten cities and one outside the County. There were 121 FIV-positive cats associated with 17 SMC cities and five with outside cities. In the third period, the two FeLV-positive cats were associated with two cities and none were from outside the County; 38 FIV-positive cats were associated with 16 SMC cities, and seven cats were from outside SMC.The four male cats in the first study period that were both FeLV- and FIV-positive were from four cities in SMC: San Mateo, South San Francisco, San Bruno, and Burlingame. In the second period, the four male cats were from three cities in SMC . The two female cats in this second period positive for both retroviruses were from two of the same cities (Redwood City and San Bruno).p = 0.07), the second period (p = 0.12), or the third (p = 1.00). There was no significant difference between FeLV cats by cities for each sex.There were no significant differences in the overall study period in the proportions of FeLV-positive cats from the four largest cities, compared with the other SMC cities or with the cities outside SMC . There wp < 0.01) (p = 0.83) or the third (p = 0.44). When evaluated by sex, there were no significant differences between FIV-positive female cats by cities. There was, however, a significant difference in the proportion of male FIV-positive cats from the four largest cities compared with the other cities within SMC in the first 3-year period. Specifically, 43 of 65 (66.15%) FIV-positive male cats were from the four largest cities and 22 (33.85%) from the other SMC cities; none were from outside SMC (p < 0.01). In the second and third study periods, no significant differences were found in the proportions of male FIV-positive cats from the four largest cities compared with the other cities inside and outside SMC .There was a significant difference in the proportion of FIV-positive cats from the four largest cities compared with the other cities within SMC during 2001–2003 ( < 0.01) . There wp < 0.01). Few of the feral cats were tested for FeLV or FIV; as such, it would not be meaningful to compare their retroviral prevalence to those of socialized cats in the Shelter tested prior to adoption or to the feral cats presented to the S/N Clinic by feral cat colony caretakers. The sex of the feral cats presented to the Shelter was not recorded.Between 2001 and 2016, 65,616 live cats were admitted to the Shelter. Of these, 8421 (12.83%) were identified as feral . Over thCities associated with feral cats presented to the Shelter between 2001 and 2016 showed a similar pattern as observed for the S/N Clinic. In the first 3-year period, the source cities for 21 feral cats were outside SMC and five from SFO, with unknown city data for the remaining 73 cats in the overnight drop-off. The four largest cities in SMC were primary sources of feral cats admitted (60.96%); these were the same four cities from which the majority of feral cats were presented to the S/N Clinic in this period. Between 2005 and 2007, 54.09% of feral cats admitted to the Shelter were from these four cities. The source cities for 20 feral cats were outside SMC and 24 were from SFO, with 180 cats having no city data. During the third period, 50.00% of feral cats admitted to the Shelter were from the four cities. The source cities for 37 feral cats were outside SMC and one was from SFO.Overall, in the first study period, the four largest cities were the sources of 72.33% of feral cats presented to the S/N Clinic, 83.33% of FeLV-positive feral cats, and 61.39% of FIV-positive feral cats. Correspondingly, for the second study period, the four largest cities were the sources of 55.11% of feral cats, 61.90% of FeLV-positive feral cats, and 60.33% of FIV-positive feral cats. In the third period, these proportions were 45.55%, 50.00%, and 42.10% .The prevalence of FeLV and FIV in feral cats presented to the PHS S/N Clinic differed from prevalence reported at similar clinics in other parts of the country, such as North Carolina and Florida, at the start of this study in 2004; specifically, prevalence was higher for FIV and lower for FeLV . While tp < 0.01) [p < 0.01) [The decrease in Shelter admissions cats  suggests that the availability of spay-and-neuter services in SMC has been beneficial in reducing the overall cat population. While other veterinary services are available in SMC, PHS is the largest provider of services to stray and feral animals in the County. It is likely that this trend in decreasing admissions may be attributed in some part to long-term spay and neuter services and public education. This pattern in reduced admission was also noted in the largest neighboring county shelter, San Jose Animal Care & Control (SJACC) , where f < 0.01) . Of thes < 0.01) . During  < 0.01) . This re < 0.01) .Local small animal veterinarians in SMC also accepted vouchers for spay/neuter between 2001 and 2016. The numbers and FeLV/FIV status of feral cats served by private practice veterinarians in SMC is unknown but is expected to be fewer than those presented to the S/N Clinic, as most of these veterinarians serve socialized cats and other animals through the voucher program. Other rescue organizations providing sterilization services for stray cats opened during the study period; however, given the reduction in feline and feral cat admissions to the Shelter, the reduction in S/N Clinic feral cat admissions cannot be explained entirely by the presence of outside services. The S/N Clinic and the Shelter serve different “populations” of feral cats, namely those with dedicated caretakers and those without advocates beyond the Shelter. Thus, the contemporaneous decrease in their numbers suggests that these reductions are an accurate reflection of SMC’s feral cat population trend. While not all feral cats live in colonies or are trapped, this should be nondifferential across groups. Comparisons between the cities associated with cats presented to the S/N Clinic and the Shelter may not be appropriate, since the S/N Clinic cats’ cities likely reflect the addresses of caretakers, while the Shelter cats’ cities may reflect the sites where the cats were found. The similar proportions of Shelter feral cat admissions from the same cities indicate that caretakers’ cities were a reasonable surrogate for their cats’ locations.The prevalence of FeLV and FIV in specific sites in the United States, Canada, South America, the United Kingdom, Europe, Africa, Australia, New Zealand, and smaller islands has been reported among shelter, stray, and/or identified feral cats ,57,58,59While the euthanasia policy for retrovirus-positive cats being spayed or neutered using a SMC voucher was concerning to some of the colony caretakers at the start of this study, the veterinarians in the S/N Clinic have indicated that feral cats testing positive for FeLV and/or FIV were always sickly in appearance; that is, they did not euthanize healthy-appearing cats simply due to test results and the voucher stipulation. Thus, euthanasia decisions were not made solely on the results of FeLV/FIV testing, but rather on the combination of test results and clinical presentation, and consideration of the welfare of each cat in free-living conditions. Since only cats presented to the S/N Clinic with the voucher were required to be tested and euthanized if positive for FeLV or FIV, other cats that tested positive may have been returned to their colonies. The results of this study agree with the findings of the PBC study that some FIV-positive cats were returned to colonies in the area served by PHS, rather than euthanized at the time of neutering and testing . During Concerns regarding retroviral testing of feral cats in high-volume clinics include the cost of tests, time involved in testing in these settings, additional time required to contact feral cat caregivers to discuss disposition for positive cats, and the perceived reduced likelihood of retroviral spread by virus-positive cats once they have been spayed or neutered. Since the S/N Clinic is a brick-and-mortar facility with spay and neuter procedures arranged via appointments, established costs for these procedures and testing, and information provided to caretakers as part of the appointment process, the first three of these arguments are not applicable. The last argument may be the least valid, since returning a virus-positive cat back into the free-roaming cat population re-introduces the potential for disease spread in a group that is unlikely to receive regular or even sporadic veterinary care. The difference between these approaches can be described as driven by facility, time, and money. In the S/N Clinic setting, testing and euthanizing have not been impacted by these considerations. In a volunteer, weekend, high-throughput feral cat spay/neuter clinic, these matter tremendously. Thus, any decision about whether to test and euthanize must take these factors into account.It must be recognized that simply altering a virus-positive cat does not mean that this cat cannot become a source of infection for cats that have not yet been spayed or neutered, especially in the first weeks following surgery; that is, they may provide a nidus of infection in a colony. The retroviral guidelines of the American Association of Feline Practitioners (AAFP) encourage veterinarians to explain to owners in detail why socialized virus-positive cats should not go outdoors so as to prevent the spread of viruses . Why do The AAFP guidelines have recommended keeping retrovirus-positive cats indoors ,17, whicMicrochips have been recommended for feral cats as a means to reunite these cats with their caretakers and colonies . This haartificially changes the prevalence of disease, and thus improves PPV. For example, suppose that only male cats are tested  and the presumed FIV prevalence among male cats is higher than for females. With increased prevalence, there may be fewer false positives than true positives. Cost savings accrue since the total number of animals tested is reduced; however, there are non-fiscal costs associated with animals that are truly positive for disease that are not tested and re-enter the environment, both for these animals and any with which they come into contact. The decision concerning testing when prevalence is low, or thought to be low, requires a cost–benefit analysis. Without testing, female cats that are positive will not be identified or removed from the population, and may continue to spread disease, albeit passively, through cats that initiate fights with them (FIV) or otherwise have close contact (FeLV). Thus, all tests must be used wisely as just one component of diagnostic or surveillance processes.Some studies have examined the sensitivity and specificity of point-of-care testing for FeLV and FIV . These pBecause feral cats are not routinely evaluated by veterinarians following their TNR experience, it can be argued that returning cats that test positive for FeLV or FIV to their communities may be placing a source of infection into the environment. Certainly many community cat caregivers diligently follow the health of the cats for whom they care; however, this surveillance is passive by design. Thus, the potential for transmission of infection among cats in a community may not be completely eliminated by the TNR experience alone. Humane education and outreach is required to address FIV prevalence in SMC, and it is important that disagreements about managing community cat colonies on the basis of health status be resolved to keep outdoor cats healthy. Enhanced communications among all who work with community cats is required to protect cats from disease. While the more recent AAFP Guidelines regarding FeLV- and FIV-positive cats pertain to owned cats, applying such guidelines to community cats has not be recommended , adding Limitations of this study include incomplete information regarding the feral cats presented to the S/N Clinic, though the proportion of such information was small. Missing or incomplete data in the S/N Clinic data may have contributed to misallocation; however, the records of 4.11% of feral cats were missing in the first 3-year period, with even fewer missing data in the latter two periods. Because the Shelter did not record sex or FeLV/FIV status on admitted feral cats, no disease prevalence comparison was possible with the cats presented to the S/N Clinic in managed feral cat colonies. While the cities were identified with feral cats admitted to the Shelter, the cities listed for cats presented to the S/N Clinic likely represented the caretakers’ residences, rather than the cities of the feral cat colonies they manage; however, education campaigns for spaying and neutering should be directed to populations with feral cats and to feral cat colony caretakers, regardless of where the cats themselves may be.p = 0.29) and the prevalence of FeLV decreased significantly from 1.73% to 0.29% (p < 0.02). The prevalence of these retroviruses was different from those of other populations in earlier U.S. studies and later worldwide studies. For each period of the study, there were significantly more FIV-positive males than females (p < 0.01). Despite a 61.63% decrease in feral cat admissions to the S/N Clinic in the third period, the prevalence of FIV for males remained similar across the years and increased for females. This increasing trend suggests the need for continued testing and surveillance of FIV among free-living community cats in SMC. Enhanced communications among all who work with community cats is required to protect cats from disease. The identification of feral cat population centers with increased retrovirus prevalence in the largest SMC cities can be used to focus attention on surveillance activities and humane education for caretakers in these areas. The impression from early studies that feline retroviral prevalence is low among feral cats in the U.S. has made testing a source of financial and emotional contention. Because some cat caretakers in the area have ceased using the SMC voucher services at the PHS S/N Clinic due to the testing policy, it is important that disagreements about managing community cat colonies on the basis of health status be resolved to keep outdoor cats healthy.Over the three 3-year study periods, the prevalence of FIV increased from 5.52% to 6.41% (


Health literacy is an effective strategy to promote more cost-effective use of health care services and a crucial tool for preventing the spread of infectious diseases. The main objective of this study was to analyze changes in health literacy from 2019 to 2021.Data were from the latest three-round cross-sectional studies with the same study design.Although the prevalence of adequate health literacy rose significantly over time, increasing from 26.9% (95% CI 20.1–33.7) in 2019 to 34.1% (32.9–35.3) in 2021, it was still at a relatively low level. The most significant decrease was observed for health skills among the three aspects and health information literacy among the six dimensions. Working as medical staff was a protective factor for adequate health literacy, health skills literacy, and health information literacy. Risk factors for adequate health literacy and health information literacy were older age and lower education level. Furthermore, adequate health information literacy was positively related to annual family income.More practical and effective policies targeting health literacy for critical aspects and groups in Central China, are urgently needed, especially during the epidemic. As defined by the U.S. National Library of Medicine and the World Health Organization (WHO), health literacy refers to the ability to obtain, understand, and process basic health information and services and use them to make sound health-related decisions to maintain and promote health , 2. HealTherefore, the international emphasis on health literacy is increasing –17. HealResearch on health literacy in North American and European countries mainly focuses on the clinical perspective , 21. WitFrom the perspective of public health, the impact of health literacy on disease prevention, healthy lifestyle and behavior, and maintenance and promotion of health was studied in China . The NatAlthough the definitions, measurement instruments, evaluation perspectives, and survey methods of health literacy are different in different countries or regions, many surveys have come to the same conclusion: Globally, health literacy needs to be improved , 27. TheOn 31 January 2020, the WHO declared the COVID-19 outbreak a Public Health Emergency of International Concern . The panPrevious studies have highlighted the significance of health literacy for the outcomes of infectious diseases and the role that health literacy plays regarding infectious diseases , 34. PeoWuhan is located in central China, with a permanent population of 13.6 million . The maiThe China Health Literacy Survey (CHLS) is a nationally representative household survey of the permanent population aged 15–69 . In conjα was the α-quantile of the standard normal distribution, p was the health literacy level, δ was the maximum permissible error, and deff was the design effect of complex sampling. Considering the rate of invalid questionnaires and rejections, the final sample size is expected to be calculated. The sampling procedure involved five stages to ensure the representativeness of the selected study population. First, the simple random sampling (SRS) method was used to select several administrative districts (six in 2019 and 2020 and five in 2021) from the 15 districts in Wuhan. Second, the SRS method was used in each administrative district to select several streets (four in 2019 and 2021 three in 2020). Third, the SRS method was used in each street to select several neighborhood committees (three in 2019 and 2021 and two in 2020). Fourth, the SRS method was used in each neighborhood committee to select several households . Fifth, one resident was selected from each household using the KISH method, and a certain number of questionnaires were completed in each neighborhood committee .The sample size was calculated by the formula The CHLSQ, as compiled by the China Health Education Center , was useThe total score of 50 items ranged from 0 to 66 points, with one point for every true-or-false and every single-choice question and two points for every multiple-choice question. Moreover, every wrong or missing choice received 0 points. The total scores of the three aspects were 28 , 22 , and 16  points. The maximum total scores for the six dimensions of literacy were 11 points , seven points , 12 points , 14 points , 14 points , and eight points .Adequate health literacy is defined as when participants achieve more than 80% of the total score (53–66 points), and limited health literacy is defined as when participants score <80% of the total score (0–52 points) , 25. TheBefore the fieldwork, the neighborhood committee issued an investigation announcement about the purpose of the study to encourage residents to participate. In the investigation, face-to-face interviews were conducted at each participant's home or in other public places at their convenience. A portable tablet was used to complete electronic questionnaires. If participants could not complete the questionnaire, the investigators would neutrally interview them as an alternative to completing the questionnaire on behalf of the participants. In addition, participants were sent small gifts as an incentive for participating. If the individuals were already participants, they could withdraw at any time without penalty or loss of benefits. Strict quality control was applied to the whole investigative process. Two training sessions were held, and all staff participated and passed the on-site exams. The investigator complied with the investigation guidelines during all processes.We used the following independent variables drawn from the literature in our analysis: , 25, 38 Data cleansing rules were created to ensure accuracy and eliminate internal inconsistencies. The sampling weight was considered since the survey adopted a multi-stage sampling procedure. The three waves of data were weighted: calculation of the sampling weight, non-response adjustment, and poststratification calibration adjustment of the sample totals to the known population totals. All of the analyses were based on a complex survey design. Rao-Scott chi-square tests were used to compare the differences in health literacy among subgroups in bivariate analyses. Cochran–Armitage trend tests were used to measure trends in health literacy over time. Multivariable logistic regression analysis was conducted to identify the risk factors related to adequate health literacy. A two-sided 5% significance level assessed statistical inferences. Data cleaning, weighting, and analysis were conducted using SAS software version 9.4 .The unweighted average ages in 2019, 2020, and 2021 were 46.9 ± 13.4, 49.5 ± 13.7, and 47.8 ± 13.9, respectively. The male:female ratios in 2019, 2020, and 2021 were 0.95:1, 0.94:1, and 0.93:1, respectively. No statistically significant difference was found in the gender or age composition of the participants among the different years.As shown in The level and trend of health literacy, the three aspects, and the six dimensions of literacy over time are presented in In 2021, the lowest prevalence of adequate health literacy of the three aspects was for health skills; the lowest prevalence of the six dimensions was for medical care literacy.In the trend analysis, the most significant increase was observed for healthy lifestyles and behavior (increased 39% in 2020 and 48% in 2021) among the three aspects and infectious disease literacy (increased 101% in 2020 and 99% in 2021) among the six dimensions; the most significant decrease was observed for health skills (decreased 15% in 2021) among the three aspects and health information literacy (decreased 13% in 2021) among the six dimensions.As the most significant decrease was observed for health skills among the three aspects and health information literacy of the six dimensions, they were also included in the multivariable logistic regression analysis along with health literacy .Compared to 2021, the odds of adequate health literacy were significantly lower in 2019. Working as medical staff was a protective factor for adequate health literacy, health skill literacy, and health information literacy compared with other occupations. Risk factors for adequate health literacy and health information literacy were older age (45–69) and lower education level (senior high school and below). Risk factors for adequate health skill literacy were older age (60–69). Furthermore, adequate health information literacy was positively related to annual family income.This is the first study describing the changes over time in health literacy in Wuhan, central China, based on representative three-time-series survey data. We observed that the prevalence of adequate health literacy rose significantly over time, increasing from 26.9% (95% CI 20.1–33.7) in 2019 to 34.1% (32.9–35.3) in 2021. Although the prevalence showed the same upward trend as a previous study  and is sIn 2021, the highest prevalence of adequate health literacy among the three aspects was for basic knowledge and concepts, and the lowest was for health skills. The prevalence of adequate health literacy for healthy lifestyles and behaviors has risen rapidly, and health skills have shown a significant downward trend. In recent years, healthy lifestyle actions have been vigorously carried out, and knowledge of infectious diseases has been spread, effectively promoting healthy behavior . Health In 2021, the lowest prevalence among the six dimensions was medical care literacy. Residents who lack medical care literacy may not be able to access and understand basic health information and services and cannot effectively utilize the complex healthcare system when they seek treatment . From thIn multivariable logistic regression analysis, working as the medical staff was a protective factor for adequate health literacy, health skill literacy, and health information literacy compared with other occupations, which is in line with the characteristics of an occupation engaged in the medical and healthcare industries , 24, 44.Risk factors for adequate health literacy and health information literacy were older age and lower education level, consistent with previous studies , 37, 45.Our study has several limitations that can be improved in further research. First, the study design was cross-sectional, and no causal relationships could be made. Second, some factors, such as health behaviors, and health service quality were not assessed. Third, we obtained data from self-reported items, which are prone to bias. Finally, our research population consisted of permanent residents aged 15–69, and some groups were not included, which should be further studied.This is the first study to characterize the levels, changes, and factors related to health literacy among residents aged 15–69 from 2019 to 2021 in central China. Overall, although the prevalence of adequate health literacy rose significantly, increasing from 26.9% (95% CI 20.1–33.7) in 2019 to 34.1% (32.9–35.3) in 2021, it was still at a relatively low level. In the context of the COVID-19 epidemic, the prevalence of adequate infectious disease literacy rose rapidly, but health skills and health information literacy declined. The protective factor for adequate health literacy, health skill literacy, and health information literacy was working as medical staff, and the risk factors were older age, lower education level, and lower annual family income. Tailored health education and promotion strategies are needed for different subgroups of residents to improve health literacy, especially for health skills and health information literacy. At the same time, medical staff with adequate health literacy can effectively be used by providing health education for people who seek treatment with a poor health status to improve the health literacy of this population.liyilin@whcdc.org.The data analyzed in this study is subject to the following licenses/restrictions: The datasets generated during and/or analyzed during the current study are not publicly available due to restrictions applied to the availability of these data but are available from the corresponding author on reasonable request. Requests to access these datasets should be directed to The processes and sampling design of the survey were reviewed and approved by the Institutional Review Board (IRB) of Wuhan CDC (WHCDCIRB-K-2019016). Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.XM: conceptualization, formal analysis, investigation, data curation, and writing—reviewing and editing. GC, YZ, and QW: formal analysis, investigation, and writing—reviewing and editing. JL: conceptualization, methodology, writing—reviewing and editing, supervision, and project administration. YL: conceptualization, methodology, investigation, writing—reviewing and editing, supervision, and project administration. All authors contributed to the article and approved the submitted version.


Significantly more patients in the CA treatment group were obtunded on presentation but all other baseline parameters were similar between groups. No differences in success , relapse, or death were identified at 1-, 3-, 6-, 9-, 12-, 18-, or 36-month time points. These results do not support treatment with CA (either as a CRI or subcutaneously) at the time of diagnosis in dogs treated with cyclosporine and prednisone.Meningoencephalomyelitis of unknown origin (MUO) is a common disorder of dogs that results in significant morbidity and mortality. The ideal treatment regimen is not known but a second immunosuppressive agent is often utilized in combination with glucocorticoids to increase efficacy and reduce side effects. Recently, a benefit to using a cytosine arabinoside (CA) constant rate infusion (CRI) at the time of diagnosis has been demonstrated. Here, a retrospective study was performed to determine if administration of CA at the time of diagnosis would alter prognosis in dogs receiving cyclosporine and prednisone for treatment of MUO. Medical records of 51 client-owned dogs diagnosed with MUO at one institution were reviewed (2009-2019). All dogs were treated with cyclosporine and a tapering course of prednisone. Twenty-one dogs received a single initial 200 mg/m Meningoencephalomyelitis of unknown origin (MUO) is a clinical diagnosis of non-infectious central nervous system (CNS) inflammation in dogs. It intended to represent a presumptive diagnosis of three histologically described variants of CNS inflammation that are overrepresented in young to middle-aged toy and small breed dogs: granulomatous meningoencephalomyelitis (GME), necrotizing meningoencephalitis (NME), and necrotizing leukoencephalitis (NLE). Although the etiopathogenesis of MUO has not been fully defined, an autoimmune etiology is suspected, and, as such, immunosuppression is the mainstay of treatment. To date, there is no consensus regarding a standard treatment protocol, and the prognosis for long-term survival remains guarded , 2.Glucocorticoids are the cornerstone of treatment for MUO but a second immunosuppressive agent is often added in an attempt to increase efficacy and reduce steroid side effects. Cyclosporine is a commonly prescribed second agent that may prolong survival times when used in addition to glucocorticoids –6. HowevRecent studies have shown that treatment with CA at the time of diagnosis can alter MUO prognosis. Dogs that received a constant rate infusion (CRI) of CA at the time of diagnosis had improved 3-month survival times compared to those that received subcutaneous CA . AdditioIn the retrospective study presented here, all dogs were treated with long-term cyclosporine and a tapering course of prednisone. One group received a single, additional treatment with CA at the time of diagnosis. Medical records were reviewed to determine outcomes at one, three, six, nine, 12, 18, and 36 months. The primary aim was to determine if short-term  relapse and mortality rates were improved with addition of a single administration of cytarabine either intravenously or subcutaneously at the time of diagnosis. Additionally, based on the fact that mortality most commonly occurs within the 3 months following diagnosis of MUO , 10, a sMedical records (2009–2019) were searched to identify dogs with a diagnosis of meningoencephalitis or meningoencephalomyelitis that also received cyclosporine and a tapering course of prednisone ± administration of a CA by CRI or subcutaneous injection at the time of treatment initiation.Toxoplasma gondii, Neospora caninum, and Cryptococcus spp. If serology for infectious diseases was not obtained, patients had to have a successful outcome (no relapse or death) for a minimum of 12 months while receiving immunosuppressive therapy or confirmation of GME, NME, or NLE by histopathology. Cases consistent with ischemic myelopathy  were excluded.Diagnostic inclusion criteria were based on a previous study with minor modifications : (i) ava2 CA either as a CRI over eight to 12 h or divided into four subcutaneous injections given every 12 h. Dogs could not receive additional immunomodulatory therapy unless it was added after diagnosis of a relapse event. A minimum of 36 months follow-up was required.Additional criteria included treatment with cyclosporine (5–12 mg/kg/day) and prednisone (1.0–1.5 mg/kg/day) initiated at the time of diagnosis. Prednisone administration followed a routine tapering schedule of 25% every 4 weeks and was discontinued after every other day administration of 0.2–0.4 mg/kg/day for 4 weeks. Dogs in the CA treatment group had to receive 200 mg/mThe following data were collected from each medical record: (i) signalment; (ii) time to presentation; (iii) history of seizures; (iv) presence or absence of obtundation; (v) complete neurological exams at 1, 3, 6, 9, 12, 18, and 36 months; (vi) MRI features including presence or absence of mass effect, sulci effacement, and transtentorial or foramen magnum herniation; (vii) CSF and infectious disease testing results; (viii) drug dosages, route of administration, and tapering protocol; (ix) survival times; and (x) necropsy results. Neurodisability scores  after initiation of the treatment protocol. Diagnosis of relapse was based on recurrence of clinical signs that necessitated a change in treatment protocol, repeat MRI and / or CSF (where available), and expected response to alterations in treatment. Death was defined by all dogs that died or were euthanized due to clinical signs or complications related to the diagnosis of MUO. Relapse and death were only recorded once for each patient at the time of initial occurrence. Time to relapse, survival times, and change in neurodisability score were also determined as a secondary measure of outcome.U-test. Outcome measures of success and relapse were compared between groups using the chi-square test where all expected cell counts were greater than five. The outcome measure of death was compared between groups using Fisher exact test. Time to relapse and survival times were conducted using Kaplan-Meier plots and were compared between groups by log-rank analysis. Cases that died of causes not related to MUO were censored in the analysis. Statistical significance for all tests was initially set at p < 0.05. To account for the 21 simultaneous independent analyses performed for outcomes measurements , Bonferroni correction was applied resulting in a significance level of 0.0024.Baseline characteristics of dogs from each group were compared. Gender, history of seizures, presence or absence of obtundation, and MRI findings were compared using the Fisher exact test. Age, time to presentation, CSF total nucleated cell count (TNCC), CSF total protein, initial prednisone dose, and cyclosporine dose were compared using the Mann-Whitney p = 0.02) (via CRI in 12/21 patients (57%) and subcutaneously in 9/21 (43%). Necropsy results were available for three dogs and confirmed a diagnosis of GME in two dogs and NME in one dog.There were 21 dogs included in the CA+ group. Represented breeds included eight Maltese, three Chihuahuas, two Boston terriers, two French bulldogs, two miniature pinchers, two mixed breeds, and one each of rat terrier and Jack Russell terrier. There were 29 dogs included in the CA- group. Represented breeds included six Chihuahuas, five mixed breeds, three dachshunds, two French bulldogs, two Jack Russell terriers, two Maltese, two Yorkshire terriers, one affenpinscher, one American shepherd, one Boston terrier, one cairn terrier, one Pomeranian, one shi tzu, one silky terrier, and one toy poodle. There was no significant difference in gender, age at presentation, time to presentation, presence or absence of seizures, neurodisability score, presence of mass effect on MRI, evidence of increased intracranial pressure on MRI, or CSF results. There were significantly more obtunded dogs in CA+ group (43%) vs. the CA- group (13%) ( = 0.02) . There w = 0.02) . Prednisp = 0.35). Overall median survival times could not be calculated for the treatment groups as 16/21 dogs (76%) from the CA+ group and 24/30 dogs (80%) from the CA– group were alive or lost to follow-up at the time of writing; however, the median survival of those dogs had to exceed the follow-up time of 1,095 days. A Kaplan-Meier survival curve was generated for 5/21 dogs in the CA+ and 10/30 dogs in the CA- group that were followed until their death. For these deceased dogs, the median survival for the CA+ group was 555 days  and the median survival for the CA- group was 344 days  (p = 0.84)  . For allWe retrospectively evaluated supplemental use of CA as a single treatment at the time of diagnosis in dogs being treated for MUO with cyclosporine and prednisone. Although relapse and death rates were lower for the CA+ group at all time points, no statistically significant changes in outcome were identified. As such, the results of this study do not support addition of CA to a treatment protocol with cyclosporine and prednisone.There are several study limitations that must be considered when interpreting these results. First, this is a retrospective study, which may have led to falsely elevated survival times. Patients were only included if they were started on a treatment regimen with cyclosporine and prednisone, which likely excluded some dogs that died prior to institution of oral medications. Additionally, although statistical significance was not reached at any time point in our study, investigation with larger case numbers might better elucidate differences in the treatment groups. Bonferroni correction was used to account for multiple simultaneous analyses. Although this conservative correction helps limit type I error, it can also lead to higher rates of false negatives. Other limitations include the fact that histological confirmation of diagnosis was only available in a minority of cases. Also, in the majority of dogs, diagnosis of relapse was based on recurrence of clinical signs and response to changes in therapy. Since numerous neurological conditions respond to treatment with prednisone, it is possible that some dogs with suspected relapse had a separate condition.The findings in this study differ from other reports where majority of death occurs within the first 3 months after diagnosis , 9, 10. Another point to consider is how CA was administered in our study. Administration of CA as a CRI instead of subcutaneously at the time of diagnosis has been shown to improve 3-month survival times . PatientFor future studies, it is probably important to better qualify the impact of relapses on patient and owner quality of life. Multiple relapses were not addressed in this study but it must be acknowledged that not all relapses have the same impact. Many relapses are mild and respond to a minor medication adjustment like increasing the prednisone dose, while others are more severe or occur repeatedly and cause emotional and financial strain for owners.In summary, we failed to identify improved outcomes in dogs with MUO that received a supplemental treatment of CA at the time of diagnosis in addition to treatment with cyclosporine and prednisone. Because there was a trend toward improved outcomes in the CA+ group that did not reach statistical significance, there may be benefit to a prospective, randomized, double-blinded treatment trial that could investigate similar treatment protocols in a larger number of cases.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.RB was responsible for study design and data collection. RB and LD were responsible for manuscript preparation. All authors approved the submitted 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. The handling editor AT, declared a past co-authorship with the author, RB.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.


Calciphylaxis is a grievous life-threatening vascular disease that commonly affects dialysis population. This is the first epidemiological survey of calciphylaxis initiated in China.In the cross-sectional survey, a stratified sampling method was used to select 24 dialysis centers in Jiangsu Province. The participants were all adult patients in each center who had been on hemodialysis for more than 6 months. Calciphylaxis patients were uniformly diagnosed based on characteristic skin lesions and histopathological features.A total of 3,867 hemodialysis patients  were included. Forty eight cases were diagnosed with calciphylaxis, and prevalence was 1.24%. Among calciphylaxis patients, 33 cases were male, and the average age and median dialysis duration were 53.85 ± 15.17 years and 84.00  months, respectively. Skin biopsy was performed in 70.83% of calciphylaxis patients, and positive rate was 64.71%. Meanwhile, the positive rate of bone scintigraphy in the diagnosis of calciphylaxis was 62.5%. The prevalence of hyperparathyroidism in case group was as high as 72.92% with longer duration, and 42.86% had undergone parathyroidectomy. Multivariate analysis indicated that increased BMI, prolonged dialysis duration, warfarin therapy, hyperparathyroidism, diabetes, tumors, low serum albumin and high serum alkaline phosphatase levels were high-risk factors for calciphylaxis.The prevalence of calciphylaxis in Chinese hemodialysis patients was 1.24% according to regional epidemiological survey, but its actual prevalence would be presumably far beyond present data. It's urgent to improve clinical understanding of calciphylaxis, and multifaceted diagnostic methods should be applied for early screening. Calciphylaxis, also known as calcific uremic arteriolopathy (CUA), is a destructive vascular disease that mostly occurs in patients with end-stage renal disease (ESRD). Main pathological features are calcification of the subcutaneous adipose tissue and dermal small blood vessel media, along with intimal fibrosis and thrombosis, which lead to tissue ischemic necrosis , 2. The The epidemiological data of calciphylaxis and its clinical characteristics are of great significance for an in-depth understanding of the disease and exploring diagnosis and treatment plan. It's reported that the estimated annualized incidence of calciphylaxis in maintenance dialysis population worldwide is 1/10,000~35/10,000 . The difIn the cross-sectional survey, a stratified sampling method was used to select 24 dialysis centers in four regions of Jiangsu Province. The subjects were all regular hemodialysis patients in each center, who were older than 18-year-old and had been on dialysis for more than 6 months, excluding some mental disorders, intellectual disabilities, and others who couldn't cooperate with the investigation. And written informed consent was obtained from all participants. This research was approved by the Ethics Committee for Clinical Research of Zhongda Hospital Affiliated to Southeast University , and registered at the Chinese Clinical Trial Registry (Registration number: ChiCTR1900022248).The study used a questionnaire that included demographic information, personal history and comorbidities, history of renal and dialysis-related diseases, CKD-MBD and calciphylaxis characteristics, nutrition and microinflammation status. Clinical medical staffs were selected as investigators and trained in advance for the investigation. With informed consent and cooperation, investigators conducted the interview survey on the subjects during the period of hemodialysis, and registered the relevant data on the Internet. For patients with clinically suspected calciphylaxis, histopathological and imaging examinations should be conducted, which would be uniformly interpreted by the calciphylaxis research team of Zhongda Hospital. For patients who had been diagnosed with calciphylaxis, the data at the time of diagnosis were chosen; for others, the last available data were used. In order to ensure the quality of data, additional personnels were arranged to conduct a review, and the proportion of random inspection was 5% to reduce the generation of invalid data. The study dates were from October 2018 to October 2019.P- values < 0.05 were considered statistically significant. Measurement data conforming to the normal distribution were expressed as mean ± standard deviation ], and comparisons between groups were performed using the Mann-Whitney U rank-sum test. Enumeration data were expressed as number (N) and percentage (%), and unordered categorical variables were compared by Chi-square test or Fisher's exact test, while Mann-Whitney U rank-sum test was used for ordered categorical variables. The odds ratio (OR) and 95% confidence interval (CI) were calculated by univariate and multivariate logistic regression analysis to analyze risk factors associated with calciphylaxis.IBM SPSS Statistics 23 software was used for statistical analysis, and two-sided test As of October 31, 2019, a total of 3,867 questionnaires were obtained in four regions of Jiangsu Province, including 1,093 in Nanjing Region, 951 in Southern Jiangsu, 1,156 in Central Jiangsu, and 667 in Northern Jiangsu . Among 32, of which the highest one was 31.75 kg/m2. Overweight people were more susceptible to have this disease, especially the central calciphylaxis. According to the affected part of skin lesions, calciphylaxis could be classified as central type and peripheral type. Among calciphylaxis patients, 33 cases were male, accounting for 68.75%. And the average age and median duration of dialysis were 53.85 ± 15.17 years and 84.00  months, respectively. As shown in P = 0.002], with the median time of up to 7 years. Although average BMI levels in both groups were within the normal range, the BMI values of patients with calciphylaxis were significantly higher than those in the non-calciphylaxis group . Hemodialysis patients with diabetes or tumors were more likely to suffer from the disease. 72.92% of calciphylaxis patients were complicated with SHPT. The duration of SHPT in the case group was longer than controls , and most of them had undergone parathyroidectomy (PTX) . Albeit only 4 calciphylaxis patients used warfarin therapy, there was still a prominent statistical difference between them and controls . Laboratory examinations indicated that the levels of white blood cells (WBCs) , serum albumin (ALB) , serum alkaline phosphatase (ALP) , serum intact parathyroid hormone (iPTH) , and hypersensitive c-reactive protein (hs-CRP)  were observably different between calciphylaxis and non-calciphylaxis patients.A total of 48 calciphylaxis cases and 3,819 cases without calciphylaxis were enrolled in current investigation. Their baseline data were tabulated in 2 increase in BMI was associated with an increased risk of the disease  (P = 0.002), but no effect on it was observed in immunosuppressive therapy and other treatment measures such as kidney transplantation. In particular, warfarin therapy significantly increased the risk of calciphylaxis . In term of comorbidities, univariate analysis revealed that diabetes mellitus, atrial fibrillation, stroke and tumors were all closely associated with calciphylaxis. SHPT was one of the vital complications of ESRD, which might be involved in the occurrence and development of calciphylaxis . Each additional month of SHPT duration  and PTX  would further increase the risk of this disease. According to blood test results, each 1 × 109/L increase in WBCs level , each 10 IU/L increase in ALP level , each 100 pg/mL increase in iPTH level , each 1 mg/L increase in hs-CRP level , and 1 g/L decrease in ALB level  at the time of diagnosis were markedly correlated with calciphylaxis.As summarized in = 0.001) . There wThe factors identified as significant in the univariate model were incorporated into the multivariate regression model. Since SHPT was correlated with duration of SHPT and PTX, they could not be contained simultaneously in the multivariate analysis. Only SHPT was included as a covariate in the multivariate statistics. The results listed in This is the first epidemiological data on calciphylaxis based on Chinese population, involving 24 hemodialysis centers. The preliminary analysis shows that the prevalence of calciphylaxis in hemodialysis patients is 1.24%. Some patients with “atypical ” calciphylaxis have not been contained in the statistics, hence the actual prevalence is presumably far beyond the estimate. A nationwide survey of hemodialysis centers conducted in Japan observed that <10% of nephrologists mastered the standardized diagnosis and treatment methods for calciphylaxis . As a diCalciphylaxis is considered to be a multifactorial disease, and analyzing its risk factors can provide important clues for disease diagnosis. The calciphylaxis patients in our survey were mainly male, but the effect of gender difference on the incidence of this disease was not observed, which was considered to be related to the high proportion of male in the hemodialysis population. Obesity has been found to be one of the risk factors for calciphylaxis . Though SHPT is a crucial risk factor for calciphylaxis. The prevalence and duration of SHPT in patients with calciphylaxis were higher than those in the control group in current survey, and the median iPTH level at the time of diagnosis was 431.30 pg/mL. This suggests that SHPT is poorly controlled in Chinese calciphylaxis patients, which may be related to the low use rate of cinacalcet. The EVOLVE trial reported that cinacalcet appeared to reduce the incidence of calciphylaxis in hemodialysis patients with moderate to severe SHPT . And cinThe currently accepted diagnostic criteria of calciphylaxis are mainly based on high-risk factors, characteristic skin lesions and histopathological features , 24, so China has a huge number of ESRD patients receiving dialysis treatment, among whom there are quite a few potential calciphylaxis patients. Whereas, Chinese research on calciphylaxis is so insufficient that it's urgent to improve clinical understanding of it. Applying multifaceted diagnostic methods for early screening and strengthening the prevention of the disease are extremely crucial to improve the overall ability of calciphylaxis diagnosis and treatment.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 the Ethics Committee for Clinical Research of Zhongda Hospital Affiliated to Southeast University . The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.Data acquisition: YL, CY, XY, XX, and LZ. Drafting and editing manuscript: YL and XZ. Administrative, technical, or material support: HL, JY, DJ, XZ, and BL. Study supervision and mentorship: XZ and BL. Study conception, design, data analysis, and interpretation: all authors. All authors contributed important intellectual content during manuscript drafting or revision, accepts personal accountability for the author's own contributions, and agrees to ensure that questions about the accuracy or integrity of any portion of the work are appropriately investigated and resolved. All authors contributed to the article and approved the submitted version.This work was funded by the National Natural Science Foundation of China (Grant Nos. 81570612 and 81870497), the Jiangsu Provincial Key Research and Development Program (Grant No. BE2021737), and the Nanjing Health Science and Technology Development Project (Grant No. YKK20237).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.


General anesthesia (GA) is the core means of surgical intervention, mainly used for analgesia and anxiety relief. Therefore, it is necessary to understand the laboratory and clinical research results during induction of GA. Penehyclidine hydrochloride (PHCD) combined with atropine sulfate (Atr) has the potential to induce GA. However, the role of PHCD combined with Atr during tracheal intubation under GA remains unclear.  The research is aimed at exploring the effects of preoperative PHCD or Atr on adverse reactions (ARs) in patients during tracheal intubation under general anesthesia (GA). n = 234) and a control group (n = 239) according to preoperative use of PHCD (with or without). Both groups of patients were given Atr postoperatively and nursing intervention. Anesthesia-related indexes, ARs, and hemodynamics were observed and compared between the two groups.  This study retrospectively enrolled 473 patients who underwent surgery under GA induction and divided them into a research group ( There were no significant differences in anesthesia-related indexes and hemodynamics between the research group and the control group. The incidence of blurred vision and diplopia in the research group was higher than that in the control group.  Preoperative PHCD combined with postoperative Atr should be avoided in clinical practice, or Atr rather than PHCD should be used preoperatively, so as to reduce the occurrence of blurred vision, diplopia, and other ARs. General anesthesia (GA), which is mainly used for analgesia and anxiety relief, is the core means of surgical intervention . AlthougGA involves the initial induction by intravenous sedatives or analgesics and the subsequent maintenance by volatile anesthetics, as well as the postoperative use of antagonists decided based on the patient's condition . Therefon = 234) and a control group (n = 239) according to the preoperative use of PHCD (with or without), and the differences in anesthesia-related indexes, ARs, and hemodynamics were observed. The purpose of this study is to reveal the influence of PHCD plus Atr as well as postoperative Atr plus postoperative Atr on patients during induction of GA, thus providing a reliable research basis for clinical application.PHCD combined with Atr has the potential to induce GA. However, the role of the combination during GA induction remains unclear. In order to explore the effects of preoperative PHCD combined with postoperative Atr versus postoperative Atr plus postoperative Atr on adverse reactions (ARs) in patients with GA, we retrospectively enrolled 473 patients who underwent surgery under GA for analysis. The included patients were divided into a research group (n = 234) and a control group (n = 239) according to whether they were given PHCD preoperatively. In the research group, there were 125 (53.42) males and 109 (46.58) females, with an average age of 53.12 ± 15.97 years and an average body weight of 61.46 ± 11.17 kg. There were 53 (22.65) cases of American Society of Anesthesiologists (ASA) I, 121 (51.71) cases of ASA II, and 60 (25.64) cases of ASA III. The control group consisted of 121 (50.63) males and 118 (49.37) females, with a mean age of 53.02 ± 16.65 years and an average weight of 60.02 ± 13.83 kg. There were 62 (25.94), 126 (52.72), and 51 (21.34) cases of ASA I, II, and III, respectively. There was no statistical difference in age, gender, body weight, ASA score, and other general data between the two groups  was injected intravenously 10 minutes before anesthesia induction to reduce airway secretion. The administration regimen of the control group is as follows: 0.5 mg Atr  was intravenously injected 10 minutes before anesthesia induction. The vital signs of the patient such as noninvasive blood pressure, electrocardiogram, and pulse oxygen saturation were monitored in real time after the patient entered the operating room. Induction plan is as follows: anesthesia induction was performed by intravenous injection of midazolam (0.05 mg/kg), vecuronium (0.8 mg/kg), and propofol (2.0 mg/kg). The patient was intubated 3 minutes after induction. Mechanical ventilation was performed after ensuring correct placement of the patient, with a tidal volume of 8-10 mL/kg, a respiration rate of 12-16 times/min, and a respiratory ratio of 1 : 2.Nursing intervention was carried out from psychological, cognitive, and emotional aspects. Psychological intervention is as follows: the communication between doctors and patients and their families was strengthened before operation, so as to understand the psychological state of patients. In addition, preoperative psychological counseling was given to patients to obtain their trust. Cognitive intervention is as follows: patients and their families were introduced to the basic process of surgery and anesthesia methods, so that patients could understand where they needed to cooperate. Emotional intervention is as follows: the relationship between emotions and diseases was explained from the perspective of biological-psychological-social medical model, and the negative effects of preoperative anxiety, tension, and other negative emotions on the operation were told to the patients' families to obtain their cooperation, all in an attempt to help patients eliminate the negative emotions.Differences in anesthesia-related indexes, including anesthesia induction time, pain disappearance time, and recovery time, were observed in both groupsDifferences in ARs  were observed2), were also observed and compared between the two groupsThe hemodynamic indexes, including heart rate (HR), mean arterial pressure (MAP), and blood oxygen saturation , the difference was considered statistically significant. All comparisons in this study were two-tailed.In this study, the measurement data is recorded as mean ± standard deviation, and the counting data is expressed as the number of cases (percentage). The data were tested for normality using the Shapiro-Wilk test. Independent samples P > 0.05).To determine the role of PHCD combined with Art in GA, we analyzed the anesthesia induction time, pain disappearance time, and recovery time of patients in both groups, and the results are shown in n = 234) and the control group (n = 239), with the results presented in P < 0.0001) and no statistical difference in other adverse events between the two groups (P > 0.05), which indicated that preoperative PHCD combined with postoperative Atr resulted in postoperative blurred vision and diplopia in patients.To determine the safety of PHCH combined with Atr during GA, we counted and compared the ARs between the research group .To further determine the safety of PHCH combined with Atr in vital signs during GA, we statistically analyzed the hemodynamics of the two groups after recovery from anesthesia, and the results are shown in Administration strategies during induction of GA should be cautious. In this study, we retrospectively analyzed 473 patients with surgical treatment under GA and compared the effects of different administration strategies implemented in the research group and the control group on ARs. The results showed that compared with preoperative and postoperative use of Atr, PHCD combined with Atr has no significant difference in anesthesia-related indicators and hemodynamics but may cause blurred vision and diplopia.2) showed no significant difference between the two groups, suggesting the combination of PHCD and Atr did not affect the safety of GA. In other words, PHCD combined with Atr may be feasible during induction of GA. Therefore, preoperative and postoperative medication should be carefully selected in the induction period of GA. For patients requiring preoperative use of Atr, preoperative Atr should be avoided, while for those who have been administered PHCD preoperatively, Atr should not be used postoperatively.As just mentioned, our results indicate that preoperative HPCD and postoperative Atr seem to cause blurred vision and diplopia in patients. Since both HPCD and Atr are anticholinergic agents , 11, we However, our findings may be limited by the sample size. In the follow-up investigation, we will expand the sample size and establish a validation set to verify the conclusions obtained in the present study.To sum up, preoperative PHCD combined with postoperative Atr may cause postoperative blurred vision and increase the risk of diplopia. Considering the possible after-effects of blurred vision and diplopia, we suggest that the combined use of PHCD and Atr should be avoided in clinical practice, or Atr rather than PHCD should be used before surgery, so as to reduce the occurrence of blurred vision, diplopia, and other ARs.


Coriaria myrtifolia, is a neurotoxic plant species endemic to the western Mediterranean area, which forms a nitrogen-fixing symbiosis with members of Frankia cluster 2. Contrarily to other Frankia clusters, the occurrence and mode of dispersal for infective cluster 2 units outside of the host plant rhizosphere remains controversial. The present study was designed to investigate the structure of the microbiomes of C. myrtifolia phytosphere, rhizosphere, and soil samples extending outward linearly up to 1 km. Results showed that the epiphyte and endophyte communities were not significantly different from each other for most of the plant tissues. The communities associated with the below-ground tissues (nodule and root) were significantly different from those found on the above-ground tissues  and had a higher community richness. Coriaria myrtifolia phytomicrobiomes were dominated by Cyanobacteria for leaf, stem, and fruit while Actinobacteria and Proteobacteria were dominant in the root and nodule organelles. The nodule, a special niche for nitrogen fixation, was mainly inhabited by Frankia but contained several non-Frankia bacteria. Beside Frankia cluster 2, the presence of clusters 1, 4, and large numbers of cluster 3 strains have been detected in nodules, roots, and rhizospheres of C. myrtifolia. Despite Frankia being found in all plots using plant trapping bioassays with C. myrtifolia seedlings, Frankia cluster 2 was not detected in soil metagenomes showing the limits of detection by this approach. This result also suggests that in the absence of appropriate host plant species, Frankia cluster 2 has a reduced number of infective units present in the soil outward from the rhizosphere.The actinorhizal plant,  Coriaria myrtifolia is a shrub endemic to the Western Mediterranean found mainly in forests and scrublands  to deepen understanding of the spatial distribution of cluster 2 Frankia strains in the soil nearby (rhizosphere) and more distant from C. myrtifolia trees, as well as spatial patterns of associated soil microbiomes.The objectives of the present study are to investigate (1) whether the wild status of the toxic actinorhizal species. C. myrtifolia plants  H2O2 for 30 min and then aseptically rinsed eight times with sterile water. This first subset of samples represents the endophytic community. A second subset of leaves, stems, fruits, roots, and nodules together with seeds of C. myrtifolia were washed with sterile distilled water several times and were used in the DNA extract process as non-disinfected plant tissues. The second subset of samples represents the epiphytic community. Frankia isolation from root nodules was performed as previously described by C. myrtifolia plants and along 1 km linear series of plots extending from three C. myrtifolia stands. A subset of soils samples was used to inoculate axenic seedlings of C. myrtifolia grown on sterile sand and watered with BD medium (n = 10) were inoculated by adding 10 g of each soil sample. Fifteen non inoculated seedlings were used as negative control. Growth was maintained for 10 months, and roots were checked monthly for nodule formation.The sampling site, “Les Gorges de kharrata Bejaia,” is located in the Mediterranean low-altitude limestone cliffs in Northern Algeria characterized by Rendzina soil under sub-humid bioclimate , which considered is appropriates for rupicolous vegetation . Leaf, sa plants  and placD medium  without Extraction of DNA from surface-sterilized and washed nondisinfected plant tissues was performed using Plant DNeasy kits . For soil samples, the DneasyPowerSoil Kit  was used. Extracted DNA was treated with 0.5 μl of RNase A (10 mg/ml) for 30 min at 37°C to remove RNA from the sample (Qiagen). For each sample, extractions were performed in triplicate. For the nodule samples, three well developed nodules were used per replicate sample.Prokaryotic community profiles from plant organs and soils were investigated using the V4 hypervariable region of the 16S subunit rRNA gene. The products were amplified and sequenced following the Earth Microbiome Project 515F/806R protocol . Paired-The 16S rRNA amplicon sequences of each sample were imported into the Quantitative Insights into Microbial Ecology (QIIME) 2 environment (version qiime2-2017.12) for processing and downstream analysis . DespiteAlpha diversity in each of the four data sets was determined based on observed operational taxonomic units (OTUs) with taxonomies assigned at both the phylum and genus level. The Shannon Diversity Index  was usedFrankia in samples from the roots, rhizosphere, and all three bulk soil types were exported and reassigned to Frankia clade level bins with a custom python script. Specifically, a BLAST database was made using the v4 region of the 45 previously sequenced Frankia strains. The average expect value for alignments between each read and the all the Frankia strain v4 sequences in each clade was calculated. All reads were then assigned to a bin corresponding to the clade with the lowest average expect value for that read. The number of reads in each clade bin was normalized by total reads per sample and used to generate a heat map.After taxonomic assignment at the genus level (QIIME2 taxa L6) was completed in QIIME2, reads assigned to the genus p < 0.05. R was used for all statistical analysis and visualization.For all statistical analyses, the significance of level was set to C. myrtifolia phytomicrobiome, rhizosphere, and surrounding associated soils. Rarefaction curves indicate that the sequencing depth was adequate to capture most of the observable diversity (iversity .p > 0.05). Community richness was significantly higher in roots and nodules than for leaves, stems, and fruit  Rarefaction curves indicate that sequencing depth of the soil and rhizosphere samples was adequate to capture most of the diversity present at the sites , or location (above- or below-ground level). The Bray–Curtis distance metric was determined for the samples and ordinated through NMDS analysis. Proteobacteria, Firmicutes, Acidobacteria, Actinobacteria, and Bacteroidetes were the most differentiating phyla level taxa between C. myrtifolia fruit and leaf tissue communities. Fruit and root communities, fruit and stem communities, leaf and nodule communities, leaf and stem communities, and nodule and root communities primarily differentiated by the same taxa: Proteobacteria, Firmicutes, Acidobacteria, Actinobacteria, and Bacteroidetes. For between the fruit and nodules communities as well as the nodule and stem communities Proteobacteria, Actinobacteria, Firmicutes, Bacteroidetes, and Verromicrobia were the most differentiating taxa. Leaf and root communities in addition to root and stem communities were differentiated most by Proteobacteria, Firmicutes, Acidobacteria, Actinobacteria, and Phragmoplastophyta. Simpler analysis of the C. myrtifolia phytomicrobiome at the genus level showed that Frankia plays a substantial role in differentiating the phytomicrobiomes of specific plant tissues despite being in a low abundance taxon. The genus Frankia was one of the top two most significant taxa characterizing the differences between fruit and nodule, leaf and root, nodule and root, and root and stem communities.Simper analysis showed that Actinobacteria, Proteobacteria, Acidobacteria, Gemmatimonadota, and Bacteroidetes were identified by Simper analysis as the most significant phyla contributing to the community differences found between and among all rhizosphere and soil samples from Algeria.Frankia OTUs by clade level binning  than other soil samples (6 months).Further analysis of the  binning  detectedC. myrtifolia phytosphere is composed of Proteobacteria, Actinobacteria, Cyanobacteria, and Firmicutes as the most abundant phyla. Core microbiomes of several plant species including crops, cultivated, wild, and trees include abundant Proteobacteria, Actinobacteria, and Bacteroidetes together with a slighter fraction of Firmicutes  are detected in A. glutinosa decaying nodules emphasizing their implication in decomposing process  and cluster 4 . Furthermore, Frankia clusters 1 and 3 strains have been shown to dominate or co-dominate in the incompatible host rhizosphere  was observable in the actinorhizal species C. myrtifolia. These rhizocompartiments are characterized by the occurrence of members of all four Frankia clusters. This fact could be possibly linked to the need of C. myrtifolia to a wider diversity of Frankia microsymbionts with diverse growth-promoting potentialities to cope with the harsher challenges of its wild status. Another possible explanation is that the actinorhizal rhizosphere may also be a primary refuge for the proliferation of all Frankia clusters. Further analysis on other actinorhizal species should clarify this phenomenon. Compared to other Frankia clusters, cluster 2 infective units are present in a less extended amount even in the presence of compatible host species. This amount will further drop outward the rhizosphere of its host plants.Neurotoxicity and wild nature of The original contributions presented in the study are publicly available. This data can be found here: NCBI, PRJNA553505, and PRJNA553534.MG, FG-G, HC-S, and LT conceived the study. AK, IS, and ES performed the research. ES, FG-G, HC-S, LT, and MG analyzed the data. MG, FG-G, ES, and LT wrote the manuscript. All authors contributed to the article and approved the submitted version.This material is based upon work supported by the New Hampshire Agricultural Experiment Station, through joint funding of the National Institute of Food and Agriculture, U.S. Department of Agriculture, and the state of New Hampshire. This is Scientific Contribution Number 2947. This project (LST) was supported by the USDA National Institute of Food and Agriculture Hatch 1019869 (LST), the College of Life Science and Agriculture at the University of New Hampshire-Durham, and the Ministère de l’Enseignement Supérieur et de la Recherche Scientifique, Tunisia USCR Bactériologie Moléculaire & Génomique, INSAT-Université de Carthage.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.https://www.frontiersin.org/articles/10.3389/fmicb.2022.1027317/full#supplementary-materialThe Supplementary material for this article can be found online at: Click here for additional data file.


Gross motor skills (GMS) are the foundation for humans reaching an optimum level of motor competence necessary to undergo normal development, maintain health, and achieve athletic excellence. Yet, there is evidence that GMS levels of children are on a decline globally. Therefore, the main purpose of this study was to investigate the effectiveness of traditional cultural games (TCG) skills, practiced according to different amounts of contextual interference (CI), on the acquisition and retention of GMS. A total of 103 Pakistani primary school children aged between 7 and 10 years were recruited for this study. Participants were randomly assigned to four practice groups with different amounts of CI: Block (B) (low interference), gradually increasing (GI) (moderate interference), random (R) (high interference), and game-based (high interference). The Test of Gross Motor Development (TGMD-2) was used to assess four tasks . The test was administered on four occasions: during pre-test, post-test, retention, and transfer. The results showed that the R group outperformed all the other groups in the post-test and the retention test. Meanwhile, in the transfer test, both R and Game-Based groups performed better than the B and GI groups. There were no differences between the R and Game-Based groups during transfer. Practicing TCG skills according to a random order was better for the acquisition and learning of GMS. The CI effect was evident, whereby high interference practice schedules were superior to low and moderate interference practice schedules. Performance of motor skills is beneficial to the overall development of children, including social , physiolBesides these programmes, traditional cultural games (TCG) have also been proposed as an activity for improving motor skills. TCG are games which have developed over time, and have been descended from one generation to another . ThroughThe execution of TCG skills to improve GMS relies on practice. Practice is considered the more important factor to improve permanently the ability to perform motor skills . PracticPittu-Garam is a popular local TCG of Khyber Pakhtunkhwa . The overall mean age of the children was 8.46 ± 1.21 years. A copy of the informed consent form was signed by the children’s parents and the research was carried out according to the ethical guidelines of the Universiti Malaya Research Ethics Committee (Reference number: UM. TNC2/UMREC_1047).In total, 103 healthy, able-bodied primary school children aged 7–10 years were recruited through convenience sampling from two schools located in the Khyber Pakhtunkhwa province of Pakistan. All children had no prior experience playing the TCG (Pittu Garam. The objective of Pittu Garam was to eliminate players and score points by hitting the Pittu (target). In this game, three motor skills are used to achieve the objective of the game, namely, overhead throw, underhand throw, and catch.The practice tasks were based on the Pakistani TCG called Participants were randomly assigned to four experimental groups, each with different levels of CI: (a) Block (B) (low CI), (b) gradually increasing (GI) (moderate CI), (c) random (R) (high CI in a closed environment), and (d) game-based (high CI in an open environment).Pittu (OUTP)] in each of the 18 training sessions. The participants of B, GI, and R groups performed 20 trials of each task per session (4 × 20 = 80/session), amounting to a total of 360 trials for each task by the end of the study.All four groups practiced four tasks using a tennis ball [overhead throw (OT), underhand throw (UT), catch (C), and overhead or underhand throw toward Participants of the B group practiced 20 consecutive trials of one task  followed by 20 consecutive trials of the second task  followed by 20 consecutive trials of the third task , and lastly 20 consecutive skills of the fourth task . The order was counterbalanced across participants. The GI group practiced the first 20 trials of the four tasks in block order , the following 40 trials in serial order  and the last 20 in random order . The R group practiced all 80 trials of each session’s tasks in random order, with no more than two consecutive trials of the same skill.Pittu Garam for 1 h and 30 min per practice session. The field used for Pittu Garam was 80 feet long and 40 feet wide. A centerline was drawn in the center of the field which divided the field into two equal parts. Each team in the GB group consisted of four players.The GB group practiced all four tasks randomly in a game of Pittu. The layout for the tests is shown in Pittu. The scores for these 10 trials were added to provide the total score for the Skill Performance Test. For each test, the minimum score that can be obtained is 0 and the maximum score is 38. The criteria for scoring can be found in Four tasks were assessed: OT, UT, C, and OUTP. TGMD-2  was usedFor the transfer test, three games of four versus four players were played by each of the four groups. The game was played on 40 feet long and 20 feet wide ground between two teams of the same group . All skill tests were videotaped and assessed by the principal researcher according to the TGMD-2 scoring criteria as stated in The duration of the study was 6 weeks (three sessions/week), consisting of 18 practice sessions. One day before starting the commencement of the practice sessions, an introduction of the study was given, including a demonstration of the four tasks . Written cues of the skills were also distributed to the participants. A video of the skills and a game of Participants then underwent 18 practice sessions, whereby each session comprised of the four tasks which were practiced according to the specified order based on their assigned group. All four groups received verbal indications and observational demonstrations of each skill and game at the beginning of each session. Once the participants commenced the practice, no feedback was given. After completing the last practice session, the post-test was conducted following the same format as the pre-test. The following day, the Game Transfer Test was carried out. Four weeks after the last practice session, a retention test following the same procedures as the pre-test and post-test was conducted. All matches of the game transfer test were videotaped. Participants execution of the four skills during the games were later assessed by the principal researcher according to the TGMD-2 scoring criteria as stated in post-hoc comparisons and the level of significance for all SPANOVA and ANOVA analyses was set at alpha = 0.05.Data were analyzed using the Statistical Package for Social Sciences (SPSS) version 23. Four groups  × three time periods  Split-Plot Analysis of Variance (SPANOVA) was used to analyze the Skill Performance Test. Separate ANOVAs were used to follow up significant SPANOVA analysis for each of the three time periods. For the game transfer test, scores were subjected to ANOVA. In all cases, the Bonferroni adjustment had been used for the The breakdown of participants according to their gender and mean age for each group can be found in F = 7.731, p = 0.000, F = 8.959, p = 0.000,  = 0.214. The GB group had a significantly lower score than the other three groups. For the post-test, there was a significant difference between groups, F = 19.00, p = 0.000, F = 37.723, p = 0.000, Using the SPANOVA, it was revealed that there was a significant time and group interaction, F = 11.507, p < 0.001, M = 43.42, SD = 4.27) had a significantly higher score than GI  and B , whilst GB  also had a significantly higher score than GI  and B . Means and standard deviations of the game transfer test for each group are shown in The ANOVA shows that there was a significant difference between groups for the game transfer test, This study aimed to investigate the effectiveness of TCG skills, practiced according to different schedules, on the acquisition and retention of GMS in primary school children. From the skill performance test, the results showed that the random practice schedule had significantly higher scores than the B, GI, and game-based practice condition at the end of practice and retention. This finding corroborates CI literature which found that random practice, with high interference, led to superior learning compared to block practice with low interference . The nonSurprisingly, the GI practice schedule did not outperform the R group. These results contradicted the existing literature regarding the use of moderate CI as a proposed alternative practice schedule to random practice, which causes too much interference and subsequently diminishing performance. For example, reducing the amount of interference with a gradually increasing schedule was found to benefit the learning of a dart-throwing experiment  and a laPittu Garam were also lower than B and GI during the post-test, and no different from the B and GI during retention. This can be explained by the significantly lower pre-test scores of the GB which had much poorer skill technique at the beginning of the study. Although GB had improved over time, the improvements gained were not substantial enough to show enhanced differences from the other groups.While it was hypothesized that GB would perform superior to R, these results were not supported. An earlier study  reportedAside from testing GMS in isolation and within a closed skill environment, this study also focused on the GMS executed in competitive game settings. In the Game Transfer Test, R once again performed better than B and GI, supporting the CI effect even when skills were assessed in a real game environment. In addition, GB also performed better than B and GI, supporting the proposition of game-based practice as an alternate form of random practice.Other studies using lab tasks  have alsLastly, on the use of TCG skills as the intervention task, previous studies have found TCGs to be beneficial within social, ethnic , and culThe findings of this study have several practical consequences. Teachers, coaches, and other school officials must be informed of the prevalence of GMS and its influence on primary school students’ motor development. A valuable aspect is to consider TCG as a dose for the development of GMS using random practice schedules, for school children. TCG has a rich history, in that children can participate in activities that their parents and grandparents have played while growing up . FinallyPracticing TCG skills according to random order was better for the acquisition and learning of GMS compared to a repetitive order. The CI effect was evident, whereby high interference schedules were superior to low and moderate interference practice schedules. The CI effect was also supported when practicing skills in random order in real-world settings.This study used Pittu Garam, a TCG which is popular in Khyber Patunkhwa, a province of Pakistan, as an intervention to improve GMS. This game involves the use of stones, which have to be built up into a pyramid shape. Playing this game may not be appealing to all children, hence, the performance and learning may be different if this game is played by children of different cultures. Additionally, the improvements in GMS after the Pittu Garam intervention may not be generalized to all TCG from different provinces, cultures and countries. This is because of the different types of TCG worldwide, all with different ways to play, different types of apparatus, different surfaces of play due to geographical locations, different environments and so on. Every region or nation has its own traditions of music, art, fiction, dance, cultural folks, and cultural games according to the environmental issues/factors/indicators such as temperature, heat/cold, day/night shifting, rains, clouds, snow, storms, sea, mountains, and forests. It has been reported by 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 Universiti Malaya Research Ethics Committee (Reference number: UM. TNC2/UMREC_1047). Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.BH conceptualized the research, collected and analyzed the data, and drafted the manuscript. JC conceptualized and supervised the research, interpreted the data, and reviewed the manuscript. Both authors contributed to the article and approved the submitted version.