Hospital-based back surgery in the United States increased by 60% from January 2012 to December 2017, yet the supply of neurosurgeons remained relatively constant. During this time, adult obesity grew by 5%.This study aimed to evaluate the demand and associated costs for hospital-based back surgery by geolocation over time to evaluate provider practice variation. The study then leveraged hierarchical time series to generate tight demand forecasts on an unobserved test set. Finally, explanatory financial, technical, workload, geographical, and temporal factors as well as state-level obesity rates were investigated as predictors for the demand for hospital-based back surgery.Hospital data from January 2012 to December 2017 were used to generate geospatial-temporal maps and a video of the Current Procedural Terminology codes beginning with the digit 63 claims. Hierarchical time series modeling provided forecasts for each state, the census regions, and the nation for an unobserved test set and then again for the out-years of 2018 and 2019. Stepwise regression, lasso regression, ridge regression, elastic net, and gradient-boosted random forests were built on a training set and evaluated on a test set to evaluate variables important to explaining the demand for hospital-based back surgery.Widespread, unexplained practice variation over time was seen using geographical information systems (GIS) multimedia mapping. Hierarchical time series provided accurate forecasts on a blind dataset and suggested a 6.52%  growth of hospital-based back surgery in 2018 . The increase in payments by 2019 are estimated to be US $323.9 million. Extreme gradient-boosted random forests beat constrained and unconstrained regression models on a 20% unobserved test set and suggested that obesity is one of the most important factors in explaining the increase in demand for hospital-based back surgery.Practice variation and obesity are factors to consider when estimating demand for hospital-based back surgery. Federal, state, and local planners should evaluate demand-side and supply-side interventions for this emerging problem. These procedures do not include needle decompression, catheter implantation, and, as of 2019, endoscopic decompression . From these data, the organization uses undisclosed algorithms to estimate all-payor claims. Columns with fewer than 11 claims or procedures are not shown because of privacy requirements [Definitive Healthcare provided the hospital, zip code, and state-level procedure and cost data from January 2012 to June 2018 through the hospital irements . For thiirements .The Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System (BRFSS) prevalence data provided the information for state-level adult obesity rates by year, from 2012 to 2017 . Guam, PHeat maps are used to plot the zip code unit of analysis procedure data by year. Heat maps provide the intensity of the number of claims by time and geographic region. These types of maps have been used for improving minority health surveillance , examiniThe data in the Definitive Healthcare dataset are nonseasonal as they provide annual-level observations by the hospital unit of analysis. Even so, generating nonseasonal forecasting models that have predictive capability on a blind withhold set at the proper level of aggregation can provide decision support for supply- and demand-side interventions. These types of models have found support in many areas of health care such as radiology  and AlzhTo this end, hierarchical time series (HTS)  using R To understand HTS, one needs to only consider a single medical system that operates in 2 separate states with 3 hospitals per state. There are then 4 basic ways using which one might forecast annual visits as an example:A forecast might be generated for each hospital, aggregated at the state level and then further aggregated at the system level. A variety of different forecast methods might be used to generate the forecasts. The term for this method is bottoms up.Forecasts might be generated at the state level and then disaggregated  to the hospitals and aggregated to the system level. Again, the forecasts might be generated in multiple ways. The term for this method is middle out.Forecasts might be generated at the system level (via multiple methods) and then disaggregated to all levels below . The term for this is top down.One might take some combination of the previous methods to minimize forecast error. This is an ensemble method that might be termed the optimal reconciliation approach, which is optimal if the forecasts are unbiased .To avoid selection bias, all methods were evaluated for performance on the test set. Furthermore, the method for forecasting at these levels of hierarchy was using autoregressive integrated moving average (ARIMA) components and as well as smoothed error and trend components .AR components are autoregressive terms, offset by time. For example, the number of claims at time t might be forecast by using the number of claims at time t-1. This would be an AR1 model, as there is 1 offset. As ARIMA models assume stationarity of the time series for forecasting, 2 other components are necessary. The first is differencing or integration, the I in ARIMA, which helps stabilize the mean (whereas transformations help stabilize the variance). Although seasonality and trend might make an ARIMA nonstationary, differencing often corrects this. Sometimes, more than 1 difference is required to make the time series stationary, for example, t-yt-1-(yt-1-yt-2y) is a 2d order differencing. The last component, the MA or moving average, corrects for autocorrelated errors as well. This component averages previous observation(s) with the previous forecast(s) [ARIMA models focus on autocorrelation of components for stationary time series data. The ecast(s) .ETS models have 3 components: error, trend, and seasonality. As the data in this study are not seasonal, only the error smoothing  and the trend component (a Holt model ) are evaWith HTS bottom-up models, a separate ARIMA/ETS is built for each bottom-level component. For middle-out models, all middle-level components have separate forecasts. For top-down models, a single forecast is generated and proportioned down to the lower levels.Stepwise linear regression (both forward and backward), lasso regression, robust regression, elastic net regression, and extreme gradient-boosted random forests are built on unaggregated data as well as state-level aggregated data to estimate the number of claims. These models are built on a random 80% training set  and evaluated on a 20% withhold set  as well. The total number of valid observations were 13,464 unaggregated and 306 aggregated. The primary hypothesis is that the inclusion of obesity rates as an independent variable will yield better explanatory models for both the number of claims and the payment per claim.Stepwise linear regression based on minimum Akaike Information Criterion was selected over best subset because of the computational complexity. By using forward and backward simultaneously, variables are added in sequence but might be removed if they no longer contribute to the model .Lasso regression is a form of constrained regression that penalizes a model that selects too many variables by using an L1-norm formulation , whereas ridge regression is similar but penalizes using an L2-norm formulation (squared coefficient estimates). Elastic net uses a weighted L1 and L2 norm penalty function to reduce the number of coefficients in the model. Formulae for estimating the parameters of the linear model, the lasso regression, the ridge regression, and the elastic net are shown in Elements of Statistical Learning [Random forests, a machine learning technique, use an ensemble of decorrelated tree models and average the estimates of those trees to build forecasts. A tree model itself classifies counts of observations by splitting variables at points based on some decision criteria. An example of a tree with a depth of 3 (3 branches) is given in Learning .All the considered variables from the Definitive Healthcare dataset are shown in There is 1 primary dependent variable of interest: number of claims for CPT 63 codes. This variable is measured at the hospital level over time and is also aggregated by zip code/year for geospatial mapping and by state/year for forecasting and additional modeling analysis. The number of claims include third-party invoices provided by the hospital, regardless of the payer. The number of claims provides a measure of the met demand for services.For the geospatial and temporal analyses, the variables year and zip code  are used to describe the intensity of both the number of claims and the payment per claim. Zip code provides a high resolution for geographic claims data. For the HTS forecasting analysis, time components are used without external regressors.Explanatory stepwise regression, lasso regression, ridge regression, elastic net, and gradient-boosted random forest models investigate financial variables, technical variables, workload variables, geospatial variables, a temporal variable (year), and obesity rates . A discussion of each of the variable groups and variables follows.The financial variables investigated include net patient revenue, net income, cash on hand, total assets, total liabilities, and proportion of Medicare/Medicaid reimbursement. The financial variables were carefully selected from the set of available financials such that they are not a linear combination of other variables or nearly a linear combination see . AlthougQuantitative workload variables include the number of staffed beds, discharges, emergency room visits, surgeries, affiliated physicians, and employees. Categorical technical variables include ownership type, medical school affiliation, and hospital type. These variables are investigated because of their availability and possible confounding effects. Geographic variables include urban/rural location, state, and zip code. These variables are important in evaluating practice area variation and associated effects.Obesity rates are of interest to the study. These rates are assigned based on the state, as county and zip code level data are not available. This independent variable is of importance to the study.Missing data were present in the Definitive Healthcare dataset. As the percentage of missing data was small, the data were imputed via regression trees (simple imputation). The total number of valid observations at the hospital unit of analysis from January 2012 to December 2017 was 13,769. There were 2244 unique zip codes with data resulting in 13,464 observations from 2012 to 2017, although many of these were true zeros. Aggregated at the state level, there were 306 observations of the 50 states plus the District of Columbia over the 6-year span.Important descriptive statistics for the Definitive Healthcare data are shown . The aveThe number of hospitals reporting CPT 63 claims increased by 91 from 2012 to 2017. Charges increased from US $2.115 million to US $4.75 million, whereas payments increased from US $1.233 million to US $2.467 million. The proportion of charges paid fluctuated between 45% and 58%. The number of claims increased from 320K to 504K, a 60% increase .Variation across states from 2012 to 2017 for CPT 63 is impressive. The maximum average payment per claim was in Delaware (US $5190.62); however, the number of actual claims was small (5569). New York had the second highest payment per claim (US $5043.79) with 72,186 claims. Texas had the largest number of claims , yet the average payment per claim was only US $4223.22. On average, 60% of charges were paid .Obesity rates by state have increased from 2012 to 2017 . In 2012Of the 13,769 hospital observations, 3153 were rural and the remaining 10,616 were urban. Most hospital observations were classified as voluntary nonprofits , whereas proprietary corporations and government entities constituted 3426 (25%) and 1466 (11%), respectively, . Most of the hospital observations  had no affiliation with medical schools. The vast majority of the observations were from short-term acute care hospitals  with nearly all of the remainder  associated with critical access hospitals.r=0.9). Most financial and workload metrics are highly correlated as well . Owing to the large sample size, nearly all correlations are statistically significant at the alpha=.05 level  highly correlated . The Eastern seaboard has activity, but it is not intense, and the Western seaboard has minimal activity, except near Seattle.By 2013, the Eastern seaboard (particularly New Jersey) has increased in intensity, and the areas around Chicago and Salem, Oregon, are emerging as well. Houston and Dallas remain the most intense regions for the number of claims.In 2014, the number of claims in Seattle and San Antonio, Texas, shifted these cities to high-intensity areas (some red visible). It must be noted that 3 of the 4 cities with visible red tint are in Texas .The year 2015 saw increasing intensity in both the New Jersey area and Chicago, Illinois. These 2 areas joined Houston, Dallas, San Antonio, and Seattle as high-intensity claims areas. Despite their populations, neither California nor Florida experienced the claims intensity of Texas.Houston, Dallas, San Antonio, Seattle, Longview (Texas), Oklahoma City, the New Jersey area, and St. Louis were the notable areas of high intensity in 2016. The California coast became more intense along with Salt Lake City.By 2017, the Eastern seaboard intensified  along with Phoenix, Arizona, and Atlanta, Georgia areas. The most intense areas remained Houston and Dallas.Overall, the maps may suggest small area variations in practice patterns . Althoughts package in R [Being able to forecast demand is necessary for decision makers to investigate both supply- and demand-side interventions. To that end, HTS for state, census bureau region, and the nation using both ETS and ARIMA components were built on 2012-2015 training dataset and compared with the 2016-2017 test set using the The ETS models performed better on the test set in terms of both variance and bias as shown , and theHTS with the middle-out approach and ETS methods was refit on the entire dataset to generate forecasts. R2=0.39 on the training set and adjusted R2=0.38 on the test set). This indicates that the sum of squared regression accounted for 38% of the variance of the sum of squared total on the test set. Payments and charges were excluded from the analysis as they are necessarily functions of claims. The variables evaluated were the number of staffed beds, discharges, surgeries, net patient revenue, net income, total assets, total liabilities, affiliated physicians, employees, percentage Medicare/Medicaid, state, year, urban/rural status, ownership, medical school status, and hospital type. To investigate explanatory variables, several models were explored. Stepwise regression for the number of claims at the hospital level using the transformed variables and an 80% training set was successfully able to predict the number of claims on the withheld test set with some accuracy  by state and by year  resulted in an impressive model using an 80% training set to predict a 20% withhold set. The adjusted R2=0.38, 0.37, 0.38, respectively.) None of these penalty-weighted models improved upon the stepwise analysis significantly, although elastic net tied. Obesity was not retained in these models. For the aggregated set (state and year), the associated R2 were 0.78, 0.75, and 0.78, respectively. The lasso and elastic net models were slightly superior to the stepwise regression model  on the unobserved test set. Comparing this value with the approximately 38% variability accounted for in the other models suggests that the random forest model is superior. Gradient-boosted random forests with hyperparameter tuning outperformed all models: stepwise, lasso, ridge, elastic net regression. On the unaggregated withhold set, a well-pruned model (depth 4) with 2000 epoch runs and a slow learning rate of 0.1 accounted for more than 78.5% of the variability  yielded only nominal improvement over the constrained regression methods, possibly because of the smaller sample due to aggregation. A well-pruned model (depth=3) after 3000 epochs with a slow learning rate (0.1) achieved an Most importantly, the gradient-boosted random forests identified obesity as the second most important factor for gain at the hospital level and as the most important factor for both gain and cover at the state level of analysis. Furthermore, the gradient-boosted random forests performed better than any other model considered on a blinded test set.In this analysis, we evaluated the location, magnitude, and reasons for the growth of CPT 63 back surgeries in the United States. The GIS heat map analysis shows large-scale growth, particularly in the Northeastern region of the United States, and sustained activity in Texas. The entirety of the Eastern seaboard has seen growth in these procedures, and the associated increased cost is estimated to be US $323.9 million by the end of 2019.The principal findings of this study are described here. Each of the following results includes a discussion of significance and (if appropriate) policy:The Northeastern seaboard is likely to see continued growth in CPT 63 procedures. The implication for states in this region is that they may see more unplanned expenditures on health care, affecting their budgets. Furthermore, cost controls and reduction of practice variation based on evidence will become more important.The cost associated with these procedures is outstripping inflation and will likely result in national expenditures in the triple-digit billions. The federal government may need to evaluate its own evidence-based, best practice policies associated with funding of procedures that link selected interventions with outcomes and that reasonably limit reimbursement.Interstate practice variation appears to be extreme. For example, large population centers in California have fewer claims than large population centers in Texas. States should also investigate intrastate variation.Hierarchical forecasts suggest an increase in the number of claims of 6.5% for 2018 and 13% in 2019. The initial models were built on a blind test set and performed well. These types of forecasts are reasonably effective for claims analysis.Explanatory regression models for nation-level claims data had only some success in internal predictions. These models excluded obesity as a predictor. Regression models were more successful at predicting aggregated state/year models, though. These traditional models should be abandoned in favor of random forests.Extreme gradient-boosted random forest models were highly successful in predicting both hospital-level unit of analysis number of claims and aggregate-level claims on an unobserved test set. These models identified obesity as an important factor in estimating the number of claims. Furthermore, the use of these models underscores that even after multivariate transformations, nonlinear functions may exist in modeled data. Random forests unearthed patterns not visible to regression and constrained regression models.all-payor data are not divulged. This omission is problematic for verification but understandable because of parochial concerns. Second, only ETS and ARIMA models were considered for the HTS fitting as these models are implemented in the R HTS package. There are an infinite number of models for forecasting, including random forest time series that might have performed better. Third, the explanatory variables are limited to those tracked by CMS and the BRFSS.There are many limitations in this work. First, the algorithms used by Definitive Healthcare to extrapolate CMS data to Hospital-based back surgeries are likely to increase dramatically over the next several years, yet the supply of neurosurgeons is constant. With that increase, the cost of the procedures (mostly borne by third-party payers) will increase as well. Practice variation appears to be prevalent across the country; however, obesity itself is a factor that must be considered as a significant influence. Policy interventions must be considered at many levels.Clinical practice variation is something that may require intervention at the federal level. For example, a study in Scandinavia found significant differences among Norway, Sweden, and Denmark in the use of concomitant arthrodesis without any difference in treatment efficacy, increasing the cost without improving outcomes . ControlStates should continue educational and financial interventions targeting obesity in adults and children. As the obesity epidemic continues to grow, the medical intervention costs are likely to grow accordingly. Furthermore, states should evaluate county-to-county practice variation as these variations often increase cost without improving quality .Local interventions should consider the targeting of food deserts  for eradication as well as educational interventions. Several studies have shown that the food environment is directly linked to obesity -31. ElimInsurance companies themselves have a vested interest in both reducing obesity and controlling practice variation. Obesity is linked to numerous health disorders such as heart disease, type 2 diabetes, and bone and joint disease , any of fattening of America and the costs associated with it are likely to continue increasing otherwise.Federal, state, and local policy makers need to address the increasing obesity epidemic and the likely associated increase in demand for back surgeries. The implications of not doing so are increased cost, questionable quality/cost trade-offs, and reduced access because of the small and steady number of available neurosurgeons. The


Solanum lycopersicum), a model plant that accumulates cadmium, and two spider-mite species, Tetranychus urticae and Tetranychus evansi that, respectively, induce and suppress organic plant defences, measurable via the activity of trypsin inhibitors. We exposed plants to different concentrations of cadmium and measured its effects on mites and plants. In the plant, despite clear evidence for cadmium accumulation, we did not detect any cadmium effects on traits that reflect the general response of the plant, such as biomass, water content, and carbon/nitrogen ratio. Still, we found effects of cadmium upon the quantity of soluble sugars and on leaf reflectance, where it may indicate structural modifications in the cells. These changes in plant traits affected the performance of spider mites feeding on those plants. Indeed, the oviposition of both spider mite species was higher on plants exposed to low concentrations of cadmium than on control plants, but decreased at concentrations above 0.5 mM. Therefore, herbivores with contrasting responses to organic defences showed a similar hormetic response to metal accumulation by the plants. Additionally, we show that the induction and suppression of plant defences by these spider-mite species was not affected by the amount of cadmium supplied to the plants. Furthermore, the effect of cadmium on the performance of spider mites was not altered by infestation with T. urticae or T. evansi. Together, our results suggest no interaction between cadmium-based and organic plant defences, in our system. This may be useful for plants living in heterogeneous environments, as they may use one or the other defence mechanism, depending on their relative performance in each environment.Some plants are able to accumulate in their shoots metals at levels that are toxic to most other organisms. This ability may serve as a defence against herbivores. Therefore, both metal-based and organic defences may affect herbivores. However, how metal accumulation affects the interaction between herbivores and organic plant defences remains overlooked. To fill this gap, we studied the interactions between tomato ( Plants are exposed to an array of abiotic and biotic stresses. The mechanisms that allow them to survive these adversities imply physiological and structural transformations that can be costly to the plants, affecting negatively their growth and fitness . One sucBesides being costly for the plant, accumulation of some metals is highly toxic to herbivores as well. Indeed, due to their elemental nature, they cannot be degraded by chemical counter-defenses of the herbivores . TherefoMost herbivores induce the production of organic plant defenses . HoweverSolanum lycopersicum, L.) and herbivorous mites is ideal to test the abovementioned issues. When growing on soils with cadmium (Cd), tomato plants show higher tolerance than other species  were sowed in a climate chamber , in a soil /vermiculite mixture (4:1) and watered 3 times per week for the first 2 weeks. In the third and fourth weeks, plants were watered once a week with tap water and twice a week with 60 mL of a Cd chloride solution with two ranges of concentrations: a wide range: 0, 0.01, 0.1, 0.5, 1, 2, or 10 mM; and a narrow range: 0, 0.1, 0.25, 0.5, 0.75, 1, or 1.5 mM. Using the wide range, we tested the effects of high Cd concentrations in the plant and on spider mites. Using the narrow range allowed us to measure plant and spider-mite traits with higher resolution. At the end of the fourth week, plants were used in the experiments.Tomato plants  since then  for the several measurements.N = 6 per Cd concentration) were used to determine Cd accumulation on the leaf, as well as the amount of calcium (Ca) and magnesium (Mg). As Cd2+ uses the same transporters as these ions, their assimilation by the plant may be hampered by Cd, which is not the case in hyperaccumulating plants (N = 6 per Cd concentration) were used to obtain the biomass parameters , however, due to technical problems, the plants supplied with 1.0 mM of Cd could not be used in this assay. The remaining plants (N = 6 per Cd concentration) were used to measure the amount of soluble sugars and to determine the carbon (C) to nitrogen (N) ratio. Nevertheless, for each plant, and before any destructive assay, we determined the spectral reflectance of the leaf, a non-invasive method that provides a general assessment of plant stress . The spectral data generated by these measurements was analyzed by calculating spectral reflectance factors (R) for each wavelength . These factors were obtained by normalizing the reflected radiation from the leaves by a reflectance white standard. Several vegetative indices can be determined using reflectance data and used as a proxy of plant stress, being the most commonly used the Normalized Difference Vegetation Index (NDVI) as it reflects the efficiency of the photosynthetic system . TherefoOne leaf from each plant was dried for 72 h at 60°C until constant mass and uniformly ground. The elements were then quantified using Inductively Coupled Plasma – Atomic Emission Spectrometry , after nitric acid digestion, with a detection limit of 0.1 μg/L.All leaves and roots of each plant were collected, then the area of each leaf was measured with a laboratory leaf meter (LI-COR Biosciences). Next, the fresh weight of leaves and roots was obtained. Each leaf and the roots were then separately dried for 72 h at 60°C until constant mass and again weighed. The ratio between the dry weight of the roots and the dry weight of the leaves (root/shoot) was determined as well as the specific leaf area  and plant water content (fresh weight–dry weight/fresh weight).One leaf from each plant was dried at 60°C until constant mass and again weighed. The total carbon (C) and nitrogen (N) contents (grams of C or N per 100g of leaf dry weight) of each leaf was determined by dry combustion using an elemental analyser  was stored at -80°C and subsequently used to quantify the amount of soluble sugars. These were extracted from the leaf disk using 2 mL of 80% ethanol at 80°C and then quantified through changes in absorbance, at 405 nm for sucrose, using the resorcinol  method , and 490N = 6 per Cd concentration for the wide range, N = 12 per Cd concentration for the narrow range) and placed on a petri dish on top of wet cotton wool. One female spider mite of one of the two species was placed on each arena (three arenas per species per plant) and allowed to feed and oviposit for 4 days. Daily survival and fecundity of each female were recorded. The daily fecundity of spider mites was obtained by dividing the number of eggs laid by the number of days the female lived. In a previous study, it has been shown that this measurement is highly correlated with total lifetime fecundity (Six leaf disk arenas (θ 12 mm) were cut from one leaf (third from below) of each plant , or they were left un-infested . Afterward, the plants were cleaned by removing all the mites, web, and eggs with a brush.To test whether the effect of Cd and jasmonate organic defenses on herbivores are independent, tomato plants were exposed to three different Cd concentrations  as described before. Next, plants from the three treatments were infested for 48 h with either 100 The performance of spider mites was determined as above.2; 1:3). Each sample was centrifuged at 4°C, 16.0 ×g for 25 min, and the supernatant was separated from the pellet and used in the spectrophotometer assay. This assay, adapted from Plant material from the leaf used to determine the performance of spider mites was stored at -80°C and used, later, to quantify the activity of TIs, as a proxy for inducibility of the jasmonic acid pathway by spider mites . ApproxiAll statistical analyses were performed with the software package R 3.0.2. The normality of the residuals of each model was tested using a Shapiro–Wilk normality test and, when needed, a Box-Cox transformation to the data was performed. Models were simplified by sequentially removing non-significant interactions and factors. Due to logistic constraints, each experiment was repeated in blocks of three plants per treatment. Block was thus included in the models as a random factor.The effects of Cd exposure on NDVI, SC index (R1110/R810) and reflectance under the UV-B spectrum were determined using general linear mixed models (lmm) with, respectively NDVI, SC index or UV-B reflectance as response variables, Cd supplied as a fixed factor and block as a random factor.The relation between the Cd contained in the solution administrated to the soil and the Cd contained in the leaves was determined with a Spearman correlation, due to the non-normality of the data. Furthermore, the relation between Cd contents and the amount of calcium (Ca) and magnesium (Mg) present on the leaves was assessed with a Pearson correlation.The effects of Cd on specific leaf area, water and soluble sugar contents were tested using general linear mixed models (lmm) with Cd supplied as a fixed factor and block as a random factor, whereas differences in root/shoot and in C/N were determined using a generalized linear mixed model (glmm) with a binomial distribution, and the same factors as above.T. evansi and T. urticae were used as response variables, the amount of sucrose and glucose plus fructose or the spectral SC index (R1110/R810), were used as fixed factors.The effects of Cd on daily fecundity of spider mites were determined for each range, using general linear mixed models (lmm) with species tested and Cd supplied as fixed factors and block as a random factor. Additionally, because the soluble sugar contents and the spectral SC index (R1110/R810) were affected by Cd, we tested whether changes in those traits influenced the daily fecundity of spider mites using a multivariate analysis of variance with distance matrices  and infestation status  used as fixed factors and block as a random factor.The statistical analysis of the interactions between Cd accumulation and jasmonate organic defenses were performed using general linear mixed models (lmm) with daily fecundity of Cadmium exposure had no effect on NDVI Table . Howevery = 52.299x + 21.165, rho = 0.945, P < 0.001; Figure R2= 0.25, P = 0.11 for Ca and R2 = 0.23, P = 0.14 for Mg).The concentration of Cd accumulated in tomato leaves correlated positively with the Cd concentrations that plants were exposed to, in a linear way . In contrast, the amount of glucose plus fructose affected this trait . Additionally, the reflectance SC index (R1110/R810) affected the fecundity of spider mites .The amount of sucrose in the leaves did not affect the fecundity of spider mites . However, variables related to leaf structure (SC index) or sugar content were affected, suggesting structural and biochemical changes in leaf cells. Spider mites infesting those plants were affected by Cd concentrations, albeit in a non-linear way. Indeed, both spider mite species had increased performance on plants mildly exposed to Cd, as compared to un-exposed plants, but lower performance after a given threshold, revealing a hormetic effect, which is a dose response phenomenon with stimulatory effects of mild concentrations and inhibitory effects at higher concentrations . FinallyMoneymaker, the variety of tomato used in our study, is as a facultative hyperaccumulator. This is further confirmed by the values of Ca and Mg in the leaves which remain stable with increasing Cd in the leaves, as seen for other hyperaccumulator plants (Studies regarding Cd accumulation by tomato plants reveal high variability in this trait , with sor plants .Here we report the absence of an immediate negative impact on plant growth, although there was an effective uptake of Cd into the leaves. Moreover, we also observe no differences in the carbon to nitrogen ratio in leaves of plants exposed to different Cd concentrations, indicating no shifts in the growth/defense balance . This coIn contrast to most plant traits that did not respond to Cd, we found changes in soluble sugar contents and leaf reflectance. Changes in the amount of soluble sugars in the leaves with Cd were non-linear. Soluble sugars are generally associated with an initial response to plant stress, with changes in their accumulation, either increasing or decreasing, affecting the REDOX reactions originated by environmental stress . CadmiumThe performance of spider mites was also affected by Cd accumulation in tomato leaves. Both species had a non-linear, hormetic response to this metal. Most herbivores are negatively affected by metal accumulation in the leaves of their host plants . Still, The similarity in the hormetic pattern of the two spider mite species suggests they both may prefer to establish on plants with intermediate Cd concentrations rather than on un-contaminated plants. Moreover, their higher oviposition probably indicates that their growth rate is higher on those plants . This maBecause the two spider-mite species have dissimilar interactions with jasmonate organic defenses, the fact that they perform best on plants with the same Cd supply also suggests no interaction between metal accumulation and the inducibility of jasmonate defenses. Furthermore, the contrasting effects of these two spider-mite species on the activity of trypsin inhibitors and its effect on subsequent infestations were consistent across Cd environments, revealing no interference of Cd on protease activity, in contrast to what was seen in other plant species . The plaAnother possible explanation for the absence of a trade-off in our study is that the effect of metal accumulation on herbivores was non-linear. Thus, if plants would produce fewer organic plant defenses, as metal accumulation increased, herbivores would have an extra-advantage at intermediate metal concentrations, benefiting from both a high performance in response to metals, and a low exposure to organic defenses. This, in turn, would pose a strong selective pressure upon plants not to shut down organic defenses. In the absence of an interaction between metal-based and organic defenses, plants occurring in heterogeneous environments may fine tune these strategies depending on their relative performance in each environment. Possibly, plants accumulate more metal when exposed to herbivores that suppress their organic defenses, overcoming the positive effects that low concentrations may have on these herbivores. This hypothesis awaits to be tested.In sum, our results show that spider mites with different effects on the organic defenses of tomato plants have a similar hormetic response to Cd accumulation. This suggests that the community of spider mites on tomato plants will be similar in contaminated and un-contaminated soils. Our results highlight the importance of studying the interactive effects of metal based and organic plant defenses on herbivores, using metal concentrations below the hyperaccumulating threshold, which allows using more facultative accumulator species, including some of agricultural importance, such as tomato plants.All data used in this work is archived in Dryad at doi: 10.5061/dryad.f274gs3.DG, SM, and CB conceived the study. DG, SM, and CB designed the experiments with help from HS and ADS. DG collected the data with assistance from HS and ADS. DG analyzed the data with help from all authors. DG and SM led the writing of the manuscript, with significant help from CB and contributions by all authors. All authors gave final approval for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The CalEnviroScreen created by the Office of Environmental Health Hazard Assessment, Sacramento, USA, is a place-based dataset developed to measure environmental and social indicators that are theorized to have cumulative health impacts on populations. The objective of this study was to examine the extent to which the composite scores of the CalEnviroScreen tool are associated with pediatric asthma hospitalization. This was a retrospective analysis of California hospital discharge data from 2010 to 2012. Children who were hospitalized for asthma-related conditions, were aged 0–14 years, and resided in California were included in analysis. Rates of hospitalization for asthma-related conditions among children residing in California were calculated. Poisson multilevel modeling was used to account for individual- and neighborhood-level risk factors. Every unit increase in the CalEnviroScreen Score was associated with an increase of 1.6% above the mean rate of pediatric asthma hospitalizations (rate ratio (RR) = 1.016, 95% confidence interval (CI) = 1.014–1.018). Every unit increase in racial/ethnic segregation and diesel particulate matter was associated with an increase of 1.1% and 0.2% above the mean rate of pediatric asthma, respectively . The CalEnviroScreen is a unique tool that combines socioecological factors and environmental indicators to identify vulnerable communities with major health disparities, including pediatric asthma hospital use. Future research should identify mediating factors that contribute to community-level health disparities. Asthma is the most common chronic health condition in children associated with hospitalization and causes severe life disruption that can be prevented with appropriate care and services ,2. EstimResearchers have documented the geographic disparity of the burden of asthma and how social characteristics of neighborhoods such as poverty, racial/ethnic segregation, psychosocial stress, and collective efficacy contribute to asthma ,11,12. BThe CalEnviroScreen, created by the Office of Environmental Health Hazard Assessment, Sacramento, USA, is one such screening tool with major societal and public health implications. It was collaboratively developed by the California Environmental Protection Agency  and the Office of Environmental Health Hazard Assessment (OEHHA) to identify communities disadvantaged by a cluster of social and environmental injustices to inform governmental agencies on where to allocate resources toward improving the environment and the health of the people. A central aim of the tool is to promote economic prosperity and to reduce public health disparities clustered in a geographic area. However, little is known about the extent to which the CalEnviroScreen tool and its composite scores do in fact identify communities with major public health concerns.This exploratory analysis investigates associations between the CalEnviroScreen composite scores, as well as between levels of separate indicators of the CalEnviroScreen screening tool, with pediatric asthma hospitalization rates, to examine the extent to which these measures are associated with pediatric asthma hospitalization.Patient discharge data , from 2010 to 2012, from California’s Office of Statewide Health Planning and Development (OSHPD) were analyzed because these years closely align with the measures within the CalEnviroScreen tool. Hospitals in the state of California are required to report all visitation records to OSHPD. The sample population of children aged 0 to 14 resided in a zip code within California and the expected source of payment was Medi-Cal  or private insurance. Children older than 14 years of age were omitted from analyses because these asthma cases made up less than 1% of all pediatric patients hospitalized with asthma. Hospital discharge date and the CalEnviroScreen were linked by the patients’ zip code of residence.The CalEnviroScreen screening tool was computed by the Office of Environmental Health Hazard Assessment (OEHHA) and has three key composite scores that are used in this study: the CalEnviroScreen score (CES), population characteristics score (PCS), and pollution burden score (PBS). The CES ranged from 0 to 100 and was the product of the PCS and PBS representing cumulative disadvantage of social and environmental risks at the zip code level. The PCS ranged from 0 to 10 and was a composite score of socioeconomic, demographic, and health indicators , children and older adults, asthma, low birth weight). The PCS ranged from 0 to 10 and was the composite score of 11 environmental pollutants , pesticide use, toxic releases, traffic density, cleanup sites, groundwater threats, hazardous waste, impaired water bodies, and solid waste sites). Diesel particulate matter (PM) was measured as the spatial distribution of gridded diesel PM emissions from onroad and nonroad sources for a 2012 summer day in July (kg/day). Diesel PM emissions data was collected from the California Air Resources Board. Poverty was the percent of the population living below two times the federal poverty level . Linguistic isolation was the percent of limited-English-speaking households (2011–2015). The racial/ethnic minorities indicator was measured as the percent of the population that was nonwhite or Hispanic/Latino including all people in the U.S. Census who identified a race other than white or who identified as Hispanic, Latino, or of Spanish origin. In this study, all composite scores and indicators were centered around the mean values prior to analyses. A full description of methodology to compute the composite scores and data sources used to create the CalEnviroScreen can be found in the Individual-level indicators included age, sex, race/ethnicity, and insurance coverage. Dummy coding was used for individual-level predictors. Age was coded to include children younger than 5; 5 to 9; and 10 to 14 (reference group). Sex was coded for boys and girls (reference group). The five racial/ethnic groups were black/African-American, Latino/Hispanic, Asian, Other race/ethnicity, and non-Hispanic white (reference group). Insurance coverage was dichotomized into Medi-Cal  and private (reference group) where all other types of coverage were omitted from the analysis.The project number is 12-06-0430. The Committee for the Protection of Human Subjects (CPHS) initially approved this project on 2 August 2013. Annually, the project is renewed and is currently active. All subject-related data for this study was collected from the Office of Statewide Planning and Development (OSHPD) and was deidentified prior to acquisition.The outcome of interest was counts of potentially preventable asthma-related hospitalizations. Prevention quality indicators (PQIs) from the Agency of Healthcare Research and Quality (AHRQ) were used as criteria in identifying potentially preventable asthma-related primary diagnoses. International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes were used to identify asthma events and included: 49300, 49301, 49302, 49311, 49312, 49320, 49321, 49322, 49382, 49390, 49391, and 49392. These ICD-9-CM codes are consistent with Lu who adapted these codes for use in a pediatric population [F = 93.9, p < 0.001, R2 = 0.47. The same regression model was used to predict the population that is eligible for private insurance coverage, F = 70.7, p < 0.001, R2 = 0.40. We then multiplied the predicted proportions of eligibility by the number of children living in a zip code to compute the population at risk (denominator of rate).Similar to previous studies, we estimated the number of children at risk for hospitalization by regression ,23. The We conducted summary statistics for the sample population by sex, age, race/ethnicity, and insurance coverage shown in Due to the nested nature of these data, children living within zip codes, hierarchical generalized nonlinear modeling was used to account for clustered data at multiple levels. It was appropriate to use Poisson-based models for parameter estimation due to the discrete, non-negative, and rare nature of the outcome of interest, asthma hospitalizations. We specified the general pediatric population in each zip code as the offset (population at risk) in each model. These methods have been used in previous research investigating rates of hospitalizations and geographical analyses ,24. We tThere were 1769 zip codes included in the CalEnviroScreen. Among all the zip codes in the screening tool, 901 valid zip codes matched a patient’s zip code of residence and were included in the analyses. b = –5.94), translating into a risk ratio (RR) = 0.0026 , or 26 per 10,000 in the population at risk. This finding suggested that multilevel modeling was appropriate. b = −7.177), translating into a risk ratio (RR) = 0.0007 , or 7 per 10,000 in the population at risk. Across zip codes, the risk for hospitalization was, on average, increased if the children were on Medi-Cal exp(1.412) = RR 4.10 , black/African-American exp(0.382) = RR 1.46 , younger than five years of age exp(1.292) = RR 3.64 , or age five to nine exp(0.246) = RR 1.27 . Children were at lower risk for asthma hospitalizations if they were Latino exp(−0.226) = RR 0.79 , Asian exp(−0.286) = RR 0.750 , or other race/ethnicity exp(−0.910) = RR 0.40 . After adjusting for level-one factors, the variance components at the zip code level remained significant . That is, significant differences in mean rates of asthma hospitalizations existed between zip codes, after accounting for individual-level characteristics. A null model (varying-intercept) indicated that mean rates of asthma hospitalizations varied significantly by zip codes (b = 0.016) and significant (p < 0.001). For every unit increase in CES, the risk ratio for mean hospitalizations would be expected to increase by 1.016  times the mean rate. Thus, if we compare a zip code with the mean CES value (24) to zip code with a CES one standard deviation above the mean (36) that are otherwise similar, we would expect an (0.016) × (12) = 0.19, RR 1.21, translating to 9 per 10,000 in population at risk. Model 2 examines the two composite scores that compose the CES, the pollution burden score (PBS) and the population characteristics score (PCS). The effect of PCS  was more than twice as large as the PBS . Individual-level effects remained similar to Model 0 for Models 1 to 3.Model 1 introduced the CalEnviroScreen Score (CES) to the model. CES was positive  was the only pollutant that remained significant after adjusting for % linguistic isolation, % poverty, and % racial/ethnic minorities at the zip code level. Increasing levels of linguistic isolation were significantly associated with lower zip-code-level asthma hospitalization . Conversely, increasing levels of poverty and racial/ethnic minorities were associated with greater zip-code-level asthma hospitalization .The aim of this study was to investigate the extent to which the CalEnviroScreen could identify populations and communities with the highest burden of pediatric asthma hospitalization rates. The composite scores  were examined, as well as the separate indicators within the composite scores. Our main finding is that the composite score of the CalEnviroScreen tool does identify communities with the highest rates of asthma hospitalizations and communities with high concentrations of diesel PM, poverty, and racial/ethnic minorities were most strongly associated. These findings contribute to the discussion on the CalEnviroScreen’s capacity to identify public health issues in disadvantaged communities as well as its use in the broader landscape of measuring the impacts of social and environmental inequities that are geographically dispersed. Although this article does not measure the potential interactions of chemicals in the environment or the synergistic effects they may have on populations, understanding how exposure to additive social and environmental inequities impact pediatric asthma has major public health implications ,27.Although Greenfield, Rajan, and McKone conducted an analysis of the CalEnviroScreen, examining the extent to which the tool identified disease burden, we build upon the literature by examining a specific disease outcome among children and by disentangling person-level effects from community-level effects . Our metAt the zip code level, increased levels of linguistic isolation were associated with a reduction in asthma hospitalizations. The clustering of immigrants, lower educational attainment, and households with non-English-speaking adults may explain the reduced rates of health care utilization . PreviouIncreased levels of poverty and racial/ethnic segregation were associated with increased mean rates of asthma hospitalizations. Concentrated poverty has been demonstrated to harbor the conditions for severe asthma exacerbations ,39,40,41The geographical distribution of diesel particulate matter was associated with increased mean rates of asthma hospitalizations. Our data suggested that the relationship between diesel particulate matter and asthma hospitalization was strongest in zip codes near highway 99 in the San Joaquin Valley. There is a large body of literature linking traffic-related air pollution to asthma exacerbations ,49,50. TThis study demonstrates that social factors, at the individual level and community level, are largely associated with asthma morbidity even after adjusting for environmental pollutants. Although diesel particulate matter was the only environmental pollutant that remained significant after adjusting for population characteristics, there is potential for misclassification errors to exist in these data. Methodology for measuring environmental pollutants are not well established, especially in comparison to population characteristic indicators. This would indicate that coefficient estimates for environmental pollutants in this study, including parameters presented for diesel particulate matter, may be underestimated and population characteristics may be overestimated. In developing the multilevel models, all environmental pollutants measured by the CalEnviroScreen were singularly significant in their association with asthma hospitalizations. It was only after adjusting for other zip-code-level factors that their effects were nonsignificant.We were only able to link 47% of CalEnviroScreen to hospital records. The values of the zip codes from the CalEnviroScreen that were retained tended to be greater than the values that were dropped. This may have biased our results because we were not able to incorporate the lower spectrum of the CES scores. Although this reduces the total amount of variability in our analysis, our parameter estimates of asthma disparities are conservative due to the omission of lower CES scores as well as the reduction in indicator variability. Our data are limited in the ability to account for well-established, in-home triggers of asthma such as smoking, mold, and other allergens. The Latino/Hispanic population in California is largely Mexican and Mexican-American, and has consistently been shown to have lower asthma prevalence compared to other racial/ethnic groups. This may present a confounding effect in our ability to identify risk factors for preventable pediatric asthma hospitalization.The CalEnviroScreen does identify disadvantaged communities with disparities in pediatric asthma hospitalizations, beyond the person-level risk factors accounted for in this study. At the state level, policy addressing diesel particulate matter, barriers to access due to linguistic isolation, concentrated poverty, and racial/ethnic segregation could be implemented to attenuate asthma disparities and provide hospital services to those who need them. However, the total score does not provide insight on the historical, contextual, or environmental risks occurring at the local level because regions and neighborhoods within California have been shaped and are impacted by different environmental pollutants and populations. Local communities need further data to inform decision making.


In a multivariate analysis using the generalized linear mixed model where locality, SES, age and MIH were taken into account as caries risk indicators, MIH was the strongest risk indicator of caries in FPMs . According to the study results, children with MIH have a higher risk for dental caries than children without MIH. The aim of this study was to investigate if a developmental enamel defect known as Molar-Incisor Hypomineralization (MIH) is associated with dental caries. Socioeconomic status (SES) was examined as a confounding factor between caries and MIH. In this cross-sectional study, 636 children, aged 8 to 13 years, from three towns  in Finland were examined for MIH in line with the criteria of the European Academy of Paediatric Dentistry. Caries status for permanent teeth was recorded as decayed, missing and filled teeth (DMFT). Caries experience (DMFT > 0) in the first permanent molars (FPMs) was set as an outcome. SES was determined using a questionnaire completed by parents. The prevalence of MIH was 18.1%. The mean DMFT in FPMs for children with MIH was higher than for their peers, 1.03 ± 1.25 vs. 0.32 ± 0.80 ( Caries rates have been declining during the past decades, and many Western populations are classified as low-caries populations. Caries control, however, remains a challenge. The distribution of caries is skewed, and a small number of individuals experience most of the caries lesions and restorations. Therefore, individuals with a high risk for caries need to be identified and treatments carried out respectively. Many caries risk factors have been identified, and one of them is low socioeconomic status (SES) . Some ofA specific type of DDE, Molar-Incisor Hypomineralization (MIH), is diagnosed when the first permanent molars (FPMs) display areas of poorly mineralized enamel, called hypomineralization . The perMIH, especially in its severe form, is often problematic both for the patient and for the dentist. Hypomineralized enamel is soft and porous, and teeth are sensitive to thermal changes, possibly due to the underlying pulpal inflammation ,8. DisorDepending on the region/country studied and diagnostic criteria used, the documented prevalence figures for MIH have markedly varied, from 2.9% to 44% . AccordiAnother subject of many studies has been the role of MIH as a risk factor for dental caries. According to a recent systematic review, most studies reported a positive correlation between MIH and caries, but the quality of the studies was compromised, and a need was expressed for more well-designed studies . Most ofThe aim of this study was to evaluate the association between MIH and caries taking into account the effect of SES. The study hypothesis was that MIH is associated with caries in FPMs regardless of SES. The participants in this cross-sectional study were 8- to 13-year-old children attending public comprehensive schools in three regions in Finland. The biggest comprehensive schools from two rural towns, Lammi and Jalasjärvi, and from the city of Lappeenranta, were selected, and the pupils in the 2nd to 5th grades, 994 children in total, were invited to join the study. The children were born in 1990–1996. The parents  of 676 children (68%) gave informed consent for the participation of the children in the clinical examination and filled out a questionnaire related to SES, health, and the way of living of the family and the child. Inclusion criteria were as follows: signed informed consent, age between 8 and 13 years, all FPMs erupted, and no fixed orthodontic appliances interfering with teeth evaluation. The final number of participants was 636 (64% of the invited children). In the Lammi region, the fluoride content in communal pipe water is <0.1 mg/L and in wells in the sparsely populated areas it is mostly <0.2 mg/L. In Jalasjärvi, the fluoride content in communal pipe water is 0.5–1 mg/L, and in Lappeenranta approximately 0.25 mg/L. The clinically experienced participating dentist (Sakari Laisi) was trained for the screening of MIH, diffuse opacities and enamel hypoplasia with Satu Alaluusua a professor of paediatric dentistry, until consensus was obtained. MIH was screened in line with the criteria of the European Academy of Paediatric Dentistry (EAPD) , and TheThe dental examinations were performed in the dental clinic under standard dental lighting. The same calibrated dentist (Sakari Laisi) performed all the examinations using a mirror and a periodontal probe.FPMs and permanent incisors were examined wet for MIH-characteristic hypomineralization defects i.e., demarcated opacities, post-eruptive breakdown of the hypomineralized enamel, and atypical form of a restoration/caries. These criteria are in line with the judgement criteria for MIH set by the European Academy of Paediatric Dentistry (EAPD) in 2003 . Since tCaries status was recorded in permanent teeth using the DMFT index . Visual investigation enhanced by fiber-optic transillumination was used to diagnose caries. Initial caries lesions, teeth extracted due to orthodontic reasons and congenitally missing teeth were not included in the DMFT value. The diagnostic criteria for caries were in line with those of the WHO . DevelopFamily income: The question about annual family gross income had six classes, from the lowest, less than 13,500€, to the highest, more than 50,400€. For further analysis, to yield a more informative distribution of the sample, the lowest three classes were combined, resulting in a total of four categories.Education of the mother: The question about mother’s education had four classes: primary and secondary school, vocational school or equivalent, high school or higher vocational school and college/university graduate. The first level also included former forms of the 9-year-long Finnish basic education.The questionnaire used in the study was originally designed for the purpose of studying associations between allergies and lifestyle . It was supplemented with questions relevant to the present study. Two variables were used to define the SES of the family:The questionnaire was filled by the parent/parents at home in advance and returned at the examination. The examiner was blinded to the information given in the questionnaire.2-test of independence. To test the study hypothesis, the outcome variable was determined by following variables: the DMFT value in FPMs, ranging from 0 to 4, and the caries experience in FPMs (DMFT = 0 vs. DMFT > 0). MIH was determined as an exposure variable. The two SES factors (family income and mother’s education level) were taken into account as possible confounding factors. Also, analyses were adjusted to age and region. The statistical analyses were conducted using IBM SPSS version 24.0 , and included descriptive statistics of MIH on tooth level, caries and SES factors, including normality tests and χ2-test. The distributions of the study variables between three regions were tested using χ2-test and Kruskal-Wallis 1-way ANOVA test. In case of statistically significant association, the Bonferroni method was used for adjusted p-values in pairwise comparisons.The Kruskal-Wallis 1-way ANOVA test was used to test the statistical difference in the DMFT value in FPMs between children with and without MIH. The association of SES factors and caries experience in FPMs (DMFT > 0) was tested using χp = 0.05 (two-tailed).To test the association between the outcome (caries experience in FPMs) and exposure variable (MIH) taking into account the confounding factors , the generalized linear mixed model analysis with logit link was conducted. Different models were conducted attempting to alternately include one of the SES variables, but a model including both SES variables was found to be most fitting. Adjusted odds ratios (ORs) and 95% confidence intervals (CI) were calculated to test whether MIH or confounding factors were associated with elevated odds of having caries relative to being caries-free. Statistical significance level was set at Parents of the children approved the participation of the children in the clinical examination and filled out a questionnaire. Clinical examinations were part of the dental check-ups that were offered to everyone regardless of the decision to participate in the study. Radiography was not used for caries diagnostics. The basic service public utility federation of municipalities JIK , the Lammi-Tuulos federation of municipalities, and the Ethics Committee at South Karelia Hospital District, Lappeenranta, Finland, approved the study (A02/03).A total of 636 children were included in the study. Distribution of the study variables between children with and without MIH are shown in n = 143) than in the mandibular FPMs (n = 82) (63.6% vs. 36.4%). There were 115 children with MIH (18.1%). The total number of FPMs with an MIH defect was 225. The mean number of MIH-affected FPMs among children with MIH was 2.0 ± 1.1. MIH was more often diagnosed in the maxillary FPMs . Children from Jalasjärvi were younger than children from Lammi or Lappeenranta . In Lappeenranta, a significantly higher proportion of children belonged to the highest mother’s education and family income groups than in Lammi or Lappeenranta .There were significantly less children with MIH in Jalasjärvi than in Lappeenranta . Other vn = 177 children) for all permanent teeth (DMFT > 0). For FPMs, the prevalence of caries was 24.0% (n = 153 children) (DMFT > 0 in FPMs). Of the FPMs affected by MIH, 24.8% had atypical restorations or demarcated opacities with caries and were deduced to be affected by caries. This was more prevalent in the mandibular (28 out of 82) than in the maxillary (28 out of 143) FPMs with MIH (34.1% vs. 19.6%).The prevalence of caries was 27.8% . To assess the pattern of caries development, the cross-sectional sample was sub-grouped by age and DMFT values were studied for MIH and non-MIH children in every age group. The mean DMFT increased by age among non-MIH children, whereas among MIH children the mean DMFT in age groups from 8 to 13 years stayed more constant . p = 0.034, χ2-test). Mother’s education level was associated with caries so caries experience decreased from lower to higher education levels . In the univariate analysis, family income was associated with caries in FPMs, so there were significantly more caries affected children in the lowest than in higher income groups  increases the child’s risk for dental caries, taking into consideration the socioeconomic status (SES) of the child as a confounding factor. MIH was associated with caries in permanent teeth with the adjusted odds ratio of more than 6-fold compared to the children without MIH. This result is in line with a recent case-control study from Brazil .Of the 636 Finnish 8- to 13-year-old children included in the study, 18.1% had one or more FPMs with enamel hypomineralization i.e., MIH. The diagnostic criteria for MIH were in line with those set by the EAPD in 2003 , but lesDMFT values both in all permanent teeth and in FPMs were higher among children with MIH than among their peers. In the multivariate analysis, the association of MIH and caries was calculated. The model was conducted taking into account that both variables, as well as the factors defining SES, varied between the three regions. MIH was the strongest caries risk indicator. As it can be supposed, age increased the risk of caries. Interestingly, fewer children in Lammi than in Jalasjärvi or Lappeenranta were affected by caries. The reason for this remains unknown. Overall, 28% of the subjects were affected by caries in permanent teeth and 24% were affected by caries in FPMs. In a low-caries population, and in young individuals, developmental defects are less likely to be masked by caries, and atypical restorations can be recognized.Maxillary FPMs were more frequently affected by MIH than mandibular FPMs. This is in line with an earlier Finnish study . DemarcaIn general, the present findings of the association between MIH and caries are in line with those from earlier studies. Children with MIH have been reported to have more caries affected teeth  than their peers ,28,30,32Morphological analyses of MIH teeth show that the hypomineralized enamel is less organized, is porous, and has a higher organic content than normal enamel ,8,36. ThVargas-Ferreira et al. conducted a meta-analysis on caries and developmental defects of enamel (DDE) and found a positive association between the two . The autAmericano et al.  conducteAlthough the study sample was not randomly chosen, the results can, with some precaution, be generalized to the population. The participants were recruited from public schools which are the only choice of schooling in most of the towns in Finland. The setting resembles a population-based study, though participation rate was reduced and may have led to skewed distribution of SES, resulting a sample with more children from higher SES families than in the background population. This study supports the findings of earlier studies that MIH increases the risk of caries. Taking into account the regional differences, MIH, in comparison to SES, was a greater risk indicator for caries in FPMs. The FPMs of children with MIH were more often affected by caries than FPMs of their peers. Especially in a low-caries risk population such as in Finland, the impact of MIH on caries development should be considered. Besides, because the treatment of caries in hypomineralized teeth is challenging, children with MIH should be considered to have a high risk for caries, regardless of their socioeconomic status, and offered versatile caries-preventive measures as well as frequent follow-up visits to dental care.


This study aimed to evaluate the clinical outcomes of intra-articular infiltration with hyaluronic acid and dexamethasone alone and in combination in the treatment of knee osteoarthritis (OA).This prospective randomized trial evaluated 44 patients undergoing treatment for OA. Patients were selected through clinical and radiological analysis using the American College of Rheumatology criteria. We included patients aged between 50 and 70 years who presented with K-L stage ≤2 knee OA and normal limb alignment. Patients with a previous history of knee injury , infection, patellofemoral OA or chondroprotective drug use in the previous year were excluded. Participants were randomized into 3 groups and underwent treatment with viscosupplementation , viscosupplementation plus dexamethasone  or dexamethasone . All patients were evaluated before and 6 weeks, 3 months and 6 months after infiltration. Analysis included a physical examination, the Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire  and an evaluation of knee extensor and flexor strength and proprioception using an isokinetic dynamometer.VS significantly improved the WOMAC total score and subscores for pain, stiffness and function for up to 6 months after infiltration. It also improved knee extensor and flexor strength during the same period. Proprioception was not affected by any of the treatments.VS alone improved pain, stiffness and function according to the WOMAC total score and subscores and improved knee extensor and flexor strength, but not proprioception, for up to six months after infiltration. These findings suggest that VS has a positive effect on quadriceps arthrogenic inhibition. Osteoarthritis (OA) is a degenerative disease that causes progressive joint pain and disability. Recently, OA was defined as a disease that involves the synovial joint as a whole . The prein vitro that could be useful in modifying the course of OA  has a structure that allows joint lubrication and restores the rheological properties of synovial fluid . HA roseHence, we hypothesized that HA combined or not with corticosteroids could help minimize the effects of quadriceps arthrogenic muscle inhibition in OA patients, as evaluated by the WOMAC total score and subscores and knee flexor and extensor proprioception and strength.The goal of this study was to clinically evaluate the use of VS with sodium hyaluronate alone and in combination with DX for arthrogenic quadriceps inhibition in patients with knee OA.This prospective randomized trial was approved by the Institutional Research Board (CAAE: 24140813.2.0000.5273), and all patients signed an informed consent form to participate.2, patients with patellofemoral arthritis, identified on radiographs, and patients who had a history of treatment with chondroprotective drugs, corticosteroid infiltration or VS in the previous year  and sealed envelopes containing the acronym identifying the groups (VS/VD/DX), which was opened after completing the clinical evaluation. Infiltration was performed by a member of the staff (PAVM) who did not participate in the evaluations. After allocation, the patients were treated as follows:®, Johnson & Johnson®) in a single shot.Viscosupplementation group (VS group): VS alone with 3 doses (6 mL) of sodium hyaluronate 15 mg/mL  plus 1 dose of DX (4 mg/1 mL) in a single shot.Viscosupplementation plus dexamethasone group (VD group): VS with 3 doses (6 mL) of sodium hyaluronate 15 mg/mL (OrthoviscDexamethasone group (DX group): 1 dose of DX (4 mg/1 mL) in a single shot.Evaluations were performed by other members of the staff who did not participate in the infiltration procedures (EBS and VRAC). Infiltration was performed with the patient seated and knees flexed through anterolateral access to the knee. To evaluate arthrogenic quadriceps inhibition, the protocol included clinical, proprioception and knee extensor and flexor strength evaluations.2), knee joint ROM and lower limb alignment were recorded in the clinical evaluation.Age (in years), laterality , weight (in kilograms), height (in meters), BMI  and lateral view of the knee joint to stratify the OA severity according to the Kellgren-Lawrence classification and measurement of the lower limb mechanical axis.The subjective functional evaluation used the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) questionnaire validated for the Portuguese language , includiThe knee proprioception evaluation involved sensing of the joint position. An isokinetic dynamometer  was used in all of these procedures. All tests were conducted with the subject in a seated position with the hip at approximately 90° and the entire back touching the backrest. The patient was fixed to the seat by means of a belt.First, the subject was required to experience and then reproduce joint positions, through voluntary movements in both cases. Two target positions were used: 20% and 50% of the flexion-extension (FLEX-EXT) ROM (0%=maximum extension). Throughout the procedure, the patient was blindfolded. Variations of ±5° around the target position were allowed. If this margin was violated, the trial was discarded, and a new attempt was made. A total of 10 trials were performed, and 5 were chosen randomly for each target position. The individual error value for each attempt was determined through the difference between the position reproduced and the position experienced. The proprioceptive performance was determined with the absolute error (AE), obtained through the arithmetic mean of the absolute values of individual errors. The commands for carrying out the task were issued verbally by the evaluator, and the direction of movement was always from flexion to extension. During the procedure, the subject was blinded with special goggles to attenuate visual bias.After 10 minutes of rest, the strength evaluation was carried out. Prior to each test, all calibration procedures were accomplished, and the participant performed a warm-up familiarization process comprising movements of knee extension and flexion at submaximal effort. Each test consisted of one set of five repetitions in the isokinetic concentric-concentric mode at an angular speed of 60°/s, and only the involved limb was evaluated. The maximum value found was defined as the peak torque (PT), which was normalized by the subject’s weight and recorded for statistical proposes.p>0.05). To compare demographic data , one-way ANOVA was used. First, one-way repeated measures ANOVA was used to compare within-subject effects over time  and between-treatment effects . When a significant within-main effect was observed, one-way ANOVA was performed again for each group separately. If sphericity could not be assumed, the Greenhouse-Geisser correction was applied. Pairwise post hoc comparisons were carried with Bonferroni’s test. To preserve the repeated measures design if any evaluation session throughout the study was lost, the respective subjects data were withdrawn from the analysis. The effect size was assessed by pη2 and classified as small=0.01, medium=0.06, or large=0.14 (The results are presented as the mean and standard deviation (SD). For the WOMAC scores, comparisons were made within groups by one-way ANOVA at each measurement time point . The dependent variables were PT EXT, PT FLEX, AE20 (absolute error at 20% of FLEX-EXT ROM), AE50 (absolute error at 50% of FLEX-EXT ROM), and the WOMAC total score and pain, stiffness and physical activity subscores. The Shapiro-Wilk test showed all variables to be normally distributed . Additionally, significant effects between groups were observed in the pain , stiffness , physical activity  subscores, but not in the total score . Pairwise verification demonstrated a difference between the DX and VS groups. Further separate analysis revealed significant differences only within the VS group regarding the pain , stiffness , and physical activity  subscores and the total score   .p=0.30, pη2=0.04; between p=0.20, pη2=0.20) or the AE50  (There were no significant differences in either the AE20 (within p2=0.21) . Generalp2=0.21) .p=0.07, pη2=0.10). However, when the groups were compared, differences were identified . Moreover, pairwise differences were observed between DX and VD (p=0.03) and between DX and VS (p=0.04). Regarding PT FLEX  and between groups . A pairwise significant difference was observed between DX and VD (p=0.03), but not between DX and VS (p=0.07). Further separate analysis revealed a significant difference in both PT EXT  and PT FLEX  only for VS.We found no significant differences in PT EXT  in any o PT FLEX , a signiNone of the patients included in the study presented adverse effects.Arthrogenic quadriceps inhibition is present in patients with knee OA and is associated with joint inflammation, pain, and swelling, contributing to muscle atrophy and hindering rehabilitation . We hypoWe designed a prospective randomized trial to compare the use of DX and HA alone and in combination in the treatment of knee OA by evaluating the WOMAC total score and subscores and knee extensor and flexor strength and proprioception. Our results show that VS alone significantly improved pain, stiffness and function, as shown by the WOMAC subscores. In addition, VS alone improved knee extensor and flexor strength, but not proprioception.Intra-articular corticosteroid use is criticized because of its short analgesic effect, which lasts for up to approximately one month after infiltration , in addith week after infiltration (One study showed significant improvement in knee pain and function in patients treated with HA infiltration compared to placebo at five weeks after treatment. However, these effects lasted only until the 25ltration ,21-22. Altration . Major eltration . Anotherth week (The use of a single shot of HA or methylprednisolone in patients with mild OA was compared. Similar clinical results were observed between the groups, but HA showed superior analgesic effects after the 12th week . Howeverth week . The effth week , while ith week . Anotherth week . In the th week . In thisInitially, it was demonstrated that proprioception was affected by knee OA and that HA infiltration did not negatively affect proprioception . Then, iThe importance of strength training has been widely proven, with the consequent development of strength -36 and pThe main strength of this study is that we compared knee OA treatment using VS alone, VS combined with corticosteroids and corticosteroids alone using the same protocol. Moreover, the evaluation was performed using not only scores but also the findings of knee flexor and extensor strength and knee proprioception evaluations performed using an isokinetic dynamometer.The limitations of the study include the small sample number and the availability of rehabilitation for the patients included in the study. All patients received guidance regarding the rehabilitation protocol to which they should have access, considering the protocol used in our institution and those available in our public health system. There is a lack of scientific evidence in the literature regarding the effect of HA on patellofemoral OA. Thus, these patients were excluded to avoid misinterpretation of the data.In conclusion, according to our results, VS alone improved pain, stiffness and function according to the WOMAC total score and subscores for up to six months after infiltration. VS also improved knee extensor and flexor strength in the same period, but not proprioception. These findings suggest that VS has a positive effect on quadriceps arthrogenic inhibition.Maia PAV was responsible for the concept and design, provision of study material or patients, collection and assembly of data, data analysis and interpretation, manuscript writing, and approval of the final version of the manuscript. Cossich VRA was responsible for the collection and assembly of data, data analysis and interpretation, and approval of the final version of the manuscript. Salles-Neto JI was responsible for the data analysis and interpretation, and approval of the final version of the manuscript. Aguiar DP and Sousa EB were responsible for the concept and design, collection and assembly of data, data analysis and interpretation, manuscript writing, and approval of the final version of the manuscript.


Chronic Obstructive Pulmonary Disease (COPD) is a clinically common chronic disease with the characteristic of recurrent attacks, difficulty of cure and high morbidity, disability, death rates. COPD exerts a great burden on patients, families and society. Acupoint Autohemotherapy (AA) is a traditional Chinese medicine (TCM) treatment by taking the patient's own venous blood and injecting them at acupoints, combined with the continuous stimulation of blood and the specific efficacy of the acupoint itself. It has been proved to be useful in pulmonary treatment and rehabilitation of COPD patients. However, the efficacy of AA on COPD patients has not been fully statistically evaluated. In this study, we aim to systematically examine the efficacy and safety of AA for COPD patients.Data from all English and Chinese databases, including Medline, Cochrane Library, Embase, China National Knowledge Infrastructure Database, Wanfang Database, China Biomedical Literature Database and Chongqing VIP information, will be used to conduct a systematic and comprehensive literature search. The range of date is from inception to July 2019. Randomized controlled trials (RCTs) related to AA and western medicine in the treatment of COPD will be included. Quality of included trials will be assessed according to the risk of bias tool of Cochrane Handbook 5.1.0. The GRADE approach will be used to rate the certainty of the evidence of estimates derived from meta-analysis. RevMan 5.3 will be used for data synthesis, sensitivity analysis, meta-regression analysis, subgroup analysis and risk of bias assessment. A funnel plot will be developed to evaluate reporting bias, and Begg and Egger tests will be used to assess funnel plot symmetries. Grading of recommendations assessment, development and evaluation system will be utilized to assess the quality of evidence.This systematic review and meta-analysis aims to summarize the direct and indirect outcomes for AA and western medicine on COPD patients and evaluate its efficacy and safety. The results will be submitted to a peer-reviewed journal once completed.The systematic review will provide evidence to assess the efficacy and safety of AA and western medicine in the treatment of COPD patients.PROSPERO CRD42019137189 It exerts a great burden on patients, families and society. According to reports, COPD is currently the fourth leading cause of death in the world. With the decline in environmental quality, it is expected to rise to the third place by 2020, becoming a health problem that cannot be ignored. However, the overall pathogenesis of COPD is not entirely clear, and the current treatments are mainly to relieve symptoms, which have significant limitations. Traditional Chinese medicine (TCM) has the advantages of multiple targets and systematic regulation, and its importance in the treatment of COPD has been highlighted.Chronic Obstructive Pulmonary Disease (COPD) is a disease characterized by persistent respiratory symptoms and restricted airflow,,6 It is a combination of TCM meridian theory, acupuncture, multi-component stimulation of blood cells and regulation of immune function of the body. Initially, the method was used to treat patients with malaise, malnutrition and anemia after malaria. After repeated clinical exploration, research and development, AA was used for more diseases treatments especially for respiratory diseases including COPD, asthma, cough variant asthma and has achieved satisfactory results.Autohemotherapy originates from Soviet in the 1940s and 1950s to treat tuberculosis hemoptysis by intramuscular injection, then it spread to China. Rui Jin, chief professor of Guangzhou University of TCM, created the Meridian Blood Injection Therapy which is also called Acupoint Autohemotherapy (AA) later, a TCM characteristic therapy that combine the continuous stimulation of blood with the action of acupoints to treat diseases by injecting the patient's venous blood into acupoints.At present, there are many clinical trials showing the efficacy and safety of AA combined with western medicine in the treatment of COPD. But the sample size varies, and it lacks certain persuasive power. The aim of this study is to comprehensively collect randomized controlled trials (RCTs) for the treatment of COPD with AA and western medicine, and to provide evidence for clinical practice by evaluating the efficacy and safety through the Cochrane systematic evaluation.22.1The study protocol has been registered on PROSPERO  (CRD42019137189). This protocol is developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses Protocols (PRISMA-P). Any protocol modifications made during the performing of the review will be recorded in the publication of the final report. The PRISMA Extension Statement is used to ensure all aspects of methods and findings are reported.2.2The PICOS (Population-Intervention-Comparators-Outcomes-Study design) framework was adopted as the eligibility criteria for the review as follows.2.2.1Whether or not blinding, allocation concealment, reporting withdrawal and loss of follow-up were performed, research that may be included in this review needs to first meet the following criteria:1.Randomized controlled trial;2.COPD patients without restrictions in sex, age, and race, and the ratio of forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) was less than 70% or FEV1 was less than 80% of predicted values according to the 2019 Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria;3.AA intervention lasted no less than 4 weeks;4.Outcome measures included FEV1, FEV1%, FEV1/FVC%, AE, 6MWD, SGRQ, CRQ, mMRC, CAT, or BMI.The following study designs or publication types will be excluded:1.Patient diagnosed with COPD but has other diseases such as respiratory failure, bronchiectasis, bronchial asthma, lung cancer, etc.2.Other interventions such as moxibustion, acupressure, Chinese medicine, etc. were combined in the treatment.3.Duplicate or non-clinical research literature.4.Containing other confusing signs or the data cannot be extracted, or lacking of outcome measures.These trails can be adopted if multiple intervention data are available. If data for comparing multiple interventions is not directly available, we will attempt to obtain the raw data by sending an email to corresponding author of the article. If the data is not available at the end, these documents will also be excluded.2.2.2 The stable phase of COPD usually means that there is no acute exacerbation within 4 weeks. Patients were included regardless of nationality, gender, age, and ethnicity.RCTs with a clear diagnosis of stable COPD were considered in accordance with the GOLD diagnostic criteria.2.2.3The control group was treated with western medicine. The main treatment option was using inhaled corticosteroids combined with bronchodilators, such as Salmeterol Xinafoateand Fluticasone Propionate Powder for inhalation and Budesonide and formoterol Fumarate Powder for Inhalation. At the same time, according to the patient's condition, using conventional therapy including bronchodilators, expectorants and other drugs combined with oxygen therapy, nutritional support therapy. The experimental group was treated with AA on the basis of the control group.2.2.4Primary outcome indicator: total effective rate of clinical treatment.Secondary outcome indicator:1.Pulmonary function:FEV1, FEV1%, FEV1/FVC%;2.The incidence of Acute Exacerbations (AE);3.Exercise endurance: 6-minutes walking distance(6MWD);4.Health-related quality: St. George's respiratory questionnaire(SGRQ)and Chronic respiratory questionnaire(CRQ);5.Health status: modified British medical research council (mMRC), COPD assessment test (CAT)and body mass index (BMI).2.3The work of document retrieval will be carried out from 3 English databases  and 4 Chinese databases from inception to July 2019. We will also undertake a targeted gray literature search on Clinical Trials.gov and the International Clinical Trials Registry Platform Search Portal to identify clinical trials, which are in progress or completed. And the following sources will also be searched including of Google Scholar, Web of Science and Baidu Scholar to identify trial protocols and other information. Furthermore, more studies will be identified after examining the reference lists of all retrieved articles.These following combined texts and Medical Subject Headings (MeSH) terms are used by us to search in the sources: ’autologous blood’, ’autohemotherapy’, 'self-blood’, ’acupoint’, ’injection’, ’chronic obstructive pulmonary disease’, ’COPD’, ’pulmonary disease’. The search terms will be ’autologous blood’ OR ’autohemotherapy’ OR 'self-blood’ AND ’acupoint’ OR ’injection’ AND ’chronic obstructive pulmonary disease’ OR ’COPD’ OR ’pulmonary disease’.2.4Two researchers  extracted data independently from the literature downloaded from 7 databases and managed by EndNote X9. Two researchers  independently screened the included studies, extracted data, evaluated the quality of included studies and cross-checked with each other according to the established selection criteria. If there are disagreements about the articles between the 2 researchers, objections will be delivered to the third researcher (Haidu Hong) and final decision will be made by him. First, the preliminary screening will be performed by reading the title and abstract of the obtained literature. Studies that fail to meet the eligibility criteria will be excluded. Then, full text of the articles will be retrieved to further determine whether they are included. The screening process will be presented with reference to the PRISMA statement as Figure 2.5The Risk of Bias Tool (ROB) in Cochrane Handbook (5.1.0) will be used to assess the methodological quality of included trials by two independent reviewers . Disagreements will be resolved by discussing with a third reviewer (Xiaohong Liu). The ROB contains the following seven items: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting and other sources of bias. The judgment of each item is divided into three levels: low risk of bias, high risk of bias and unclear risk of bias.We will evaluate the quality of evidence of the included studies through the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The limitations of the study, inconsistencies, indirect evidence, inaccuracies and publication bias will also be considered. Four levels of quality of evidence will be used: high, moderate, low, or very low.2.6If necessary, we will contact both senior and/or corresponding author of articles through email or telephone for further information about any missing data or unclear measurement scales. If no one responds or sufficient information cannot be obtained in this way, we will analyze the available data. The potential impact of insufficient data on the review results will be took into account in the discussion section.2.72 test and the I2 test. Heterogeneity will be considered as substantial if the I2 statistic≥50% and P < .10. If heterogeneity is considered as substantial, reasons for this heterogeneity will be searched for and a random-effect model could be used for comparison.The statistical analysis will be performed according to their commendations of the cochrane handbook and using the software of cochrane collaboration, RevMan 5. 3, available from the cochrane website. All outcomes will be continuous variables. The standardized mean difference and its 95% CIs will be calculated. Initially, a fixed-effect model will be used to compare with the outcomes expressed in the same scale. The heterogeneity of the effects of trials will be evaluated by the QSensitivity analysis, meta-regression, and subgroup analysis might be conducted if there are potential sources of heterogeneity. Qualitative synthesis will be performed if data extraction is insufficient.2.8This part is not covered in this study.3We aim to publish this systematic review in a peer-reviewed journal. This study aims at providing available evidence for the efficacy and safety of AA on the treatment of stable COPD patients. Ethical approval will not be demanded since there is no participant privacy involved.4 If the COPD is not controlled, it will develop into the final outcome of chronic pulmonary heart disease. At present, the main treatment methods of Western medicine included smoking cessation, oxygen inhalation, lung volume reduction surgery, and drug treatment . However, there are still controversies and limitations in the development of individualized programs, the use of bronchodilators in the initial treatment, the side effects and withdrawal of ICS and so on.The latest research shows that the overall prevalence of COPD in China is 8.6%, while the subgroup of patients over 40-year-old has nearly 99 million people, accounting for 13.7%. The theory of AA comes from the TCM mainly. First, blood can nourish the weak state of the body, and the meridians can connect with the major organs of the body and be effective through specific acupoints. Second, the lungs lead the blood vessels and veins, so treatment with blood can be effectively applied in lung diseases. Third, the stimulation produced by acupuncture and blood synergy is long-lasting, slow, continuous and effective. Modern research shows that the human body's own blood is rich in hormones, antibodies, complement and other elements, does not have rejection and can stimulate the body to release more immunoglobulin, enhance microcirculation. At the same time, it antagonizes histamine, acetylcholine and serotonin to reduce the permeability of capillaries and inhibit allergic reactions.,16 Therefore, based on the theoretical basis of Chinese and Western medicine, AA is particularly suitable for improving the long-term weakness of COPD. In terms of treatment, the back-three-needles , EX-B1 and other pulmonary meridian acupoints are mainly used. According to the different symptoms of the patients, other auxiliary acupoints such as BL20 and ST36 are appropriately included.COPD belongs to the category of ’lung distention’ in TCM theory, which is due to repeated episodes of chronic lung diseases, prolonged unhealed, resulting in lung, spleen, kidney 3 visceral damage, lung qi stagnation, chest fullness.Although a large number of studies have shown that AA is effective in treating patients with COPD, the evidence for AA in improving FEV1, 6MWD and reducing the number of acute attacks is still insufficient. In order to systematically assess the effect of AA on all aspects of COPD treatment, our goal is to include adequate research on meta-analysis to ensure sufficient evidence. We expect AA to have a more positive impact on COPD patients. The results of this review may help provide more reliable evidence for the advancement of AA management and application in the treatment of COPD.Conceptualization: Haidu Hong, Chushuan Huang, Jieying Li.Data curation: Chushuan Huang, Chumin Chen, Rui Zhou.Formal analysis: Chumin Chen, Rui Zhou, Jieying Li.Funding acquisition: Rui Zhou, Xiaohong Liu.Investigation: Haidu Hong, Chushuan Huang, Jieying Li.Methodology: Chushuan Huang.Project administration: Chumin Chen.Resources: Chumin Chen, Rui Zhou.Software: Haidu Hong, Chushuan Huang.Supervision: Rui Zhou, Xiaohong Liu.Visualization: Chushuan Huang.Writing – original draft: Haidu Hong, Chushuan Huang, Xiaohong Liu.Writing – review & editing: Haidu Hong.