Background: Ultrasound-guided axillary brachial plexus block (ABPB) is a technique of choice for regional anesthesia during hand and forearm surgery. Intravenous sedation may facilitate this procedure, particularly for those suffering from anxiety; however, it can also be associated with respiratory, cardiovascular, and neurological side effects. The objective of this study was to evaluate the effect of intravenous sedation on perioperative respiratory depression for patients undergoing day-case hand surgery under ABPB. Methods: A prospective, observational, single-center study was conducted between 1 May and 1 November 2016. Results: A total of 2318 patients were included, with 501 patients in the group with IV sedation and 1817 in the group without. A multivariable propensity-score matched analysis showed that the variables associated with the number of desaturation were: (i) sedation (aRR 1.534 [95% CI: 1.283 to 1.836]), (ii) age and sex, (iii) type of surgery, and iv) Body Mass Index (BMI). Conclusions: Supplementing ABPB with IV sedation was associated with an increased rate of respiratory depression (episodes of desaturation) compared to fully awakened patients. The rate of oxygen administration was also higher in sedated patients even though they had fewer cases of chronic respiratory diseases and fewer were active smokers than non-sedated patients. Future research should consider precisely evaluating patient satisfaction, as well as the differences between sedation and drug-free approaches. Monitored Anesthesia Care (MAC) during hand and forearm surgery usually involves Axillary Brachial Plexus Block (ABPB) to control pain and ensure that a limb is immobile as well as conscious during sedation to diminish patient anxiety concerns ,2. CurreIntravenous (IV) conscious sedation reduces anxiety more effectively ; howeverThe primary aim of this study was to evaluate the effect of conscious IV sedation on perioperative ventilatory depression in patients undergoing day-case hand surgery under ABPB. The secondary aims were to study the effect of conscious IV sedation on perioperative hemodynamic parameters, patient satisfaction, and average time spent in the post-anesthesia care unit (PACU) and determine the variables associated with a risk of desaturation that could influence an anesthesiologists’ decision to use sedation.A prospective observational study evaluating usual ABPB procedures at the Fontaine-Lès-Dijon Clinic between 1 May 2016 and 1 November 2016 was carried out. Patients undergoing day-case hand surgery under ABPB were eligible for this study. The inclusion criteria were age ≥18 years, American Society of Anesthesiologists (ASA) physical status score of 1 to 3, and were undergoing day-case hand surgery (either planned or emergency) under ultrasound-guided ABPB. The patient’s consent was recorded orally.Patients with hand surgery were referred to our center, and therefore there were no patients with other trauma. The types of surgeries performed in our study were mainly: carpal tunnel, dupuytren, trapezio-metacarpal prosthesis, jump fingers, and De Quervain’s tenosynovectomy. Most emergency surgeries involved fractures or hand injuries. The exclusion criteria were refusal to participate, patients <18 years of age, pregnancy, major dementia that would prevent employing usual procedures or data collection, and chronic respiratory failure. The sample was a convenience sample based on the maximum number of patients available during the study period. Blocks were conducted in a dedicated block room. Patients were then transferred to the operating room and then to the PACU. The ultrasound machine used to perform the ABPB was a NextGen LOGIQ by General Electric with a linear, 47mm, high frequency 4–13Mhz probe. The patients were placed in a supine position; their arm was abducted 90° from the body at the shoulder and flexed 90° at the elbow. After appropriate skin preparation with 2% chlorhexidine plus alcohol, the block was performed. The probe was placed in the transverse plane at the lateral border of the pectoralis major muscle to obtain the best view of the brachial plexus. The practicians used an in-plane approach with a short-beveled, 5-cm, 22G insulated needle; after that, each nerve was identified and blocked separately, and an ultrasound-guided block of the medial brachial cutaneous and the intercostal nerves was performed to prevent pain associated with the use of tourniquets .Patients admitted for planned surgery received either oral premedication with alprazolam one hour before being transferred to the operating theater or no premedication in accord with the arrangement chosen during the pre-anesthesia consultation. Patients admitted for emergency surgery were transferred directly to the operating theater with no premedication. Patients were compared according to the use of IV sedation. During regional anesthesia, the attending physician was free to use IV sedation in accordance with the patient’s wishes, by either administering midazolam (1 to 2 milligrams depending on the patient’s weight and level of anxiety) or by an association of drugs (1 to 2 milligrams of midazolam associated with propofol (20 mg maximum), sufentanil (5 ug maximum), or ketamine (10 mg maximum)). The choice of local anesthetic and/or administration of oxygen was left to the attending physician. The level of anxiety was a subjective evaluation by the physician, and no objective criteria were used to decide if IV sedation drugs should be used. The ABPB was ultrasound-guided, and music could also be provided with headphones for a patient to listen to. The choice between mepivacaine and ropivacaine was left to the discretion of the anesthesiologist who performed the block. Most of the time, mepivacaine was used for short, painless, post-operative surgeries, such as carpal tunnel. Ropivacaine was used for long surgery that caused postoperative pain, such as fractures.Patients were then transferred to the operating room for surgery, after which they were monitored in the PACU following the usual criteria for postoperative observation. Patient satisfaction was rated on a ten-point Likert scale. On the day following the procedure, patients were contacted by telephone and asked about any post-surgery complications that may have occurred. Data collected included: age, gender, ASA score, height, weight, history of arterial hypertension, chronic respiratory disease , smoking habits, antihypertensive medication or beta-blockers, body mass index (BMI), type of surgery (emergency or planned), attending surgeon and anesthesiologist’s names, operation site, premedication and the molecule used, sedation methods and the molecule used, presence of music during the procedure, choice of local anesthetic and adjuvant (if applicable), oxygen administration, mean systolic and diastolic blood pressure in the operating theater, mean oxygen saturation in the operating theater, mean heart rate in the operating theater, number of episodes of decreased oxygen saturation in the operating theater, pain in the PACU , a patients Aldrete score when leaving the PACU, patient satisfaction in the PACU, time spent in the operating room, time spent in the PACU, and the total time spent on site. Data collected by telephone the following day included: whether the call was answered or not, and if so, if there was any pain during the night after surgery, pain medication taken, nausea and/or vomiting, food intake, presence of fever, bleeding, rate of compliance with prescribed treatment(s), and any presence of dyssomnia. The primary outcome was the number of oxygen desaturation, which was defined as pulse oximetry readings (SpO2) below 93%  and which required physician intervention. Monitoring of SpO2 began upon arrival in the regional anesthesia preparation room and continued until departure from the PACU. In case of desaturation associated with somnolence, verbal stimulation was conducted. In case of persistent desaturation, oxygen was provided at 4 L/min with a nasal cannula. Secondary outcomes were oxygen administration, total time spent in the operating theater, patient satisfaction with the monitored anesthesia care evaluated in the recovery room, mean heart rate, and systolic and diastolic blood pressure in the operating theater. t-test, and non-normal quantitative variables were compared using Mann–Whitney’s U test.Qualitative variables were presented as absolute frequencies with associated percentages. Normally distributed quantitative variables were presented as means with their standard deviations (SDs). Quantitative variables that were not normally distributed were presented as medians with the interquartile range. Qualitative variables were compared between sedated patients and non-sedated patients using a Chi-squared test or a Fisher’s exact test according to their distribution. Normally distributed quantitative variables were compared using a Student’s To account for the non-randomized nature of the data, a propensity score analysis was conducted. We estimated the predicted probability of sedation using a multivariable logistic regression model. The variables included in the model were those associated with a risk of desaturation that could influence the anesthesiologists’ decision to use sedation. These variables were: respiratory disease, age, sex, BMI, anesthesiologist’s name, operating surgeon’s name, and the ASA score. To reduce indication bias, we matched patients by using their calculated propensity scores. A fixed ratio of 1:1 matching without replacement was also used. Patients who could not be matched to a similar patient in the opposite group were excluded from the analysis to limit indication bias.A multivariable analysis was also performed as an additional step to account for residual confounding that could be present after matching. This analysis was based on a negative binomial (NB) model with the number of desaturation episodes as the independent variable. The NB model was used because of the right-skewed nature of the outcome, which has a higher variance than would be expected with a Poisson distribution. The main parameter of interest in our study was the exponentiated regression coefficient of the sedation variable.www.R-project.org). Multivariable analysis was performed using SAS version 9.3 .The variables included in the multivariable model were sedation, ASA score, age (included as a continuous variable), gender, time in the operating room (included as a continuous variable), type of surgery (emergency or other), respiratory disease, BMI (included as a continuous variable), high blood pressure (yes/no), and any use of a beta-blocker. Data management and matching were realized using R version 4.0.0 , our study was submitted to the National Commission of Data Protection (CNIL) via the hospital’s personal data protection correspondent (Declaration N°1975811v0) on 16 July 2016. Patients received an informational leaflet concerning the design and aims of the study, their right to refuse to participate, and their right to leave it at any time (Appendix 1). Their consent was recorded orally. ABPB and anesthesia case studies are common practices in our center. The data used in the study were also routinely collected during such procedures. p = 0.009) and active smoking was lower in the sedated group . Sedation more frequently involved the use of midazolam alone rather than an association of sedative drugs .During the study inclusion period, 2844 patients were screened . Of thesp = 0.002). The highest number of desaturation was recorded in patients sedated with multiple drugs: median 3.5 (Q1–Q3 1–33). The administration of oxygen was more frequent in sedated patients . In addition, scores of patient satisfaction were lower (60.2 % of maximum scores vs. 67.0%). The median time spent in the recovery room was longer in the sedated group , as was the median time spent in the operating room . Information collected by phone on the following day is presented in p = 0.006). There were no between-group differences related to pain during the first night, use of pain medication, nausea/vomiting, food intake, fever, bleeding, treatment compliance, or dyssomnia. The median number of desaturation was higher in the sedated group than in the non-sedated group: 3 (Q1–Q3 1–17) vs. 1  for the covariates used in the propensity score calculation is presented before and after matching. A high SMD indicates that the treatment group is different from the control group for the relevant covariate. SMDs in the matched population are shown in red. After matching on the propensity score, SMDs for all covariates were <0.20, indicating an acceptable balance.The dispersion coefficient of the multivariable model was 2.57 [95% CI 2.20 to 3.01], which suggests that the use of the NB model was adequate. Sedation was associated with a higher number of desaturation (aRR 1.534 [95% CI 1.283 to 1.836]) . Other vThe results of this study showed that when ABPB is associated with sedation, the rate of ventilatory depression (oxygen desaturation number) was higher than for ABPB alone. Furthermore, the rate of oxygen administration was higher for sedated patients even though the patients in this group had fewer chronic respiratory diseases and fewer were smokers. The time spent in the recovery room was also higher for sedated patients. The time spent in the operating room was not significantly associated with sedation; therefore, it is unlikely to explain our results. On the other hand, as patients are released from PACU when the effects of anesthesia and sedation wear out, any additional time spent in PACU can be seen, therefore, rather than a cause of the number of desaturation. Therefore, we did not adjust for time spent in PACU because such an adjustment could bias the results by masking a true effect of sedation. Lastly, patients who were sedated were less satisfied.Limited information is available in the literature about the complications associated with IV sedation. This may mostly be because of the diverse types of MAC and the lack of clearly defined study protocols. An epidemiological study into the complications associated with sedation by the American Society of Anesthesiology published in 2006  showed tIn this study, the rate of desaturation increased with sedation. In addition, oxygen was administered to 5% of sedated patients compared to only 0.3% of non-sedated patients. The rate of hemodynamic side effects, however, was not higher in the sedated group, which was probably due to the high proportion of patients sedated by midazolam, which has fewer hemodynamic effects than other sedative drugs . Satisfaction scores were lower in the sedated group even though they were generally very high in our study. The clinical significance of this difference is therefore limited. The high satisfaction scores may not be surprising since patients who undergo day-case surgery are usually very satisfied with their care . They alAn important secondary finding was the increase in the time spent on-site, which was over ten minutes longer in the sedated group and was mainly due to the increased time spent in the recovery room. This increase, which could be attributed to the neurological effects of midazolam, is consistent with previous findings . Since tOnly 28% of patients were successfully contacted on the day following their surgery. This response rate is lower than previous studies that had a contact rate between 35% and 52% . Our finTo the best of our knowledge, this is the first study to evaluate the effects of sedation during regional anesthesia in an operating theater in a large cohort of sedated and non-sedated patients. Our study had several limitations. First, it was open-label, single-center, and non-randomized. The results are therefore subject to selection and interpretation biases since the choice of sedation was left to the discretion of the attending physician. However, the groups were generally comparable except for the presence of respiratory disease. This may suggest that anesthesiologists were more reluctant to sedate patients with a history of respiratory problems. It would be reasonable to expect that this choice would have led to a lower rate of ventilatory depression in the sedated group; however, the results show the opposite and suggest that in spite of the methodological limitations of this study, there is a tangible effect of sedation on respiratory function.Measurement error may have occurred for pulse oximetry recordings because SpO2 and blood pressure were measured on the same limb, given that the other limb was positioned within the surgical field. It has been reported that measuring blood pressure can decrease SpO2 ; howeverThe pertinence of patient satisfaction measurement using a simple Likert-type numeric scale may be questionable given the complexity of evaluating such a variable . A multiThe results found in this study suggest that sedation increases perioperative ventilatory depression without increasing patient satisfaction. Thus, the use of sedation may not comply with current rapid rehabilitation objectives during day-case hand surgery. Further studies are needed to accurately evaluate patient satisfaction, whether different drugs used for sedation would yield different outcomes, and the differences between sedation and non-sedation techniques.


Background: This study aimed to determine whether the prevalence of acute vertebral osteoporotic compression fractures (VOCF) in the elderly population is related to the distribution of muscles and fat in the human body.Methods: Data of acute VOCF and non-VOCF patients presenting at our institution between January 2018 and May 2020 were analyzed. Patients aged 65 years and older, who underwent body composition test and dual-energy X-ray absorptiometry at the same time were enrolled. After applying exclusion criteria, patients were divided into four groups: normal, sarcopenia without obesity, obesity without sarcopenia, and sarcopenic obesity. Body mass index ≥25 kg/m2 was considered obesity, and sarcopenia was defined as skeletal muscle index lower than 7.0 kg/m2 in males and 5.4 kg/m2 in females. The VOCF rate was analyzed between the groups.Discussion: A total of 461 patients were included, of whom 103 were males. Among them, 163 (35.36%) had normal body composition, 151 (32.75%) had sarcopenia without obesity, 110 (23.86%) had obesity without sarcopenia, and 37 (8.03%) had sarcopenic obesity. The sarcopenic obesity group had the highest rate of acute VOCF (37.8%), which was statistically significant. Specifically, females with sarcopenic obesity and sarcopenia without obesity had significantly higher acute VOCF rates compared to those with normal body compositions. Multivariate analysis showed that sarcopenic obesity was significantly associated with acute VOCF rate overall, as well as in females.Conclusion: Sarcopenic obesity is strongly associated with acute VOCF, especially in females, and it could be an essential criterion for the prevention of acute VOCF. Vertebral osteoporotic compression fracture (VOCF) causes a reduction in vertebral body height and is most frequently seen in the thoracolumbar transition zone . SymptomMany risk factors associated with VOCF have been reported. Risk factors are categorized into not modifiable, such as age, gender, and race, and potentially modifiable factors such as alcohol use, osteoporosis, early menopause, and malnutrition . RecentlSarcopenic obesity is a combination of two words: sarcopenia and obesity. Appendicular lean mass (see Diagnosis Criteria for Sarcopenia and Obesity section) is used to define sarcopenia. If sarcopenia coexists with excess body fat, it is called sarcopenic obesity . NumerouIn this cross-sectional study, we collected the data of patients who underwent dual-energy X-ray absorptiometry (DEXA), including body composition tests, and analyzed the rate of acute VOCF according to the groups divided by criteria of bone mineral density (BMD) and muscle volume. With the difference in the prevalence of acute VOCF and adequate statistical methods, we aimed to determine the relationship between body composition category and acute VOCF.n = 12); 2. Patients with old VOCF history (n = 95) since we only focused on acute VOCF; 3. Patients with high-energy injury mechanisms, such as severe traffic accidents or falling from a tall height (n = 14) as most patients presented with mild back pain or other soft tissue injuries; 4. Patients who underwent body composition tests more than 2 weeks from the diagnosis of acute VOCF (n = 36) since the treatment of acute VOCF can influence the patient's nutrition and activity so that the body mass index and body composition can change; 5. Patients with possible secondary cause, such as bone metastasis and primary hyperparathyroidism (n = 4). Finally, a total of 461 patients were included in the statistical analyses , we initially set up the range of the reference group. Informed consent for participants is waived. We included patients who were presented to the spine center and health promotion center at the CHA Bundang Medical Hospital between January 2018 and May 2020. For the patients who visited the spine center, those who were diagnosed with acute VOCF, based on history taking, physical examination, and spine radiography, was included in the experimental group (Acute VOCF group). We only assumed that the patient had the acute VOCF when the patient had the recent trauma history and the tenderness on the fracture site without callus formation on the spine radiography. Finally, we created a list of patients aged 65 years and over, who underwent DEXA with body composition tests at the same time. On the other hand, patients who visited the health promotion center were selected as a reference group. Since people over 65 can receive insurance coverage in our country. These patients took the same tests but did not have acute VOCF on spine radiography. As it was designed as a retrospective study, a total of 622 patients were enrolled initially. After detailed history taking and baseline evaluation, the patients were excluded based on the following exclusion criteria: 1. Patients with incomplete data  – [Sum of bone mineral content] (g) is the exact calculation method. Among various cut-off values from numerous studies, and especially for ASIA consensus, SMI lower than 7.0 kg/m2 in males and 5.4 kg/m2 in females were employed  was calculated as body weight divided by squared height, and it was used as an index of obesity. Participants with BMI ≥ 25 kg/m outcome , 18. Nexemployed .3-specific kit  was used for vitamin D measurement. Also, we measured Serum PTH levels by standard enzyme-linked immunosorbent assay-PTH immunoradiometric assay  with 1.0 pg/ml as a minimal detection amount.Age, gender, BMI, height and weight, body composition, and T-score at the lumbar vertebrae and hip were obtained. T-scores were measured using DEXA  and were calculated by taking the difference between a patient's measured BMD and the mean BMD in healthy young adults, matched for gender and ethnic group, and expressing the difference relative to the standard deviation (SD) of the young adult population . In addihttp://www.R-project.org/). Continuous, normally distributed data are presented as mean and SD. Statistical significance was set at p < 0.05. We used the unpaired t-test and Pearson's chi-squared test to compare characteristics of subjects according to the gender. We also used Pearson's chi-squared test to confirm the difference between distributions of the body composition by gender. Univariate analysis was performed to determine the factors associated with acute VOCF. In addition, we performed post hoc analysis using Fisher's exact test, which is appropriate for handling small sample sizes, and compared the four body composition groups according to the presence or absence of acute VOCF. Multivariate logistic regression analysis was used, adjusting for factors and covariates to confirm the simultaneous effect of multiple factors associated with acute VOCF in female. Normal body composition was used as the reference category. Results were presented as odds ratios (ORs) with 95% confidence intervals (CIs) and Akaike Information Criteria (AIC) values, which estimate the quality of each model.The data manipulation and statistical analyses were performed using R software   .p < 0.001 by Pearson's chi-squared test. The details of the proportions of subjects in each of the four body composition groups are summarized in Regarding body composition category, ~30–40% of the study population was in the normal body composition group, irrespective of gender. The proportion of subjects with obesity, with or without sarcopenia, was higher in the female group. In contrast, the rate of sarcopenia, with or without obesity, was higher in the male group. Consequently, among the total patients, 163 (35.36%) had a normal body composition, 151 (32.75%) had sarcopenia without obesity, 110 (23.86%) had obesity without sarcopenia, and 37 (8.03%) had sarcopenic obesity with p < 0.001). The T-scores of the acute VOCF group were significantly lower than those of the healthy control group (p = 0.002 for the spine and p < 0.001 for the hip). In addition, calcium and phosphorus were also significantly different between the groups . However, co-morbidities, such as hypertension and diabetes mellitus, were not significantly different between the two groups. In the normal group, 14.1% of the patients had acute VOCF. The sarcopenia without obesity group had a fracture rate of 22.5%. The obesity without sarcopenia group had the lowest fracture rate (11.8%). Finally, the sarcopenic obesity group had the highest fracture rate (37.8%). Pearson's chi-squared test demonstrated that the fracture rate was significantly different among these four groups (p = 0.003)  .post-hoc analysis with Fisher's exact test was applied to assess fracture rate of each body composition group compared to that of the normal body composition group. In the entire study population, a significant difference was found only between normal and sarcopenic obesity (p = 0.002). Regarding the females, we observed that both sarcopenia without obesity and sarcopenic obesity groups had significantly higher rates of acute VOCF than the normal group . However, in the male group, there were no statistically significant correlations in the post hoc analyses . Sarcopenic obesity was especially significant in all the models  had a significantly higher fracture rate suggesting that both weight control and muscle gain may give a protective effect to the bone health, especially in vulnerable patients. Also, this result was prominent especially for the female patients. In addition, obesity may intensify sarcopenia by acting in concert with it, resulting in physical impairment, metabolic disorders, and mortality.Previously, these important concepts have been broadly used in various studies, and their utilization is gradually increasing. Furthermore, several studies have already reported analyzed the association between body composition and VOCF and have not reached a conclusion yet. For instance, Hida et al. found a higher prevalence of sarcopenia and lower leg muscle mass among patients with acute VOCF compared to those without acute VOCF . On the We found some mechanisms and supporting reasons for the findings of the present study. The back muscles that protect the spine around us are huge, and when standing up, they have a significant impact on our stability, various exercises, and daily lives. Therefore, this reduction in muscle mass not only weakens the muscle strength but also contributes to body instability. Song et al. reported that lumbar disc degeneration was correlated with multifidus degeneration . AccordiIn this study, the fracture rates among four body composition groups were not significantly different in males. It can be considered in conjunction with a higher BMD in males. In many previous studies, BMD has been proven numerically or biomechanically to be positively associated with osteoporotic fractures. Ehsanbakhsh et al. reported that vertebral fractures were observed in 43.6% of osteoporotic patients, 37.5% of osteopenic patients, and 22% of patients with a normal T-score . Jager eThis study has some limitations. First, as mentioned above, the number of male patients is less than the female patients and the ratio of fracture was also lower. In the further study, more male patients would be collected and we hope to find some other meaningful result regardless of gender. Second, because of the characteristics of a cross-sectional study, it was impossible to establish a real cause-and-effect relationship. It is expected that prospective research will be needed in the future to identify the causes and results throughout the periodic examination and analyses. Third, while the T-score of the spine was meaningful in the univariate study, it was not in the multivariate study, although we measured the BMD clearly according to the criteria, such as the exclusion of the vertebra with fractures. We think that this is because of the sclerotic change in the spinal body with aging. Also, unlike hip, abdominal fats in obese group could also influence the result of spine T-score . FinallySarcopenic obesity can be one of the expectation factors of the acute VOCF. It could be an essential criterion for the prevention of fracture, thus finally could also be used as an fracture fragility indicator.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Institutional Review Board Approval (No. 2021-02-019). Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.YL: manuscript writing and data curation. H-JL: conceptualization, investigation, manuscript review, and editing. SY: data curation and methodology. JS and K-CP: data curation. S-yL: project administration and funding acquisition. SL: project administration, funding acquisition, and formal analysis. All authors have read and approved the manuscript.This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korean government (MSIT)  and by Korea Health Technology R&D Project through the Korea Health Industry Development Institute, funded by the Ministry of Health and Welfare, Republic of Korea (Grant Number HI16C1559).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Background: The COVID-19 pandemic has caused significant disruption to healthcare worldwide. In this study, we aim to quantify its impact of chest related radiological procedures over the different waves of local infection in Hong Kong across the territory's public hospitals.Methods: This was an observational study enrolling patients between January 2017 and December 2020. Consecutive population-based chest radiographs, CT, US, and interventional radiology (IR) procedures were obtained public hospitals across Hong Kong.Results: A significant reduction of 10.0% (p < 0.001) in the total number of chest radiographs was observed. Non-significant reduction of 2.5% (p = 0.0989), 39.1% (p = 0.2135), and 1.9% (p = 0.8446) was observed for Chest CT, Chest US, and Chest IR procedures, respectively, in 2020 compared to the projected values.Conclusion: Although, it was anticipated that there would be a significant impact to health services caused by the pandemic, for chest-related investigations in Hong Kong, the impact was not as severe. Quantitative analysis could help with future planning and public health decision making. Significant impact of coronavirus disease 2019 (COVID-19) was observed in the year 2020. In particular, medical services have been reduced or have been redirected toward caring for patients with coronavirus disease 2019 (COVID-19) –6 were rp < 0.05. The analysis was performed using R Studio version 1.3 .The Hong Kong Hospital Authority Clinical Data Analysis and Reporting System (CDARS) was used to conduct a retrospective search of electronic records of patients using a national database. The study was approved by the institutional review board, and, due to the retrospective nature of the study, the patient consent was not required. The study retrieved data between January and December of the years 2017 and 2020, covering chest imaging investigations, specifically chest radiographs, chest computed tomography (CT), chest ultrasound (US), and chest interventional radiology (IR) procedures. The time series model was conducted on the data from the prior years of 2017–2019 to estimate the predicted number of procedures in 2020 . Differences in counts between the predicted and actual values were compared using a generalised linear model with the Poisson distribution. Statistical significance was set as p < 0.001) in the total number of chest radiographs was observed in 2020 compared to the predicted value based on the time series model. Non-significant reduction of 2.5% (p = 0.0989), 39.1% (p = 0.2135), and 1.9% (p = 0.8446) was observed for Chest CT, Chest US, and Chest IR procedures in 2020 compared to the predicted values based on the time series model .For chest radiograph, reduction was observed in all the months of 2020 compared to predicted numbers . For chest CT, although marked reduction was observed initially, there was an increase in number of investigations in the months of June, and September to December, and, by the year end, there was only minimal overall reduction of 2.5% for 2020. For chest US, the monthly changes showed a double-digit percentage reduction in January to November (−12.1 to −71.3%) in 2020 with only a mild catchup (2.2%) in December. For chest IR, monthly analysis showed a reduction in the period of January to March in 2020, and subsequently increased in the following months with another reduction in October, with increasing numbers again toward year end. As a result, the overall yearly reduction was mild  compared with inpatient . For Chest CT, outpatient investigations were more affected with overall reduction observed  compared to mild increase for inpatient investigations . For Chest US, the inpatient contributed a marked reduction  compared to a modest reduction for outpatient . Finally, for chest IR, the reduction by type of a patient was mild for inpatient  and large for outpatient . However, the total chest IR done for outpatient was <10 procedures, which may be regarded negligibly small to draw firm conclusion . It must be noted that the numbers were few, in general, to draw any firm conclusion. It was not possible to clearly identify the reasons  due to retrospective nature of the study across multiple sites. Looking ahead, as we move toward living with COVID-19 as endemic infections, continued practises of enhanced precautions may become permanent. Health providers must, therefore, try to be more proactive and anticipate potential impact in the event of an outbreak, and minimise the impact of reduction in radiological investigations as far as possible. There are a few ways that one could do this. First, for urgent investigations, provisions must be put in place to be able to provide these services and minimise the cancellations as far as possible. Second, if cancellations were to occur for non-urgent cases, the healthcare providers should adopt a system that allows for a more rapid rearrangement and, for example, may increase the quota of non-emergency outpatient investigations to offset any reduction of services during the localised outbreaks. Radiologists should work closely with their referral doctors to review and reschedule such examinations.In conclusion, despite relatively low case numbers in Hong Kong compared to other countries, a significant reduction in chest radiographs investigation was seen, but not for chest CT, chest US, or chest IR procedures when analysed at a population level based on yearly analysis.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Cluster Research Ethics Committee/Institutional Review Board (REC/IRB). Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.KN and VV were involved in study conception, statistical analysis, drafting of the initial version of the manuscript, data collection, and statistical analysis. VV supervised the work and offered significant intellectual contribution. All the authors offered significant intellectual contribution for the last version of the manuscript and approved the final form.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Obesity is a heterogeneous disease in terms of body mass index (BMI) and metabolic status. The purpose of this study was to investigate the risk of type 2 diabetes mellitus (T2DM) in subjects with metabolically abnormal but normal weight (MANW) in China.A prospective cohort with a total of 17,238 participants of the Zhejiang metabolic syndrome cohort was recruited. According to the standard of the Working Group on Obesity in China, general obesity is defined. Metabolic abnormality was defined as two or more abnormal components (elevated triglycerides (TG), low high-density lipoprotein cholesterol (HDL-C), elevated systolic blood pressure (SBP) or diastolic blood pressure (DBP) or use of antihypertensive therapy, and elevated fasting plasma glucose or antidiabetic treatment). The hazard ratio (HR) and its 95% CI were calculated using a multiple regression model, adjusted for the potential confounding factors.Compared with metabolically normal and normal weight (MNNW) subjects, the metabolically abnormal and obesity/overweight (MAO) subjects had the highest risk of T2DM disease, with an HR of 4.67 (95% CI: 3.23–6.76), followed by MANW subjects  and metabolically normal but obesity/overweight (MNO) subjects  after adjusting for age, sex, smoking, drinking, physical activity, and family history of diabetes. Compared with that in the MNNW subjects, the HR in MANW subjects was significantly higher than that in MNO subjects. In normal-weight subjects, the HR of T2DM was significantly positively correlated with the number of components with metabolic abnormalities.MANW subjects had a higher risk of T2DM. MANW subjects should be given more attention in the prevention and control of common chronic diseases. Over the past few decades, the prevalence of overweight and obesity has risen rapidly around the world and has become a serious public health concern . ObesityPrevious studies have reported that MANW subjects might have an increased risk of long-term effects –11, but In this study, we investigated the association between the heterogeneous phenotype of obesity and the risk of T2DM using a prospective cohort study of a total of 17,238 participants in China, and we tested the hypothesis that MANW individuals are at increased risk of diabetes.The subjects were recruited from the Zhejiang metabolic syndrome cohort in the Zhejiang Province, Southeastern China.The cohort is a community-based prospective cohort that started from 2010 to 2014. This investigation was a study of 22,649 participants in five counties/communities in Zhejiang Province. The subjects were recruited from the residents of the cluster sample communities. This sample can represent the general population of the Zhejiang Province in terms of geographical location, demographic characteristics, and socioeconomic status. The epidemiological investigation, clinical health examination, and routine biochemical measurements were conducted at baseline. The protocols have been described in detail in the previous studies  and are 2. Participants were excluded from baseline if they had cancer, diabetes, severe cardiovascular disease, or cerebrovascular disease  or if they had missing data for physical examination, such as weight, height, blood pressure (BP), waist circumference (WC), or biochemical determination, including triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), and fasting plasma glucose (FPG). The participants who failed follow-up or migrated to other places (out of the county or city) were also excluded from the study. Ultimately, a total of 17,238 participants were recruited in the cohort.The participants were recruited for this study if they were ≥18 years old and had a BMI ≥18.5 kg/mThe protocol was approved by the Ethics Committees of both Zhejiang University School of Medicine. Written informed consent was obtained from each participant.At the baseline, the participants were interviewed face to face with a structured questionnaire; the details were reported previously , 16. TheThe anthropometric index, which includes weight, height, WC, systolic BP (SBP), and diastolic BP (DBP), were measured by well-trained investigators or doctors with a standard protocol . Height The overnight fasting blood samples were collected for each subject. Biochemical variables, including TG, total cholesterol (TC), HDL-C, and low-density lipoprotein cholesterol (LDL-C), were determined by a biochemical autoanalyzer . FPG was analyzed using the glucose oxidase method with the Beckman Glucose Analyzer .2). General obesity was defined by BMI with the criteria of the Working Group on Obesity in China (WGOC)  high TG (≥1.7 mmol/L), 2) low HDL-C (men <1.03 mmol/L and women <1.29 mmol/L), 3) high SBP (≥130 mmHg) or DBP (≥85 mmHg) or use of antihypertensive drug therapy, and  divided by the square of height (ma (WGOC) . Obesityapy, and  high FPGTherefore, metabolically normal and normal weight (MNNW) represents metabolic normality and normal weight, and MANW represents metabolic abnormality but normal weight. Metabolically abnormal and obesity/overweight (MAO) represents metabolic abnormality and obesity/overweight, whereas MNO represents metabolic normality but obesity/overweight.All the subjects were followed up after the baseline investigation and ended on the date of diagnosis of T2DM, lost to follow-up, or censoring date , whichever came first. After exclusion of type 1 diabetes mellitus, gestational diabetes mellitus, or diabetes due to other causes, T2DM was defined using the following criteria: 1) FPG ≥7.0 mmol/l, 2) any treatment for diabetes, and 3) self-reported history of diabetes, which were previously diagnosed by clinical physicians.In the cohort, the incidence of T2DM was identified through the Zhejiang Chronic Disease Surveillance System or by field-epidemiological investigation. The details of the Zhejiang Chronic Disease Surveillance System were reported previously . The invContinuous variables of normal distribution were described as mean and SDs, while continuous variables of skewed distribution were expressed as medians and interquartile ranges (IQRs). Categorical variables were expressed as number (%).The chi-square test was used to compare categorical variables such as metabolic components and behavioral factors. One-way ANOVA was used to compare the four metabolic phenotypes.The person-year of follow-up was calculated from the date of recruitment to the end of the follow-up period. The incidence of T2DM was calculated as the number of new cases divided by the person-years of follow-up. We have tested assumptions of the Cox proportional-hazards model using the Kaplan–Meier survival curves and a graphical approach based on a cumulative risk function, and the study was consistent with the Cox proportional-hazards model assumptions. The hazard ratio (HR) and its 95% CI of the obese phenotypes were calculated using a multiple Cox regression model, with the MNNW group as a reference group. There are three models used in the analysis to adjust for potential confounding factors: unadjusted model 1, model 2 with adjustments for age and sex, and model 3 with adjustments for age, sex, smoking, drinking, physical activity, and family history of diabetes.In the sensitivity analysis, we first excluded subjects whose outcomes occurred in the first 2 years of follow-up to avoid reverse causation. The analysis was performed using the strict definition of metabolic normality as zero abnormal components, while metabolic abnormality was defined as ≥1 abnormal components. We also analyzed subjects who were restricted to non-smokers or stratified by sex.p < 0.05 was considered statistically significant. All statistical analyses were conducted using PASW Statistics version 20.0 for Windows .A two-tailed There were 17,238 participants recruited in this study. Their mean age is 54.1 years (SD: 13.9 years), and 42.6% of the subjects were male.p-values <0.05).The basic characteristics of the subjects with the four obesity phenotypes are presented in p > 0.05), and this result may be due to the limited sample size .The results of the sensitivity analysis of the study are presented in Qualitatively consistent results were also found when the analysis was performed without adjustment, when adjusting for sex and age only or when making additional adjustments for smoking, drinking, physical activity, and family history of diabetes 3.In this prospective cohort study, we found that MANW subjects had a higher T2DM risk than the MNNW subjects. The risk was also positively correlated with the number of abnormal components in normal-weight subjects.There are different metabolic heterogeneities in obese and normal-weight subjects. Heterogeneous phenotypes may be associated with the risk of long-term effects. Many previous studies have investigated the effects of MNO, but the results have been inconsistent –13. ThesAlthough previous studies have mainly focused on MNO, recently, researchers have started to pay attention to the biological effect of MANW. MANW is an individual with a normal BMI and metabolic abnormalities. This phenotype accounted for approximately 5% to 45% of the normal-weight individuals . This prIn the cohort, the subjects with obesity and abnormalities also had the highest risks  in .These results indicated that MANW individuals were also the higher-risk population for T2DM. Compared with individuals with MNO and MAO, MANW more easily masks the need for screening, thereby delaying diagnosis and treatment and neglecting health management due to seemingly normal weight or normal BMI. Therefore, the public health implication in this study lies in the fact that phenotype-based management is important for obesity and that MANW individuals should be given more attention in clinical and public practice. Our results showed that the average age of the MANW group was higher than that of the other three groups and that in addition to weight control, attention should be paid to changes in biochemical indicators such as blood glucose, BP, HDL-C, and TG in the MANW , becauseThe Zhejiang cohort was recruited with a relatively large sample size of 17,238 participants and a long follow-up period of 10 years. The epidemiological data and the biochemical measurements were collected by trained health professionals following standard protocols. The incidences of T2DM were ascertained by record linkage with the data from the local chronic disease surveillance system or by field-epidemiological investigation. The potential confounding bias was controlled with a multiple Cox regression model, although similar results were found using different models. Sensitivity analysis also indicated consistent results under different conditions. These strengths increased the reliability of the evidence.However, there were some limitations in the study. First, there were multiple definitions of obesity and metabolic abnormalities, and no consensus has been reached until now, so the results may restrict the extrapolation to some previous studies using different definitions. To increase extrapolation, the present study used the most common definition of metabolic abnormality of ≥2 abnormal metabolic components. Second, repeated baseline surveys are ongoing, and the dynamic information on metabolic and obesity status has not been completely collected.Briefly, we found that MANW subjects had a higher T2DM risk, and this risk was higher than that in MNO subjects when compared with MNNW. The risk positively correlated with the number of abnormal components in normal-weight subjects. Phenotype-based management is important for obesity, and MANW individuals should be given more attention in clinical and public practice.The datasets used and/or analyzed in the current study are available from the corresponding authors and investigating coordinators upon reasonable request.The studies involving human participants were reviewed and approved by The Ethics Committees of Zhejiang University School of Medicine. The patients/participants provided their written informed consent to participate in this study.All authors listed have made substantial, direct, and intellectual contribution to the work and approved it for publication.This work was supported by grants from the National Key Research and Development Program of China (2017YFC0907004), the Hangzhou Science and Technology Project (20171226Y27), and Zhejiang Health Science and Technology Project (2021KY268).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


To create an instrument to assess smoking-related health literacy among smokers, and to estimate validity of its content and reliability. A methodological, quantitative study. The creation of the instrument included the following steps: establishing a conceptual structure; defining objectives and target population; preparation of items or response scales; selecting and organizing items; instrument structuring; content validation and pre-test. The instrument was named Smoking-related Health Literacy Assessment Scale. The Smoking-related Health Literacy Scale had statistically significant measures of validity and reliability. Test-retest revealed substantial to almost perfect levels of reliability (reproducibility). The Smoking-related Health Literacy Scale can provide researchers with a valid and statistically significant instrument, regarding content validity and reliability. Also, the Brazilian Public Health System (SUS - Sistema Único de Saúde) hospitalization and chemotherapy procedure costs attributable to smoking among individuals aged 35 years or older, in 2005, amounted to R$ 338,692.516,02 - approximately one third of overall SUS costs.According to the World Health Organization (WHO), 6 million deaths per year are caused by active or passive smoking.-12In this context, smoking has been attracting increasing attention in research globally. Smoking prevalence, the profile of smokers and their practices, motivations for smoking cessation or continuation, and addiction-related factors are major focuses of investigation. The motivation to understand smoking encourages investigations into the topic, including health literacy, since is thought to be associated with health outcomes and is, therefore, a matter of growing concern among researchers and professionals in this field. Health literacy includes personal, cognitive, and social skills associated with the ability to access, understand, evaluate and use health-related information, which is required to promote and/or maintain good health. It also involves individual and contextual determinants, such as patient-health care professional communication skills, cultural aspects, health system complexities, and demands driven by different scenarios or contexts.The current dynamics of interest for health-related issues and respective outcomes has led researchers and international organizations to develop instruments with applications, aimed to assess and/or measure health-related events.,14 The usefulness of instruments and their ability to provide robust results from a scientific standpoint are directly related to their quality; i.e., their reliability, validity, responsiveness and interpretability. Hence, in 2006 and 2007, an international, multidisciplinary Delphi consensus study, addressing quantitative assessment of health-related states and events, was conducted by 43 experts to establish standards for examination of the methodological quality of studies investigating these events or states . A checklist  comprising consensus-based standards for post-assessment selection of health measurement instruments was created. COSMIN checklist includes a set of parameters across four domains: three for instrument assessment - reliability, validity, and responsiveness - and one for interpretability. Interpretability is not a measure per se. However, it is a significant factor in the assessment of instrument appropriateness for application in research and/or clinical practice.There is a growing number of assessment scales and/or questionnaires. However, the quality of many of these instruments was incompletely and/or inappropriately examined. No instruments examining levels of health literacy about smoking have been found.Questionnaires are ancillary instruments in clinical practice, and are also used in health assessment and scientific research in the field of public health. Hence, these instruments have a significant impact on care-, treatment- and/or intervention-related decisions, as well as on formulation of health programs and institutional policies.To create an instrument to assess smoking-related health literacy among smokers, and to estimate validity of its content and reliability.Estratégias Saúde da Família (ESF) [Family Health Strategy program] units, in the city of Montes Claros, MG, Brazil.A methodological, quantitative study conducted in 2016, with 62 participants registered at two  First, an instrument aimed to measure health literacy about smoking named Smoking-related Health Literacy Scale (EAS-T) was created. Scale content validity and reliability (psychometric properties) were then examined.This study included the following steps when creating health measurement instruments: establishing a conceptual structure; defining of objectives and target population; preparation of items or response scales; selecting and organizing items; instrument structuring, content validation and pre-test.®, PubMed® and Virtual Health Library (VHL) databases. Publications in Portuguese, English and Spanish were retrieved. The purpose of the instrument to be created was defined: to assess health literacy about smoking. This step also included the definition of the target population: individuals aged 18 years or older registered at ESF located in the city of Montes Claros.The first step to create the instrument was a literature review, conducted to identify studies addressing “health literacy” and “smoking”, as well as the major measurement instruments used. This review was performed at MEDLINE was particularly emphasized, and some health literacy assessment instruments, such as the Short Assessment of Health Literacy for Portuguese-speaking Adults (SALPHA) selected for analysis.In the second step, items and the response scale were designed. These were carefully defined based on findings of the specific literature search on health literacy and Smoking, as well as on analysis of several pre-existing health literacy assessment instruments. With regard to theory, the theoretical model proposed by Sørensen et al.,Items included in the Smoking-related Health Literacy Assessment Instrument were methodically organized for general formatting purposes. The title, instructions and response scales were defined in this step of the process. The appropriateness and consistency of instrument items were examined using the content validation technique. At this stage, the instrument was submitted to expert judgment, with particular focus on quality of items, and their representativeness regarding the proposed objectives. The instrument was judged by ten health professionals, with different levels of education and expertise , who were invited by convenience, based on their respective professional activities and background.,18Content validation was carried out as follows. Invited professionals agreed to participate as judges by signing a term of acceptance and authorization. Judges were duly informed about objectives, methods, and procedures of instrument creation. Each judge conducted an independent assessment prior to meetings with other panel members. Judges were then asked to judge items and determine their comprehensiveness. Judges determined whether concepts were duly covered by the set of items, whether the content was appropriate for the target population, whether domain structure and content were correct, and whether domain content was representative. In the third step examined instrument items for propriety and qualitative properties .The above-mentioned procedures were conducted in an individual and independent manner, addressing the quantitative aspect of content assessment. Qualitative assessment was performed during meetings with judges and instrument creators. These meetings were guided by questions brought up over the course of item definition and selection, and involved different specialists, who were selected according to the nature of the piece of information. The fourth and last step involved content validation and consisted of discussion groups, including all judges to produce the final version of the instrument. Following conclusion and inclusion of all suggestions, the instrument was released and applied to a pilot sample comprising 60 individuals selected out of the target population.Pilot study interviews were conducted by previously trained interviewers . Data were collected at the home of individuals registered in the ESF following awareness raising efforts and invitation by members of the ESF team. Upon completion of the pilot study, interviewers participated actively in discussions with judges, during which their impressions regarding the need of instrument modifications/adjustments were communicated.Reliability assessment was based on test-retest and internal consistency. Test-retest was used to examine the ability of the test to produce identical results when measuring a given event in the same people on different occasions. Ideally, measures obtained on different occasions should be correlated. using the test-retest method. Selected participants were duly registered in two ESF units belonging to the Primary Health Care network of the municipality. Estratégias Saúde da Família units were selected at random and pilot study participants were excluded. Samples comprising a minimum of 50 and a maximum of 100 subjects are thought to be appropriate to examine the internal consistency and test-retest of measurement instruments.,21In order to determine the reliability of the instrument designed to assess smoking-related health literacy, the instrument was applied to a sample comprising 62 participantsParticipants were interviewed by the same interviewer on different occasions, 7 to 14 days apart. This sample comprised participants who signed an Informed Consent Form (ICF) and met the following criteria: 18 years of age or older, and registration at selected ESF units. Exclusion criteria were as follows: obvious signs of cognitive impairment and/or depression, illiteracy, non-native speaker of Portuguese, vision/hearing problems (reported or perceived), and/or intoxication by drugs or alcohol at the time of interview. Cognitive impairment assessment was based on the Mini Mental State Examination (MMSE).Statistical analyses were performed using (SPSS) for Windows, version 20.0, and Excel software. Sample profile was described using absolute and relative frequencies  or mean, standard deviation (SD), median and maximum and minimum values (continuous variables). In the reliability and internal consistency study, the level of agreement between two independent observations was measured using test-retest. Given the binary nature of assertive responses in the Smoking-related Health Literacy Assessment Instrument, the Kappa coefficient was applied to each instrument item. Agreement was rated according to dedicated literature, as follows: Kappa <0.00, almost non-existent; 0 to 0.19, low; 0.20 to 0.39, unsatisfactory; 0.40 to 0.59, moderate; 0.60 to 0.79, substantial; and 0.80 to 1.00, almost perfect.Instrument internal consistency was tested using Cronbach’s alpha. This parameter is calculated to examine the internal consistency of items and ranges from zero to one. The closer to one, the greater the reliability of the assessment instrument. Values equal to or greater than 0.7 are considered acceptable.Universidade Estadual de Montes Claros (Unimontes) and registered at the Sistema Nacional de Informações sobre Ética em Pesquisas envolvendo Seres Humanos (SISNEP), opinion no. 764.743, CAAE: 34687414.0.0000.5146.This research project was approved by the Research Ethics Committee of Most participants in this study  were female. The mean age was 54.9±9.97 years (range 29 to 77 years). Level of education ranged from zero to 12 years or more of study (mean 5.63±3.99 years).As to stratified age, a large proportion of participants  were aged 40 to 59 years. With regard to level of education measured in years of study, a significant proportion of participants  had between 1 and 4 years of study, whereas 19 (30.6%) and ten (16.1%) had from 5 to 8, and from 9 to 11 years of study respectively.As to occupation, most participants were housewives , retired , construction workers , teachers  or shop assistants . These data as shown in Content validation procedures, variables and items included in the final version of the Health Literacy Assessment Scale are shown in The reliability (reproducibility) of responses given to each word and/or term ranged from 0.75 to 1 (Kappa coefficient) . The ins Smoking habit assessment provides insights into people’s relationships and life context. Likewise, collective action planning and implementation must be based on people’s actual opinions and behaviors. Hence, the selection of assessment instruments is a vital decision. Investigations in this field may support policies and therapeutic approaches designed to tackle this significant public health concern in the individual and the community level.Smoking is a major public health concern in Brazil from a morbidity, mortality and health care cost perspective.,19Measurement of certain constructs requires valid and reliable instruments. The full development of a novel health measurement instrument is a complex procedure, demanding several resources and mobilization of abilities and knowledge in different areas.,25,26Population health assessment requires instruments capable of providing accurate, valid and interpretable data. Measurements must also provide robust results from a scientific standpoint. The significance of findings derived from such measurements is closely related to instrument reliability and validity. In spite of divergences, researchers believe reliability and validity to be the most important properties of measurement instruments.The assessment of psychometric properties of measurement instruments has been modified in the last century and trends pertaining to other contexts have been incorporated. According to such trends, the longer the instrument employed to assess a given construct, the better the validity. Therefore, a larger number of items would contribute to the calculation of reliability formulas, such as Cronbach’s alpha. However, in the last decades, this concept has been modified by a theoretical line of thought known as “item response theory” (IRT), which suggests shorter scales are as reliable as long ones.i.e., whether the instrument actually measures the intended theoretical construct). Cronbach’s alpha is an expressive and desirable measure of internal consistency for instruments aimed to measure a single construct using multiple items. It measures the correlation between questionnaire responses according to the profile of responses given by respondents, and therefore represents a mean correlation between questions. Ideally, the value should fall between 0.70 and 0.95.,27 Cronbach’s alpha values in this study were higher than 0.90, indicating very high internal consistency. The exclusion of four items in the scale  led to a slight increase in the alpha factor (from 0.915 to 0.916). However, this increase was not significant and both values reflect excellent reliability.With regard to reliability, high internal consistency was detected in this study. Internal consistency can be defined as the ability to determine the correlation or homogeneity between items in a scale type instrument  correlating both questionnaire application time points achieved good levels of agreement in all items (r>0.70).Test-retest is often used to assess the reproducibility and stability of measurements. However, natural changes over the course of test-retest applications are thought to be the primary source of error in reproducibility estimation obtained using retest-based, particularly when intervals between applications are long or when maturational aspects interfere with test-retest results.Processes described in this study are only a part of the steps in a set of methodologies, which must encompass additional measurements to assess other types of validity and reliability. The Smoking-related Health Literacy Assessment Instrument instrument may provide researchers in this field with a user-friendly tool, with good levels of content validity and reliability, and applicable to longitudinal or interventional epidemiological studies in public and collective health, designed to investigate changes in smoking-related health literacy levels. Findings derived from the application of this tool in research settings can be used to inform related interventions.This study describes aspects involved in the process of creating and measuring of content validity and reliability of a scale aimed to assess health literacy about smoking. The EAS-T achieved good levels of validity and reliability. Test-retest revealed substantial to almost perfect levels of reliability (reproducibility).Investigations with populations immersed in different contexts in the country are warranted to support findings of this study. Instrument development, including assessment of remaining psychometric properties, shall be continued.


Although economic factors account for the digital divide, the effect of economic insecurity on information communication technology (ICT) access has not been determined. The market-oriented reform of Chinese state-owned enterprises in the 1990s resulted in massive layoffs, encouraging us to investigate the relationship between economic insecurity and the digital divide. We draw on data from the China Health and Retirement Longitudinal Study (CHARLS). To handle the endogeneity related to economic insecurity, we use experience in a management position and the number of siblings as instruments for economic insecurity. With the introduction of these two instrumental variables, we find a negative relationship between economic insecurity and ICT access. This study provides insight into ICT policies involving underprivileged people in developing countries. The digital divide refers to the gaps in the access to ICT, ability to use ICT, and outcomes of the use of ICT , 2. The The major objective driving this research is to investigate the relationship between economic insecurity and the digital divide. Previous research has shown that economic factors  exacerbate the digital divide, whereas social factors involving social influence and social capital facilitate the narrowing of the digital divide , 13. HowThe digital divide is divided into three degrees: access to IT, ability to use IT, and outcomes of the use of IT , and ecoHowever, the link between economic insecurity and the digital divide remains unknown. For instance, COVID-19 as a potential source of economic insecurity  has raised concerns because of its effect on digital access –19. AddiIn Mao Zedong's era (1950s–1970s), SOEs had two defining characteristics: being a self-sufficient community and permanent employment , 24. On With the economic reform and open-up policy proposed in Deng Xiaoping's era (1980s–1990s), the successor of Mao Zedong, the Chinese economy transitioned from a state planning pattern to a free market in the next decades. In the process of market-based reforms, SOEs were characterized by low transparency, low competitiveness, and low profitability . In 1995Two datasets are used in this study: the China Health and Retirement Longitudinal Study (CHARLS 2011) and the CHARLS Life History Survey (2014). The CHARLS is a survey of middle-aged and elderly people (aged 45 and above) in China. It is based on similar surveys, such as the English Longitudinal Study of Aging (ELSA) and the Survey of Health, Aging, and Retirement in Europe (SHARE). The CHARLS (2011) covered 150 counties and 450 communities across China, involving 17708 individuals. The participants were selected via probabilities proportional to size at the neighborhood level and geographic information systems at the household level. Therefore the repetitiveness was guaranteed . The CHAFollowing suggestions of previous studies , 27, we The digital divide has three types: access to ICT, ability to use, and outcomes of the use of ICT . In this(1) Health Condition. We divide health conditions into chronic disease and infectious disease. The CHARLS (2011) provides the self-reported number of chronic and infectious diseases diagnosed by physicians. Respondents in our sample have an average of 1.324 chronic diseases and 1.005 infectious diseases.(2) Education. Education is divided into four groups: illiterate , primary (elementary school), medium (middle school), and high (college and above). The distribution of the education level is 16.06% (illiterate), 36.63% (primary), 43.35% (medium), and 3.96% (high).(3) Wealth. Because more than half (63.19%) of the respondents lived in rural areas, it is difficult to measure income. As suggested in the previous research [research , we adop(4) Residence. The type of hukou is used to identify residents in rural and urban areas. Considering the urban-rural disparity in China, we use the category of hukou to identify respondents' residence, and 64.14% of residents lived in rural areas and 35.86% in urban areas.(5) Living Arrangement. Household size and living with adult children are used to measure the living arrangements of respondents. The mean household size is measured by family members living in the same household, which is 3.566, and 55.73% of respondents live with adult children (aged above 16).(6) Community Infrastructure. Community infrastructure is a multidimensional construct, ranging from facilities to services available in communities [munities . To meas(7) Public Investment. Public investment is measured by the general budgetary expenditure of the respondent's local government . The general budgetary expenditure involves education, social safety net and employment effort, medical and healthcare services, agriculture forestry, and water conservation. The public investment data are from the Statistical Yearbook of China's Regional Economy (2012).The endogeneity of economic insecurity may result in biased estimation of the causal link because of potential omitted variables , such asFirst, we assessed the relationship between layoff in SOEs and two instrumental variables: management experience (ME) and siblings.Because instrumental variables (IVs) are related to instrumented variables but with no direct association with the dependent variable, we use management experience (whether the respondent used to be a manager) and siblings (number of respondent's living siblings) as IVs.(1) Management Experience. Employees with management experience obtain extra advantage over their peers because management positions are related to valuable information and social connections. For instance, middle managers serve as a bridge between top managers and frontline workers, ensuring the implementation of the strategic aims of enterprises [ME equals 1 and the respondent will be marked as having management experience.erprises . Managererprises . Therefo(2) Siblings. The number of the respondent's living siblings was used as an instrumental variable because social networks  have been shown to facilitate job hunting and promotion. A bigger social network predicts an advantage in employment [ployment , 38. Forployment . Job seeployment . Similarployment , 42. Guaployment . Althougployment . Taken tβ = −0.025, p < 0.01) predicts less unemployment opportunities; siblings in SOEs  are negatively associated with being laid off. Thus, we conclude that ME and siblings are not weak IVs. However, the F-value of the POE model is 1.34, and the relationship between siblings and POEs is not significant, indicating that the endogeneity of POEs cannot be eliminated via the IVs; the different role of IVs can be explained by the variance in features between SOEs and POEs that we mentioned above. Therefore, SOEs are a more appropriate proxy variable to measure economic insecurity.Weak IVs refer to the situation where IVs are weakly related to dependent variables via instrumented variables, resulting in a problematic estimation of coefficients . Two crip < 0.05). When the IVs are put into models, the coefficient of SOEs in model 1-2 is −3.738 (p < 0.01). In the models assessing mobile phone access, the coefficient of SOEs in model 2-1 is −0.185 (p < 0.05), and it remains significant after introducing the IVs into model 2-2 .We assessed Internet access and mobile phone access separately; results are shown in (1) Endogeneity Assessment. The Wald test has been recommended to assess the endogeneity of SOEs [p < 0.01), indicating that SOEs are endogenous variables when used to assess Internet access. Omitted variables may influence the estimates. In model 2-2, similar results  indicate that SOEs in models assessing mobile phone access are endogenous. Taken together, without the introduction of the IVs, the estimates will be biased. of SOEs . Table 3(2) Validity of IVs. IVs are expected to be associated with instrumented variables but not with dependent variables. In other words, the exogeneity of instrumental variables should be guaranteed. To prove that the IVs are exogenous, we applied the generalized method of moments (GMM) as suggested in the past research. As shown in p > 0.1), indicating the null hypothesis that the overidentifying restriction in the model is valid. That is, ME and siblings as IVs are exogenous in both models 1-2 and 2-2. However, the results of Hansen's J chi-square in the third column is 15.291 (p < 0.001), suggesting that at least one of the IVs is related to omitted factors. When assessing the relationship between economic insecurity and mobile phone access (model 2-2), the IVs are not valid. Therefore, the endogeneity of economic insecurity cannot be eliminated by the IVs; in other words, the effect of economic insecurity on ICT access is established in infrastructural ICT but not in personal ICT.β = 0.134, p < 0.01) and to mobile phone access in model 2-2 , suggesting that more wealth predicts more ICT access. Similarly, education is positively related to Internet access and mobile phone access. For instance, a higher education level predicts higher Internet access in model 1-2, and a similar pattern can be observed in mobile phone access in model 2-2. Note that a high education level is significant in the Internet access model  but not in the mobile phone model . The different role of a high level of education can be accounted for by high mobile phone access in our sample and by mobile phones as personal ICT being cheaper than infrastructural ICT. Additionally, the coefficients of residence are 0.994 (p < 0.01) in model 1-2 and 0.321 (p < 0.1) in model 2-2, indicating that living in urban areas provides more advantage than living in rural areas. Because wealth, residence, and education are indicators of social structure, the empirical findings mentioned above suggest that the digital divide among older people is part of the structural disparity.As shown in β = −0.061, t = −3.10, p < 0.01), suggesting that only chronic disease contributes to the digital divide among elderly people. This different role can be attributed to the fact that chronic disease demands continuous treatment and daily management, and the cost is relatively higher than that of an infectious disease. For instance, families with chronic patients are confronted with higher financial risks, which further broadens inequality [Regarding health conditions, the number of infectious diseases has no link to digital access, whereas in model 2, chronic disease is negatively related to Internet access  but not in personal ICT (mobile phones). In other words, the effect of economic insecurity depends on the ICT feature. Infrastructural ICT, such as broadband connection, demands more massive investment from the community and government than personal ICT. Comparatively, personal ICT is less sensitive to economic insecurity. Because communities and families are a critical context for elderly people to receive health management, m-health services in communities can be designed to provide services via affordable equipment; for instance, short messages involving suggestions from community physicians are expected to work. Sufficient ICT infrastructure investment, such as Internet connection and mobile phone networks , should be provided as public goods. Subsidies from NGOs and the government are expected to increase access to infrastructural ICT.Third, the divide in ICT access deserves more attention from m-health policy makers and researchers. In developing countries, the gap in ICT access has been a major obstacle for ICT diffusion . Althoug


Internet addiction is characterized by excessive and uncontrolled use of the internet affecting everyday life. Adolescents are the primary risk group for internet addiction. Data on internet addiction is lacking in Africa. Thus, this review aimed to determine the pooled prevalence of internet addiction and its associated factors among high school and university students in Africa.2 test statistics and small-study effects were checked using Egger's statistical test at a 5% significance level. A sensitivity analysis was performed. A random-effects model was employed to estimate the pooled prevalence and associated factors of internet addiction among students. The primary outcome of measure of this review was the prevalence of internet addiction and the secondary outcome of measures are the factors associated with internet addiction.A comprehensive literature search was conducted using electronic databases  to locate potential studies. Heterogeneity between studies was checked using Cochrane Q test statistics and I2 = 99.20%]. Male sex , urban residence , and duration of daily internet use for more than 4 h : 26.83, 42.23, IAlmost one-third of university and high school students in Africa are addicted to the internet. Male students, those from urban areas, and those who use the internet for more than 4 h per day have higher odds of internet addiction. Thus, we recommend that health planners and policymakers pay attention to the use of the internet and internet addiction in Africa. Internet and smartphone use has increased worldwide over the recent decades and has become a critical part of modern-day life [World Health Organization (WHO), Appropriate internet use is important in communications, research, socialization, entertainment, and many other benefits. However, internet use also has negative impacts, in which internet overuse has been associated with addiction and mental health issues  approach for prevalence studies to declare the inclusion and exclusion criteria.Studies reporting the prevalence of internet addiction in university and high school students in any of the African countries using Young's Internet addiction test (YIAT) were included. Additionally, full-text articles written in English were included in the review. Studies conducted on postgraduate students; studies that used tools other than YIAT were excluded.The primary measure of the outcome of this review was the prevalence of internet addiction according to young's internet addiction Test. The IAT questionnaire was used as a screening tool to examine the level of Internet addiction. The tool was developed by Young and colleagues in 1996. It contains 20 items to examine symptoms of IA based on a 5-point Likert scale ranging from 0 to 5 . According to the tool, the severity of IA is scored as follows: 20–49 points is “average Internet users”; 50–79 points are “possible problematic Internet users”; and 80– 100 points is “severe Internet addict.” The cutoff points for all studies included in this review were standardized in this review, a score below 50 was classified as “normal internet use” and a score of 50 and above was classified as “internet addiction” Young, .The second outcome was the factors associated with internet addiction, which were determined using the odds ratio (OR) and calculated based on binary outcomes from the included primary studies.All the studies reviewed through different electronic databases were combined, exported, and managed using Endnote version X7.2  software. All duplicate studies were removed and full-text studies were downloaded using Endnote software and manually. The eligibility of each study was assessed independently by two reviewers (EA. and SA.). Subsequently, studies were screened and excluded based on their titles and abstracts. Full-text articles or reports were assessed in the remaining articles. The eligibility of the studies was evaluated based on the predetermined inclusion and exclusion criteria. Differences in the results of the two reviewers narrowed through discussion and other reviewer members (TT and GY).Hoy quality assessment tool was used to assess the quality of the studies. It has nine questions. Based on the score of the quality assessment tool, the lowest score had the minimum risk of bias. Overall scores range from (0–3), (4–6), and (7–9), which are declared low, moderate, and high risk of bias respectively  independently extracted the data using a standardized data extraction checklist on a Microsoft Excel spreadsheet. The discrepancies between the two authors were managed by discussion and by other reviewers . For each study, authors, year of publication, region, study design, sample size, the prevalence of internet addiction with standard error, and determinant factors, with effect size and their standard error were extracted.2 statistics  indicates the presence of a small study effect, and is handled by non-parametric trim and fill analysis using the random-effects model  of internet addiction was reported in Nigeria   . Significant heterogeneity was observed among studies (I< 0.001) . There w = 0.07) .Significant heterogeneity was observed from the random-effects model. To handle this heterogeneity; sensitivity analysis, subgroup analysis, and meta-regression analysis were performed. In sensitivity analysis, there were no studies that excessively influence the pooled prevalence of internet addiction. Subgroup analysis was performed based on the region and target population, Based on the region, the highest prevalence of internet addiction was observed in a study conducted in Mauritius 63%  . Additionally, there was no single study that excessively influences the estimate of the effect size  . There wect size .2 = 59.39%, P-value = 0.08)  and in sensitivity analysis, no study influences the estimates  . Egger'sstimates .2 = 0.00%, P-value = 0.83) . In sensitivity analysis, no single study influences the estimates  , and no stimates .2 = 0.00%, P-value = 1) . And by sensitivity analysis, there was no study that excessively influences the pooled association between duration of internet use and internet addiction  . There wddiction .2 = 0.00%, P-value = 0.78) , and in the sensitivity analysis, there was no study that influences the estimates  . Egger'sstimates .2 = 0.00%, P-value = 0.92)  and in sensitivity analysis, there was no single study that influences the pooled estimates  . There wstimates .2 = 0.00%, P-value = 0.82) . In sensitivity analysis, no single study was found to influence the estimates  . In sensitivity analysis, no single study was found to influence the estimates  . Egger'sstimates . To assestimates . Again,  = 0.94) . Egger'sstimates .This review aimed to assess the prevalence of internet addiction and its associated factors among adolescents in Africa. Twenty-eight studies from 10 countries were included in the review. The overall pooled prevalence of internet addiction among adolescents was 34.53% (95% CI = 26.83–42.23). It was comparable to other meta-analyses conducted in the Gulf Countries 33% (Al-Khani et al., In sub-group analysis based on the economic status of the country, higher prevalence was observed in countries with upper middle income, followed by lower middle income, and lower prevalence was observed in countries of lower-income. Other studies have also shown that students with higher socioeconomic status have higher levels of internet addiction (Kayri and Günüç, In this review, male adolescents were found to have a 92% increased risk for internet addiction. There were similar findings from another review (Su et al., Again, in our review, we have found that adolescents who reside in urban areas were more likely to have internet addiction as compared with adolescents residing in rural areas. Similar findings have been reported from studies conducted elsewhere (Cao et al., In this review duration of internet use, more than 4 h was found to be significantly associated with internet addiction. Adolescents who stay online for more than 4 h have 2 times more risk for internet addiction. Similar findings have been reported from other studies (Tonioni et al., The strength of this study was that various databases were used to search literature, and both published and unpublished studies were included in the study. All studies included have standardized tests and the same cutoff point was used for all studies. The review has limitations, The term Internet addiction is used in this review is a general term although internet users may be addicted to a variety of activities online. Again, terminologies used to describe internet addition are different in different literature. In this review, internet addiction is used to describe a score of 50 and above on the IAT, this merges the scores for severe internet addiction and problematic internet use. Furthermore, most of the studies selected for the final analysis were conducted only in some countries of Africa, which is not the true representative of the remaining countries.Results from this review suggest that internet addiction is a major public health problem in Africa. Nearly, one-third of college and high school students in Africa are addicted to the internet. Male sex, urban residence, spending 4 h or more online were significantly associated with internet addiction. Based on the findings of this review, we recommend policymakers and all concerned bodies to give due attention to prevent and decrease internet addiction among the adolescent population.The original contributions presented in the study are included in the article/EZ, ST, and TT involved in data conceptualization, searching critical appraisal, and statistical analysis. GA, MA, FA, GY, and TA involved study selection and quality assessment. EA, ZM, MM, TF, and MZ participated in reviewing and editing the manuscript. All authors involved in the preparation of the final manuscript and approved the final submission.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.