Background: Diabetic nephropathy (DN) is one of the most serious chronic micro-vascular complications of diabetes and the leading cause of end-stage kidney disease (ESRD) worldwide, with reduced expectancy and quality of life and colossal financial and social burden worldwide. In spite of emerging treatments on DN, effective therapy on delaying the progression of DN is still lacking. In clinical practice, there are many studies focusing on Abelmoschus moschatus (AM) capsules together with Tripterygium glycoside (TG) tablets in the treatment of DN, and excellent results have been obtained.Objective: The study aimed to evaluate the efficacy and safety of AM combined with TG in the treatment of DN.Methods: Databases including PubMed, Web of Science, Cochrane Library, Embase, CNKI, WF, and VIP were searched from their inception to 1 March 2022. The “risk of bias” evaluation tool produced by the Cochrane Collaboration Handbook was used for evaluating the quality of the included studies. Revman 5.3 software was used for meta-analysis.Results: Here, 11 studies with a total of 1,072 participants were included for this meta-analysis. Our results showed that AM combined with TG plus basic treatment could lower levels of 24 h-UP , Scr , and BUN . Meanwhile, the adverse reaction rate increased in the combination group .Conclusion: Current evidence suggests that AM combined with TG may be more effective in the treatment of DN, which will be highly beneficial to further theoretical discussion and practical clinical applications. However, the safety cannot be ignored because of nearly increasing 2-fold adverse events, although they can be mitigated through systematic treatment. Meanwhile, due to low quality of the included studies, great possibility of publication bias, and large heterogeneity among different studies, the results of our review should be evaluated with more prudence and high-quality RCTs are warranted to confirm this in the future.Systematic review Registration:www.crd.york.ac.uk, identifier CRD42022344359. Diabetic nephropathy (DN) or diabetic kidney disease (DKD), recognized as one of the most prevalent microvascular complications of diabetes mellitus (DM) and a dominant cause of the end-stage renal disease (ESRD), has brought a great threat to health along with severe financial and social burden worldwide . AccordiAbelmoschus moschatus (AM) capsules and Tripterygium glycoside (TG) tablets are adapted to kidney disease; the former is of damp-heat syndrome  and its bioactive ingredients has produced more potential possibilities and might be useful for the identification and validation of new biomarkers and drug targets for early detection and treatment of DN . They exsyndrome , whereassyndrome .Abelmoschus manihot (L.) Medik. with total flavones as primary active ingredients  . The proAbelmoschus moschatus”, and “Tripterygium glycosides” and “diabetic nephropathy” were searched in combination.We searched for eligible trials in electronic databases, including PubMed, Web of Science, Cochrane Library, Excerpta Medica Database (Embase), China National Knowledge Infrastructure Database (CNKI), Wanfang Database (WF), and China Science and Technology Journal Database (VIP), from the earliest publication date available to 1 March 2022 with the restricted language of Chinese and English. In parallel, the reference lists of published systematic reviews and included trials would also be retrieved to obtain additional eligible clinical trials. The predefined search terms included “Studies were selected if they were eligible for criteria based on PICOS as follows: 1) participants: adults diagnosed with DN in accordance with the Kidney of Disease Outcomes Quality Initiative of National Kidney Foundation in 2007  or the EStudies were excluded if they were not eligible for conditions as follows: 1) patients who received hemodialysis or peritoneal dialysis in stage V. 2) Other TCM characteristic therapies including acupuncture, TCM enema, and physical therapy in the intervention group. 3) No primary outcomes described. 4) Theoretical explorations, case reports, systematic review, observational research without a control group, and animal or cell experiments. 5) No RCTs. 6) Duplicated publicationsRelevant studies were carefully screened by two independent investigators on titles and abstracts after removing duplicates. Full texts were also obtained by two investigators. When disagreements occurred between two investigators, they would be resolved through consultation with a third investigator. The data were extracted independently and double-checked from the included studies, for instance, first author, year of publication, sample size, gender, average age, course of the disease, methodological details, treatment duration, and outcomes.Two investigators accessed the quality of the included studies separately according to the Cochrane Collaboration Handbook for Systematic Reviews of Intervention. It was sorted into three levels of bias: “low risk,” “unclear risk,” “high risk”. The following six domains were evaluated: 1) selection bias included random sequence and allocation concealment; 2) performance bias referred to blinding of participants and personnel; 3) detection bias equaled to blinding of the outcome assessment; 4) attrition bias was the incomplete outcome data; 5) reporting bias referred to selective reporting; 6) bias of other resources. Divergences were resolved by discussing and reaching a consensus with a third investigator if necessary.p-value was used for calculating outcomes, and when less than 0.05, it was recognized as statistically significant. The I2 statistic was used to evaluate heterogeneity among the included studies. I2>50% was indicative of high heterogeneity, and the random-effect model was applied; if not, the fixed model was employed. Meanwhile, sensitivity analysis was also performed by deleting included studies one by one to testify to the robustness. In order to analyze the possible sources of heterogeneity, subgroup analyses were conducted based on treatment duration, average age, and baseline of Scr. Funnel plots were employed for examining potential publication bias when more than 10 studies were brought into the analysis.Review Manager 5.3 was used for graphing and accessing the results from the aforementioned evaluations. The pooled risk ratio (RR) with a 95% confidence interval (CI) was used for assessing discontinuous variables; otherwise, the pooled mean difference (MD) with 95% CI served as continuous variables. The In total, 83 studies were identified through database searching. First, 31 studies were screened out by eliminating duplication. Second, eight studies were removed due to no RCT trials and systematic reviews after screening title and abstracts. Then, 12 studies were swept away because of obtaining incomplete information, no primary outcomes, duplicated articles, and not meeting the criteria of the control group. Ultimately, 11 studies were included in the qualitative and quantitative synthesis. The study selection process is depicted in Eleven studies with a total of 1,072 participants (538 from the intervention group and 534 from the control group) were included for meta-analysis after careful screening and evaluation. All included studies were single-centered published from 2010 to 2021 and conducted in China. The sample size ranged from 64 to 180, and the average course ranged from 3.21 to 10.2 years in every recorded study. The mean age was 55.39 years old in the intervention group and 55.74 years old in the control group with 549 males and 433 females, except for one study  with uncThree studies  made ran2 = 97%), a random-effect structure was conducted, and the result showed that it was significantly decreased in the combination group compared with AM  , a random-effect structure was utilized, and the result showed that levels of Scr in the combination group were significantly decreased compared with AM  ; p = 0.40] and 50–60 years old , baseline of Scr <100 μmol/L , 100–133 μmol/L  and >133 μmol/L .Furthermore, we looked for the sources of high heterogeneity on Scr e of Scr . The het2 = 83%). The meta-analysis indicated that in comparison with the control group, the combination group could further decline in levels of BUN  ; p = 0.88].Moreover, we conducted subgroup analyses according to the following criteria for grouping: treatment duration, average age, and baseline of Scr . Heterog2 = 10%), a fixed-effect structure was used to analyze the data. The combination group could further improve the clinical improvement rate compared with the control group  (Six studies  describe0.00001] .2 = 0%); therefore, we conducted analysis by using a fixed-effect structure. The meta-analysis indicated that the combination group showed a higher adverse reaction rate in comparison with the control group  inhibitors , which wUp to now, although there are many meta-analyses researching AM or TG on the treatment of DN, only one study focus on AM together with TG versus TG . CompareSome inevitable limitations exist in this meta-analysis, which are needed to be taken into further consideration. First of all, the language of included studies is restricted to Chinese and English, which leads to selection bias. Second, since no high-quality enough studies are included, serious attention should be paid to interpreting the results. Third, there are still great limitations on 24 h-UP, Scr, and BUN as surrogate end points to judge the progression of DN. Last but not the least, there is publication bias in the evaluation of Scr and BUN, so the results should be explained with caution. Hence, more studies with a multi-center, canonical methodology of random, blindness, allocation concealment, and reporting negative results in reality are urgently warranted in real-world research.Although there are limitations mentioned earlier, this meta-analysis and systematic review still provide valuable insights. The combination of AM and TG on the basis of BT in treating DN is one of the most revealing findings of this meta-analysis, which is more effective and challenging. This is of clinical importance and a promising choice for patients with DN when symptomatic treatments are identified to be less effective.Abelmoschus moschatus capsules combined with Tripterygium glycoside tablets may be more effective in the treatment of DN, which will be highly beneficial to further theoretical discussion and practical clinical applications. As to safety, more adverse events in the combination group cannot be ignored because of nearly increasing 2-fold adverse events than those of the control group with no TG, although they can be solved through corresponding systematic treatment. However, due to the low quality of the included studies, the great possibility of publication bias, and large heterogeneity among different studies, the results of our review should be evaluated with more prudence, and high-quality clinical RCTs are warranted to confirm this in the future.Current evidence suggests that


The available nomograms used to predict acute pancreatitis (AP) are not comprehensive. We sought to investigate the effect of red blood cell distribution width (RDW)-albumin ratio (RA) on prognosis of patients with AP and develop a new nomogram to identify AP patients at high risk for mortality.  We used data from the Medical Information Mart for Intensive Care IV version 2.0 (MIMIC-IV v2.0). A total of 487 patients with acute pancreatitis were included. Patients enrolled in the study were randomly assigned to the training set and validation set at a 7 : 3 ratio. According to the 30-day mortality rate, the data were divided into a survival group and a death group. Multivariate logistic regression was used to establish a prognostic nomogram for predicting the 30-day mortality in AP patients. The area under the receiver operating characteristic curve (AUC), calibration curve, the net reclassification improvement (NRI), the integrated discrimination improvement (IDI), and a decision curve analysis (DCA) are used to verify the overall performance of the model.  Among 487 patients, 54 patients died (11.1%). 338 patients were assigned to the training cohort and 149 were assigned to the validation cohort. The multivariate analysis results showed that RA, age, heart rate, temperature, AST/ALT, BUN, hemoglobin, potassium, and bilirubin were independent risk factors. The prediction performance of the newly established nomogram was better than those of other common scoring systems . The nomogram suggests that RA  is the most significant laboratory test indicator influencing prognosis.  The new nomogram incorporating RA performed well in predicting AP short-term mortality. A prospective study with a larger sample is needed to validate our findings. Acute pancreatitis is a complicated gastrointestinal-related disease with considerable morbidity and mortality and a fluctuating course that is frequently difficult to predict in its early stages , 2. In pThere are already a number of prediction models or scoring systems available for doctors to use in assessing the severity of AP in its early stages, but none are ideal. The Ranson score, for instance, requires lactate dehydrogenase (LDH) at admission, which is not routinely evaluated in the emergency department of many hospitals and is frequently missed. Too many parameters are included in the Acute Physiology and Chronic Health Evaluation II (APACHE II) score , preventBy quantifying the size of peripheral red blood cells, the red blood cell distribution width (RDW), a common blood test item, can indicate the heterogeneity of red blood cell volume . It is wA nomogram is a helpful mathematical tool for forecasting certain endpoints, such as the evolution of disease progression or mortality, depending on a number of critical parameters. Researchers frequently use nomograms to calculate the risk of a clinical event occurrence . A totalAll the data for this study were derived from MIMIC-IV (2.0), a public critical care database developed by MIT. The database collected data on 315,640 inpatients at Beth Israel Deaconess Medical Center (BIDMC) from 2008 to 2019. Laboratory tests, treatment records, demographic information, and so on are all examples of data. The database has been thoroughly de-privatized of all personal information. The researcher has completed an ethical training program and has been granted access to the database by the MIT Institutional Review Board (Certificate number: 43700334).The data were collected from the database using PostgreSQL tools and SQL structured query language, and patients with acute pancreatitis were identified using the ICD-9 diagnosis code (5770). The following patients were omitted from the study: (1) Patients younger than 18 years of age. (2) Patients' hospital stay was less than 24 hours. (3) Red blood cell distribution width and albumin data were missing. (4) Patients with missing information rate >10%. If the patient was hospitalized more than once, only data from the first hospitalization were evaluated.The extracted data included demographic information, prognostic scoring systems, vital signs, comorbidities, and laboratory findings within 24 hours. Demographic information includes sex and age. The prognostic scoring systems included Sequential Organ Failure Score Assessment (SOFA), Acute Physiology Score III (APS III), and Oxford Acute Disease Severity Score (OASIS). Vital signs include heart rate, mean blood pressure, breath rate, and temperature. Laboratory findings included red blood cell distribution width (RDW), albumin, red blood cell distribution width-albumin ratio (RA), aspartate aminotransferase-alanine aminotransferase (AST/ALT), blood urea nitrogen (BUN), creatinine, blood glucose, hemoglobin, white blood cell count (WBC), platelets, blood calcium, blood sodium, blood potassium, and total bilirubin. Comorbidities include chronic heart failure (CHF), chronic pulmonary disease, liver disease, malignant cancer, diabetes, and sepsis. The primary outcome of this study was 30-day mortality.T test. Continuous variables that did not fit the normal distribution were expressed as medians (quartiles), and group comparisons were made using the Mann–Whitney U tests. Categorical variables were written as frequency (%), and the chi-square or Fisher's exact test was used to compare groups.This study included variables with a missing rate of less than 10% to reduce the possibility of information bias. In variables that do not fit a normal distribution, we use the median to fill in the missing values. We use the mean to fill in the missing values in variables that fit a normal distribution. The included cases were then randomly assigned in a 7 : 3 ratio to the training cohort and the validation cohort. Continuous variables with a normal distribution were expressed as mean standard deviation (Mean ± SD), and group comparisons were made using the independent sample P of value less than 0.1 obtained from univariate regression were included in multivariate regression for further analysis. The backward stepwise regression method was applied to a multivariate logistic regression model to select variables in the training cohort. For continuous variables that comprised all independent risk factors in the final model, we tested for multicollinearity amongst prognostic components using variance inflation factor (VIF), and an arithmetic square root of VIF ≥2 was considered as collinearity.In the training cohort, we utilized univariate and multivariate logistic regression to identify characteristics associated with 30-day mortality in individuals with acute pancreatitis. Variables with a The independent risk factors in the multivariate logistic model were used to construct a nomogram to predict the 30-day survival rate of patients with acute pancreatitis. The area under the receiver operating characteristic curve (ROC-AUC) was used as the evaluation index of the nomogram. The calibration curve was used to evaluate the consistency between the predicted probabilities and the actual results. If the calibration curve is close to the diagonal, the calibration is considered good.P < 0.05 was considered statistically significant.Additionally, net reclassification improvement (NRI) and integrated discrimination improvement (IDI) were utilized to evaluate this nomogram. NRI and IDI reflect the improved performance of the new model in comparison to the old model. NRI was utilized to compare the accuracy of two models. IDI was utilized to assess the effectiveness of the improvements. NRI and IDI are more sensitive to differences in discrimination between two models than AUC. Using a decision curve analysis (DCA), we evaluated the clinical value of the prediction model. DCA shows the clinical validity of the prognostic model by showing the net benefit of clinical action guided by the prognostic model. In this study, SPSS (22.0) and R (4.0.5) were used for statistical analysis and mapping. A total of 487 eligible patients were screened for this research, comprising 272 males (55.9%) and 215 females (44.1%), with a 30-day mortality rate of 11.1%. 338 patients were assigned to the training cohort and 149 to the validation cohort, and none of the characteristics were significantly different between the two cohorts. The training cohort consisted of 194 (57.4%) males and 144 (42.6%) females, with a median age of 59 years. The validation cohort consisted of 78 (52.3%) males and 71 (47.7%) females with a median age of 58 years. Using univariate logistic regression analysis, we discovered that age, heart rate, MBP, breath rate, temperature, RA, AST/ALT, BUN, creatinine, hemoglobin, WBC, platelet, potassium, bilirubin, CHF, and sepsis were risk variables for 30-day death in patients with acute pancreatitis. We integrated these variables into multivariate logistic analysis, and the results indicated that age, heart rate, temperature, RA, AST/ALT, BUN, hemoglobin, potassium, and bilirubin remained risk factors for mortality in acute pancreatitis patients. Among them, we discovered that RA was strongly associated with 30-day mortality, with an OR of 1.706, implying that every one-point increase in RA increases the probability of death by 70.6%. The VIF was computed, and none of the variables listed above had an arithmetic square root of VIF greater than 2, suggesting that multicollinearity was not present in the model. ROC curve analysis of RA, albumin, and RDW showed that the AUC value of RA was 0.771(95% CI: 0.69–0.852) , which wWe establish a nomogram prediction model based on the results of a multiple logistic regression model. The bootstrap method was used to generate the internal calibration curve, and the calibration curve nearly matched the reference curve, showing that the nomogram's capacity for differentiation and prediction was excellent . We put After comparing the nomogram with SOFA, OASIS, and APS III, the NRI of the training cohort was 0.35, 0.407, and 0.25, respectively. The NRI of the validation cohort was 0.473, 0.515, and 0.372, respectively. In addition, the IDI of the training cohort was 0.199, 0.249, and 0.159, respectively. The IDI of the validation cohort was 0.355, 0.382, and 0.37, respectively. The essence of acute pancreatitis is autodigestion of the pancreatic parenchyma, which means that there is a local inflammatory response but also a systemic inflammatory damage, which can be secondary to serious bacterial infection and multiple organ damage . The sevIn recent years, a number of diagnostic and prognostic markers, both alone and in combination, have been tested on individuals diagnosed with AP –18. AfteHowever, it remains challenging to reliably estimate the prognosis of a disease based on a single laboratory marker. Increasing the number of indicators used in a diagnostic procedure can improve either its sensitivity or its specificity, and a nomogram is a visual graph of the findings of a multivariate regression analysis . BecauseIn this work, we established a nomogram for the early prediction of death in AP patients based on a large population gathered from a critical disease database. The variables included in the nomogram were RA, age, heart rate, temperature, AST/ALT, BUN, hemoglobin, potassium, and bilirubin. In addition, the clinical indicators and laboratory test data included in this nomogram can be easily obtained. The model was validated, and its predictive performance was comparable to that of current scoring systems.The roles of BUN and creatinine in predicting the prognosis of AP are still debatable. Both renal damage induced by inflammation and renal hypoperfusion produced by hypovolemia can elevate BUN and creatinine levels. Yang et al.  revealedOur study has several strengths. First, we found that RA is a significant independent risk factor that was absent from earlier AP models. Second, we constructed a nomogram with readily accessible parameters. This nomogram presents the probability of AP short-term mortality outcomes and allows practitioners to analyze patient outcomes. The performance of our model is far superior to that of traditional disease severity scores.However, it is vital to point out some of the study's shortcomings, which are as follows: We should note that because this was a retrospective observational study, there is still the possibility of selection bias and confusion bias in our findings. In regard to the second issue, this study's conclusions are not supported by multicenter clinical data, which raises questions about the validity of these findings. Ideally, we should perform additional multicenter research in the future using a large number of study sites.Our study reveal the predictive values of RA in patients with AP. Concurrently, the new nomogram demonstrated good performance in predicting short-term mortality in AP by constructing a nomogram employing RA and a number of other easily accessible clinical parameter relevant to AP prognosis. However, additional confirmation of the present findings requires the conduct of larger prospective investigations with a greater duration of follow-up.


However, both groups’ means at the six-month follow up were significantly greater than those at pre-intervention (p < 0.05). At the post-intervention and follow-up evaluations, comparisons between groups revealed a statistically significant difference in all measured parameters for the study group against the control group (p < 0.05). It can be concluded that adding hyperbaric oxygen therapy to physical therapy rehabilitation could be effective in improving spatiotemporal gait parameters and functional balance in children with cerebral palsy.This study aimed to explore the long-term effects of hyperbaric oxygen therapy on spatiotemporal gait parameters and functional balance in children with cerebral palsy. Thirty-nine children with hemiplegic cerebral palsy were randomly allocated to one of two groups: control or study. The children in both groups received traditional physical therapy three times per week for six months. In addition, the children in the study group received hyperbaric oxygen therapy five times/week for eight weeks. The GAITRite system and pediatric balance scale were used to assess spatiotemporal gait parameters and functional balance at baseline, post-intervention, and six months after the cessation of hyperbaric oxygen therapy. Post-intervention means of all measured parameters were significantly higher than pre-intervention means, but only for the study group ( Cerebral palsy (CP) is a collection of sensory and motor disorders, as well as postural disorders, caused by non-progressive injury to the immature brain . These oChildren with CP have a compromised ability to respond to a loss of balance, in addition to spasticity, muscular weakness, and adaptive muscle length changes. The primary dysfunctions are caused by motor disorders during posture and movement, which limit activities such as walking . ChildrePostural control deficits are a primary challenge to motor improvement in CP children. Postural instability limits these children’s ability to complete static and dynamic tasks such as sitting, standing, and walking . ImpaireThe major postural dysfunction in CP children is the failure to coordinate the correct sequence of activation of postural muscles, particularly during functional activities and participation limitation . As a reBecause of changes in neurological organization, the clinical condition of CP can vary during maturation and its symptoms can fade over time. Occupational, speech, and physical therapy, and palliative care, are the commonly used interventions to improve function and develop compensatory strategies . In receHBO2 therapy is a medical treatment that entails the delivery of 100 percent oxygen at pressures higher than the surrounding atmosphere (greater than sea level). This allows for a much higher partial pressure of oxygen to be delivered to the tissues, which helps to alleviate hypoxia at the cellular level ,12. FurtSeveral mechanisms of cellular and vascular healing mediated by HBO2 have been proposed besides tissue oxygenation. Improved mitochondrial function and cellular metabolism, a better blood–brain barrier and inflammatory responses, less apoptosis, lower amounts of oxidative stress, higher levels of neurotrophins and nitric oxide, and the activation of axonal guiding agents are among these benefits ,15. Some disorders, including gas gangrene, hypoxia, diabetic foot, carbon monoxide poisoning, stroke, and some thermal burns, have been successfully treated with HBO2 therapy . MoreoveAlthough multiple previous experimental studies on the effects of HBO2 therapy in children diagnosed with CP have been carried out, the proof of the therapeutic effect of HBO2 therapy remains scarce and the results remain inconsistent . One ranThis was a randomized clinical experiment. It was approved by Batterjee Medical College’s ethics and research committee (RES2020-0030) in conformity with the Declaration of Helsinki’s ethical standards. The study was registered at clinicaltrials.gov (NCT05136716).Initially, 48 children diagnosed with spastic hemiplegic CP, referred by local pediatric physicians ’offices, were assessed for eligibility. A total of 39 children  were chosen based on the following inclusion criteria: age range from 5 to 10 years, being medically cleared by their doctor to use a hyperbaric oxygen hood or mask, the ability to swallow or blow via a straw on command in order to reduce barotrauma, hypertonia range from 1 to 1+ according to the Modified Ashworth Scale, level I or II on the Gross Motor Function Classification System (GMFCS), and the capability to understand and follow instructions. Previous HBO2 treatments, botulinum toxin A treatments, thoracic surgery within six months, significant changes in spasticity medication within the last three months, unstable epilepsy, pulmonary dysfunction, and cardiovascular disease were all exclusion criteria . All chiThe sample size was calculated to be 36 children using G*Power  with an alpha of 0.05, power of 80%, and an effect size of 0.48. I. Spatio-temporal Gait Parameters.The GAITRite System  was utilized to test the temporal and spatial gait parameters. The GAITRite is a 17 ft. long, 2.9 ft. wide instrumented carpet. The active part of the walkway is 14 ft. long and 2 ft. wide with pressure sensors implanted in the horizontal grid of the carpet (each divided by 0.50 inch). The sensors recorded the location of the activated sensors and the time of sensor activation/deactivation with each step, allowing for dynamic pressure mapping during walking and the computation of a variety of temporal and distance gait parameters to be recorded. The sensors provided information about the two-dimensional geometry of the footprints as the child moved across the carpet. The walkway was connected to a computer, and the GAITRite Version 3.2b software package was used to measure and record spatiotemporal parameters . This toBefore the actual measurement, all subjects were given a 5 min acclimation period. The child then completed three walking trials at their own pace with their own footwear to collect data. When gait data for three full strides at a steady pace on the walkway were recorded, the trial was rated successful. A meter was installed at both ends of the walkway to allow for acceleration and deceleration stages . ParametII. Functional Balance.To assess the functional balance of the children, the pediatric balance scale (PBS) was used . CollectFunctional balance and spatiotemporal gait parameters were measured three times: pre- and post-intervention, and six months after the stopping of HBO2 therapy to examine the long-term impact.The children in the study group were treated with HBO2 therapy and received 100% oxygen at a pressure of 1.7 atmospheres (atm) in a multi-patient hyperbaric chamber. A 15 min period was used for the gradual increase in the chamber pressure. When 1.7 atm was reached, the participants were fitted with acrylic hoods or a mask and 100% O2 was delivered. For 60 min, the participants breathed 100% O2. Afterwards, participants breathed air for 15 min to decompress. Each session took approximately 90 min to complete. The treatments were given 5 times/week for eight weeks, for a total of 40 treatments . Prior tOne hour of traditional physical therapy was provided to both groups three times per week for 6 months. The neurodevelopmental treatment approach included tight muscle stretching, weak muscle strengthening, postural reaction training, proprioceptive training, and walking training.t-test was used to investigate the significance difference between the mean of both groups regarding age, weight, and height, while the χ2 test was used to check the difference between groups in terms of sex, hypertonia, and GMFCS level. Finally, Multivariate analysis of variance (MANOVA) was used to compare the means of the study and control groups in terms of all the study’s outcome measures. A post hoc test with the Bonferroni corrections was used in the case of significant results. With 95% confidence intervals, a probability of p < 0.05 was statistically significant.The authors used the Statistical Package for Social Sciences (SPSS) for Windows, version 20.0 . The choice of parametric statistical methods in this study was based on the results Shapiro–Wilk test that ensured the normal distribution of the collected data. An unpaired t-test showed no significance difference between the control and the study group at baseline in terms of age, height, and weight . Additionally, the chi-square test showed that the difference of the means of both groups in terms of sex, hypertonia, and GMFCS level were not significant  as illustrated in The independent p = 0.007, 0.009, 0.021, 0.009, 0.011, and 0.008, respectively) with a non-significant difference for the control group . Moreover, the means at the six-month follow up were significantly higher than those at pre-intervention for the study group  and the control group  as illustrated in p > 0.05). However, comparisons between variance (mean differences) in the pre–post and pre-follow-up evaluations of both groups showed statistically significant differences in all measured parameters in the study group compared to the control group (p < 0.05). Within-group comparisons using MANOVA showed that the post-intervention means of PBS, walking velocity, cadence, step length, step-length symmetry ratio, and single limb support were significantly higher than the pre-intervention means for the study group  in the children who were treated with HBO2 therapy.These findings could be attributed to an increased oxygen availability to neural cells, which may stimulate them to function normally by reactivating them metabolically or electrically, resulting in angiogenesis and other signs of healing . FurtherHBO2 therapy advantages in CP are related to a rise in dissolved oxygen in plasma and tissue, which helps regeneration in light of the theory that increased oxygen availability to injured brain cells can reawaken normal functions . Based oA randomized controlled study conducted by Collet et al.  reportedThe improvement in gait parameters and functional balance in the study group after 6 months could be explained by the fact that HBO2 therapy enhances nerve cell regeneration and re-growth, starting about 4–6 months after beginning therapy. Physical therapy treatment given during this period magnifies the rate of neurodevelopmental progress and significantly closes the gap between recognized growth patterns and observed growth rate .These results are in agreement with Machado  who founOn the other hand, our results disagreed with those of Lacey et al. , which fMoreover, the current study disagrees with Jain,  who statAdditionally, the present study found significantly higher improvements in all measured outcomes after 6 months in the study group compared with the control group, which contradicted Hegazy et al. , who staThe limitations of this study are as follows: First, we did not assess the anatomical and physiological changes in the brain after application of HPO2 therapy by using a single-photon emission computerized tomography (SPECT) scan. Second, a double- or single-blinded experimental model was not used, since the same group of researchers conducted both the HBOT and the assessment processes. This entails a considerable risk of observer bias. Third, a medium effect size was chosen to detect decent changes in the means of the outcome measures. More large-scale randomized controlled studies are required to determine who the best candidates are and what the optimum HBO2 strategy is for children with CP.The current study findings indicate a significant improvement in gait parameters and functional balance immediately post-intervention and in a follow up after 6 months. Based on the results of this study, HPO2 therapy when added to physical therapy rehabilitation could be an effective intervention for improving spatiotemporal gait parameters and functional balance over time in children diagnosed with spastic CP. Moreover, the changes in function may extend over a prolonged period of time, even after the cessation of HBO2 therapy.


Artificial intelligence (AI) is steadily entering and transforming the health care and Primary Care (PC) domains. AI-based applications assist physicians in disease detection, medical advice, triage, clinical decision-making, diagnostics and digital public health. Recent literature has explored physicians' perspectives on the potential impact of digital public health on key tasks in PC. However, limited attention has been given to patients' perspectives of AI acceptance in PC, specifically during the coronavirus pandemic. Addressing this research gap, we administered a pilot study to investigate criteria for patients' readiness to use AI-based PC applications by analyzing key factors affecting the adoption of digital public health technology.n = 447).The pilot study utilized a two-phase mixed methods approach. First, we conducted a qualitative study with 18 semi-structured interviews. Second, based on the Technology Readiness and Acceptance Model (TRAM), we conducted an online survey (The results indicate that respondents who scored high on innovativeness had a higher level of readiness to use AI-based technology in PC during the coronavirus pandemic. Surprisingly, patients' health awareness and sociodemographic factors, such as age, gender and education, were not significant predictors of AI-based technology acceptance in PC.This paper makes two major contributions. First, we highlight key social and behavioral determinants of acceptance of AI-enabled health care and PC applications. Second, we propose that to increase the usability of digital public health tools and accelerate patients' AI adoption, in complex digital public health care ecosystems, we call for implementing adaptive, population-specific promotions of AI technologies and applications. Artificial Intelligence (AI) is a multidisciplinary field of science with the goal of creating intelligent machines , 2. AI iAI has gradually transformed medical practice. Recent progress has been made in the direction of digitized data acquisition, machine learning and computing infrastructure, resulting in AI applications that are steadily entering novel domains that were previously governed solely by human experts. Research has outlined breakthroughs in AI technologies, identified challenges for further progress in health care and medical AI systems , 5 and rResearch suggests a transformation in AI in the Primary Care (PC) domain . TechnolDue to the coronavirus pandemic, health care providers are adjusting health care delivery channels to protect both patients and medical staff from infection through resource allocation directed at new and acute needs. As a result, routine services have stopped or slowed substantially, and strict isolation and separation protocols have been introduced .Prior to the current pandemic, some studies focused on the barriers to using digital public health solutions . HoweverThe digital public health care transformation reinforces additional challenges. For example, potential conflicts exist based on patients' sociodemographic backgrounds. Digital tools can provide collective public health benefits; however, they may be intrusive and erode individual freedoms or leave vulnerable populations behind. The coronavirus pandemic has demonstrated the strong potential of various digital solutions . The intIn light of recent calls to advance PC with AI and machine learning , the goaThe study results indicate that patients' privacy concerns, professionalism perceptions, motive perceptions and innovativeness (proneness to technology use score) are all key factors in AI-based technology acceptance in PC during the coronavirus pandemic outbreak. However, we conclude that neither patients' health awareness and empathy needs, nor their sociodemographic factors as described in the TRAM model, such as age, gender and education, are significant predictors of AI-based technology acceptance in PC. Therefore, we suggest exploring the effects of population-specific promoters of individual impediments to accelerate the adoption of AI-based applications in PC to increase their usability in complex digital public health care ecosystems.The factors that cause individuals to accept new technologies have been researched over the past few decades. However, AI-based technology adoption, specifically in PC, has not been deeply researched even though, in recent years, the topic of AI in health care has been increasingly investigated. For example, Yu and colleagues  presenteAI-based applications have been used in medical imaging of the liver , cardiolAI is utilized to support and improve health services in many high-income countries. There is great hope that AI can also improve health service delivery in resource-poor settings . AI-baseOur proposed research model examines antecedents extracted from the TRAM model at the individual level through perceived usefulness and perceived ease of use and their effect on readiness to use AI-based mobile applications. The research model aims to explore the influence of privacy, professionalism, empathy, motive, proneness to technology use and health awareness utilizing an individual-level approach.In this study, we investigated the potential to use the TRAM model see  to prediH1: Optimism (motive) has a positive influence on readiness to use AI-based applications in PC.It was stated that “innovativeness” is used to assess the “newness” of an innovation, with innovative products being labeled as having a high degree of newness . ParasurH2a: Innovativeness  has a positive influence on readiness to use AI-based applications in PC.H2b: Innovativeness (proneness to technology use) has a positive influence on readiness to use AI-based applications in PC.Discomfort attributes have been defined as “a perceived lack of control regarding technology and the sense of being overwhelmed by it” [43 (p. 311)]. The authors argued that the high-complexity features of technology products have a negative impact on product evaluation because of the user's learning cost . BuildinH3: Discomfort (privacy) has a negative influence on readiness to use AI-based applications in PC.Insecurity “implicates a distrust of technology and the disbelief about its ability to work properly” [43 (p. 311)]. Although the TRAM model suggests that insecurity has a negative impact on the perceived ease of use and perceived usefulness, some recent studies have not been able to find a correlation , 36. BuiH4a: Insecurity (empathy) has a negative influence on readiness to use AI-based applications in PC.H4b: Insecurity  has a negative influence on readiness to use AI-based applications in PC.We added “referrals to a doctor” as a control variable by asking the respondents for the number of times they have contacted a physician during the past year. According to prior research , older aIn line with Lancaster et al. , the stun = 447), we identified criteria for readiness to use AI-based applications in PC by analyzing the factors that affect the adoption of medical technology based on TRAM. The survey examined six factors that may affect patients' readiness to use AI-based applications in PC: privacy concerns, perception of professionalism, need for empathy, motive perception, proneness to technology use and health awareness  framework to validate the research variables and the complete structure of the hypothesized model. Specifically, prior to implementing complex indicators, a validation process is necessary to confirm the theoretical constructs, with a complex indicator referring to either a simple or a weighted combination of the original items . Seven svia social media. This approach yielded an acceptable and varying response rate . The ages of the respondents ranged from eighteen to eighty-five. The average respondent age was 46.09 (SD 0.63), with 4% of individuals aged <25, 18% aged between 26 and 35, 48% aged between 36 and 50, 22% aged between 51 and 65, and 8% aged over 65 years old. Thirty-four percent of respondents had a bachelor's degree, 50% had a master's degree, and 7% had a PhD see .Sixty-five percent of respondents were employed, 14% were self-employed, 9% were retired, 5% were unemployed, and an additional 7% were unemployed or on leave due to the coronavirus pandemic. The results show that 80% of the respondents in this sample were born in Israel. The vast majority of respondents reported being married (75.3%) and not having any chronic disease (76%). Regarding HMO distribution, half (50%) of respondents obtained their health services from “Maccabi Health Services” and an additional 40% obtained their health services from “Clalit Health Services” – the two largest HMOs in Israel.We tested the construct validity of the TRAM factors within a measurement model. Specifically, a measurement model with six latent constructs and four observed variables was fitted using Mplus version 8.1 . We evalReliability was measured based on the Cronbach's alpha coefficients of the constructs , 56. As P-values, which demonstrate high significance.To test our hypotheses, we built a structural model that included the background variables – gender (men vs. women), education level (years of education), age (five age groups), and number of visits with the family physician (from 1 to 5) see . An illup < 0.01; β = 0.21, p < 0.001; β = 0.11, p < 0.05, respectively), whereas women's results were lower on the empathy, technology, and health awareness factors . Additionally, a higher education level was associated with higher health awareness, and vice versa . However, older age and more frequent visits to the family physician were negatively associated with health awareness . Older respondents were less prone to technology use, as expected . However, respondents who made a higher number of visits to the family physician were also more prone to technology use . A high number of visits to the family physician was negatively associated with professionalism and positively associated with empathy .We found that gender affected all model factors except the readiness to use AI-based applications in PC. The results indicated that privacy, professionalism and motive were higher among women .Notably, respondents' age and number of visits were somewhat correlated F (4.446) = 2.888, p < 0.001; CFI = 0.925; TLI = 0.915; RMSEA = 0.053; and RMSEA = 0.053.As shown in As demonstrated in As expected, we found a positive relationship between innovativeness  and readiness to use AI-based applications (H2a and H2b). This was not surprising, as people who are prone to use technology tend to use AI applications for various usages. Because innovative people are more open to new ideas in general , this fiAccording to the study results, H1 was supported, confirming that optimism (motive) had a positive influence on readiness to use PC applications. The motive represents the individual's belief that the HMO's offers of AI-based applications are indeed intended to improve the quality of service to insured individuals.Finally, the results supported H3, indicating that discomfort (privacy) was positively correlated with readiness to use AI applications in PC. This finding implies that if individuals are uncomfortable with technology, they will be less likely to use AI-based applications in PC. To conclude, four out of six research hypotheses were supported due to high levels of significance.AI in health care management is an emerging topic in academia and in practice. However, while physicians' perspectives regarding the utility of AI in PC management have been recently studied , patientUnderstanding the key social and behavioral determinants of acceptance of AI-enabled public health care and PC applications is of utmost importance. Understanding behavioral models for AI acceptance in public health care is important in accepting alternative approaches to assess patient attitudes and beliefs about AI applications in health care. Exploring patients' perspectives in evaluating and accepting AI-based applications is key to understanding the sources of anxiety and enthusiasm about these emerging technologies. Therefore, the importance of understanding behavioral antecedents to predict how patients are likely to form attitudes and beliefs about medical applications of AI in public health care and PC is important for developing AI tools that match patient needs and anticipate potential patient concerns. This may assist AI developers in aligning patient acceptance to new AI applications, assist in clinical implementation, and direct AI innovation toward those applications for the benefit of patients and the public health care system .Previous research concluded that patients' social context impacts their orientation to utilize AI in health care. It is known that patients' interpretations of their previous experiences with the health care system and non-AI health technology are nested within their broader social context, including social identities and the communities they belong to. These social factors also influence how patients engage with AI in health care. For example, a common social factor is known to be the generational differences in trust in technology .To deepen this investigation, in this article, we explored the potential to use the TRAM model to predict user readiness to use AI-based applications in the PC management domain. Specifically, we examined the relationship between individual characteristics and readiness to use new technology in PC. To our knowledge, this study was the first to apply the TRAM model to investigate patients' perspectives during the coronavirus pandemic.We detected positive correlations between the respondents' perceptions of HMO motive, perceptions of professionalism, proneness to technology use and privacy and readiness to use AI-based applications in PC. Additionally, our analysis indicated that a portion of the population was ready-to-use AI applications in PC during the coronavirus pandemic. This may be explained by the dependency on technology due to social distancing, fear from contagion and an increased need to examine health status according to symptoms .The AI revolution influences many domains, including health care in general and PC management more specifically , 17, 24.Our study results indicated that patients' privacy concerns, perception of professionalism, motive perception and proneness to technology use are all key factors in readiness to use AI-based technology in PC during the coronavirus pandemic. However, we found that health awareness, empathy needs, and patients' sociodemographic factors as described in the TRAM model, such as age, gender and education level, are not significant predictors of readiness to use AI-based technology in PC. Therefore, to increase the usability of digital public health and accelerate patients' AI adoption, exploring the effects of population-specific promoters of and individual impediments to accelerating the adoption of AI-based applications in PC and public health care and increasing usability in complex digital public health care ecosystems is needed , 64. ThuAI has the potential to reduce physicians' emotional burden and make them more available for patients, thus enabling a shift from a focus on transactional tasks toward personalized care. Future research can examine the impact of AI technologies in achieving better PC at lower costs and improved wellbeing for physicians and patients alike , 25.Our results may be valuable in a global context. These results may assist policy-makers and possible health institutions, as well as those in the technology industry, in communicating stronger and more effective messages to the public toward a smoother acceptance of new AI-based technologies . The impPrimary health care and AI experts agree that AI has the potential to improve managerial and clinical decisions and processes. Thus, AI adoption in PC may be facilitated by common data standards . While tAI has the potential to impact the global use of technologies in health care and additional computational AI-based tools in primary health care for the benefit of the entire health care network. Thus, both health care professionals and policy-makers may find the potential for advancing AI-based tools in primary health care , 67.via two different research tools, they were collected in a single country. However, we tried to overcome this shortcoming in two ways: first, by broadening and enhancing the variety of research tools and therefore performing Study 1 and Study 2; and second, by diversifying our sample in light of the unique coronavirus situation, which influences remote users of AI-based applications (This research is subject to several limitations. First, the five Likert-scale measures we used to measure most of our dependent variables in Study 2 may have captured a limited dimension of these variables . Future ications . Howeverications , and ackFinally, the convenience sample survey data are less ideal for external validity and may be subject to common method bias. Since the bias of the sample cannot be measured, inferences based on the convenience sampling were made with regard to the sample itself.AI has the potential to impact the global use of technology in health care, and additional computational AI-based tools in primary health care can benefit the entire health care network. Thus, both healthcare professionals, as well as policy-makers, may find the potential in advancing AI-based tools in primary health care , 67.This paper has two major contributions. First, we highlight the key social and behavioral determinants of the acceptance of AI-enabled health care and PC applications. Second, we propose implementing adaptive, population-specific promotions of AI technologies and applications to increase the usability of digital public health and accelerate patients' AI adoption in complex digital public healthcare ecosystems.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by Tel Aviv University. The patients/participants provided their written informed consent to participate in this study.HCB: writing—first, second and final drafts, writing—review and editing, validation, writing—final draft, overall supervision, and project supervision.


To investigate the effect of bicalutamide combined with docetaxel on the levels of prostate-specific antigen (PSA) in serum and vascular endothelial growth factor (VEGF) in patients with advanced prostate carcinoma (PCa).  The clinical data of 103 patients with advanced PCa at our hospital between Feb. 2020 and Feb. 2021 were retrospectively analyzed, the 90 of whom screened by inclusion and exclusion criteria were finally chosen as research objects. They were divided into a control group and an experimental group according to the order of admission, with 45 cases in each group. The control group was treated with conventional treatment, while the experimental group underwent the combination of bicalutamide and docetaxel, and the clinical indices of the two groups were compared. P < 0.001), with remarkably lower incidence of toxic and side effects (P < 0.05) and higher Expanded Prostate Cancer Index Composite (EPIC) scores (P < 0.001) in the experimental group than in the control group.  After treatment, the serum indices in the experimental group were remarkably lower than those in the control group ( The implementation of bicalutamide combined with docetaxel in patients with advanced PCa is effective in reducing the inflammatory expression and improving quality of life and has a higher safety profile. Compared with conventional treatment, this method is of high application value, and further studies will help establish a better solution for such patients. As a common disease in urology, prostate carcinoma (PCa) is the epithelial malignant tumor occurring in the prostate . AccordiSurgery, radiotherapy, chemotherapy, and androgen deprivation therapy (ADT) are the main clinical treatments for PCa . SurgeryThe clinical data of 103 patients with advanced PCa at our hospital between Feb. 2020 and Feb. 2021 were retrospectively analyzed. Among them, 90 cases met the inclusion criteria and 13 cases were excluded. They were divided into a control group and an experimental group according to the order of admission, with 45 cases in each group. The study was in accordance with the Declaration of Helsinki .Inclusion criteria. ① The patients met the diagnostic criteria of PCa in the Diagnosis and Treatment of Prostate Cancer  and confExclusion criteria. ① Patients who had received chemotherapy or other treatment regimens before; ② patients with psychiatric abnormalities or cognitive impairments that affected treatment and communication; ③ patients with contraindications to treatment or drug allergies; ④ patients with severe cardiac, cerebral, hepatic, or renal insufficiency; ⑤ patients with other malignant tumors; and ⑥ patients with pituitary or adrenal cortical dysfunction.Patients in the control group were given abiraterone acetate tablets , once a day, 1000 mg. On this basis, prednisone acetate tablets  were introduced, 5 mg-10 mg each time and 10 mg-60 mg per day orally.2-75mg/m2, with an intravenous drip of 1 h, once every 3 weeks.Patients in the experimental group received bicalutamide capsules  with 50 mg each time, once a day. On this basis, an intravenous drip of docetaxel  was administrated. Based on the calculated amount of medication for the patients, the required dose was inhaled with a syringe and diluted into 5% glucose injection or 0.9% sodium chloride injection, gently shaken, and mixed well to a final concentration of ≤0.74 mg/ml. The docetaxel dosage was 70 mg/mPatients in both groups were reviewed once every 30 d. When the PSA index was <0.2 ng/ml, the medication could be stopped, and when the PSA index was >4 ng/ml, the medication needed to be continued, for 12 months.After treatment, 5 ml of fasting venous blood was collected from both groups, which was centrifuged at 3000 r/min for 10 min by a centrifuge , with the upper layer of serum preserved. Serum PSA indices were detected by the electrochemiluminescence method, with VEGF indices detected by enzyme-linked immunosorbent assay. All operations were carried out strictly according to the instructions of the kit .The incidence of toxic and side effects was compared between both groups, including gastrointestinal reactions, abnormal liver function, sexual dysfunction, and sensory abnormalities.The quality of life was assessed by the Expanded Prostate Cancer Index Composite (EPIC) , whose ex2 test and expressed by ((n%)), with measurement data by the t test and , see No remarkable differences were found in the age, BMI, mean disease duration, clinical stages, number of comorbidities, education levels, career, religious beliefs, family income, smoking, drinking, and residence between both groups (P < 0.001), see After treatment, the serum indices in the experimental group were remarkably lower than those in the control group (P < 0.05), see The incidence of toxic and side effects in the experimental group was remarkably lower than that in the control group (P < 0.001), see After treatment, the EPIC scores in the experimental group were remarkably higher than those in the control group (P < 0.001), indicating that the continuous implementation of this treatment scheme significantly reduced and maintained serum PSA and VEGF levels. The reasons were analyzed as follows. As an antiandrogen drug, bicalutamide can bind to the androgen receptor in the body with high intensity, thus reducing the growth-promoting effect of testosterone and dihydrotestosterone on cancer cells, maximally controlling the metastasis of prostate cancer cells and consolidating the therapeutic effect. In addition, this treatment can effectively reduce testosterone. Docetaxel, an antitumor drug of taxane compounds, can destroy the mitosis of tumor cells by enhancing tubulin polymerization and inhibiting tubulin depolymerization, thereby inhibiting the division and proliferation of tumor cells, and also reducing the serum PSA and VEGF levels of patients. The combination of the two greatly reduces the serum PSA and VEGF levels of advanced PCa patients, which is positive for the improvement of the disease. Meanwhile, Yang et al. [Significant racial and geographic differences in the incidence of PCa have been reported, and in the US, the incidence of PCa has surpassed lung cancer as the number one tumor endangering men's health . The incg et al.  have fouP < 0.05), indicating that bicalutamide combined with docetaxel is safer than conventional treatment. Moreover, it has been shown that intermittent endocrine treatment for advanced PCa in the elderly can arrest the progression of PCa to the androgen-independent phase, significantly improve the prognosis of patients, and improve their quality of life [The incidence of toxic and side effects is an important evaluation index of treatment safety. Gastrointestinal reactions, abnormal liver function, sexual dysfunction, and sensory abnormalities are common adverse reactions in PCa patients, which seriously affect their quality of life. In this study, the overall incidence of toxic and side effects in the experimental group was remarkably lower than that in the control group ( of life . The EPI of life  have fouIn summary, bicalutamide combined with docetaxel is a reliable regimen for the treatment of advanced PCa, and the application of this regimen can benefit the patients by effectively reducing serological indexes and improving quality of life. Therefore, it is recommended for the clinical treatment of PCa.


Staphylococcus aureus (MRSA) is an opportunistic bacterium that causes many human and animal infections worldwide. MRSA infections are classified as priority infections owing to their high morbidity and mortality, with a significant risk of zoonotic transmission. This study aimed to determine the pooled prevalence of MRSA in dairy cattle farms and its heterogeneity. Relevant studies were retrieved from three databases: PubMed, Web of Science, and Scopus. The pooled prevalence of MRSA in dairy farms was estimated using a random-effects model. Subgroup and meta-regression analyses were used to assess the probable sources of heterogeneity. Sensitivity and publication bias analyses were also performed. A total of 94 articles were eligible for inclusion in this meta-analysis. The pooled prevalence of MRSA was estimated to be 3.81% [95% confidence interval (95% CI) = 2.61–5.20] with significantly high heterogeneity . For the subgroup analysis among continents, the prevalence was highest in Asia  and lowest in South America . As for the year of publication, MRSA prevalence was highest in reports published from 2015 to 2018  and lowest in reports published before 2015 . As for sample type, the prevalence of MRSA in cattle milk  was higher than that in other sample types . These three factors were not significantly associated with the pooled prevalence of MRSA (p > 0.05). Therefore, the findings of this study indicate that the prevalence of MRSA has been minimal and consistent in dairy cattle farms over time.Methicillin-resistant  Staphylococcus aureus is a commensal bacterium that can be found on the skin, mucous membranes, and upper respiratory tracts of both animals and humans  was first documented in 1961  guidelines were adopted for this study. Relevant studies published until 31 December 2021 were retrieved from three online databases: PubMed, Scopus, and Web of Science. The search was limited to original articles published in English. The keywords used for searching the relevant studies were “MRSA” OR “Methicillin-resistant mecA and/or mecC genes, in dairy cattle farms were considered for analysis. The inclusion criteria were observational, cross-sectional, and case–control studies that determined the prevalence of MRSA from any sample source in dairy cattle farms. Studies were excluded from the analysis if they were (1) review articles, (2) experimental studies, (3) not written in English, (4) lack of a clear report on the prevalence of MRSA from any sample sources in dairy cattle farms, (5) lack of clear sample size, (6) performed on archived isolates, (7) no full text available, and (8) studies that used only phenotypic tests to detect MRSA. The titles and abstracts of the retrieved studies were evaluated for eligibility. After title and abstract screening, the full text of each article was thoroughly reviewed for inclusion. Two authors, SK and SB, independently performed study screening and selection. Disagreements were resolved through discussion.All original publications reporting the prevalence of MRSA, as determined by the detection of S. aureus isolates, (6) the number of MRSA isolates, and (7) the detection method used.Two authors individually extracted data from all included studies. Discrepancies between the data obtained by these two authors were discussed with a third author for consensus to avoid bias. The extracted data included (1) the name of the author and year of publication, (2) the continent where the study was conducted, (3) sample size, (4) sources of samples, (5) the number of The quality assessment criteria derived from Ding et al.  were useMeta-analysis was performed using the R package meta in the statistics software R , 22. TheQ-test was used to determine the heterogeneity of the pooled prevalence. Furthermore, the I2 statistic was used to characterize the degree of heterogeneity across studies, with values of 25, 50, and 75% indicating low, medium, and high heterogeneity, respectively . Cochran's The subgroups in each study were used as the unit of analysis for all subgroup meta-analyses. Subgroup analyses were performed to investigate the heterogeneity between three variables: year of publication, continent, and sample type. The year of publication for each study was categorized into three groups consisting of “before 2015,” “2015–2018,” and “after 2018.” Each study was classified into five continents: “Asia,” “Africa,” “Europe,” “South America,” and “North America.” Sample type, referring to the sources of samples, was analyzed as two subgroups: “cattle milk” and “others.” The “cattle milk” category included quarter milk, composite milk, bulk tank milk, and milk from clinical and subclinical mastitis cases. Other sources of samples, such as cattle nasal swabs, human samples, and environmental samples collected from dairy cattle farms, were included in the “others” category.p ≤ 0.25 in the univariable meta-regression analysis were introduced to the random-effects multivariable meta-regression model.Meta-regression analyses were performed to investigate the significance of the between-study heterogeneity associated with three independent variables: year of publication, continent, and sample type. Levels within each independent variable were similar to those described for the subgroup meta-analyses. A univariate meta-regression model was created to determine the association between each independent variable and the prevalence of MRSA in dairy cattle farms. Furthermore, variables with p < 0.05 indicates statistical significance , lack of clear sample size (n = 13), archived isolates (n = 56), not written in English (n = 9), and studies that used only phenotypic tests to detect MRSA (n = 53), as shown in A total of 2,601 records were identified from the three databases searched. These records consisted of 69 from PubMed, 2,446 from Scopus, and 86 from Web of Science. Of these, 155 records were duplicates and were removed before screening the titles and abstracts. After the screening process, 272 articles were included in the full-text review for inclusion criteria. Finally, 94 studies met the inclusion criteria and were included in the meta-analysis , 27–118.n = 38). These studies reported the prevalence of MRSA in 30 countries across five continents. Most studies were conducted in Asia (n = 43), followed by Africa (n = 20) and Europe (n = 20). The majority of studies reported MRSA detection in milk samples (n = 90), whereas only 22 studies reported the presence of MRSA from other sample types. The mean ± standard deviation of quality scores of all included studies was 7.91 ± 1.62, with a range from 4 to 10. The characteristics of the selected studies are shown in The 94 studies considered in this review were published between 2003 and 2021, with the majority published after 2018 . These data are shown in After data extraction, a total of 1,251 MRSA strains isolated from 47,236 samples collected from dairy cattle farms worldwide were included in the meta-analysis. As estimated from the random-effects model, the overall pooled prevalence of MRSA in dairy cattle farms was 3.81% (95% CI = 2.61–5.20), with high heterogeneity , revealing evidence of small-study effects. Furthermore, sensitivity analysis was performed to assess the robustness of the models used to estimate the pooled prevalence of MRSA. The overall pooled prevalence of MRSA in dairy cattle farms using a fixed-effects model was much lower than that using a random-effects model, as shown in The funnel plot created from the data obtained from the selected studies demonstrated asymmetry of distribution, as shown in The current study revealed that the global prevalence of MRSA isolated from various sample sources in dairy cattle farms, using a random-effects meta-analysis model, was 3.81%. Recently, Zaatout and Hezil  reportedSubgroup analyses were carried out depending on the year of publication, continent, and sample type. We observed that the number of selected articles published before 2015 was limited (19/94). Increased numbers of studies were observed from 2015 to 2018 (37/94) and after 2018 (38/94). The highest pooled prevalence of MRSA was observed from 2015 to 2018 (4.36%) but not statistically different from that before 2015 and after 2018. In contrast, a recent meta-analysis on MRSA associated with bovine mastitis reported a significantly increasing trend in prevalence by the year of publication and suggested that it might be influenced by the advancements in the detection methods used . This coAlthough we could not demonstrate a statistically significant difference in pooled prevalence among subgroups, our results showed a substantially higher prevalence of MRSA in dairy cattle farms in Asia (4.89%) than in South America (1.33%). The milk production and dairy animal population in Asia have been increasing . During S. aureus than other pathogenic or non-pathogenic S. aureus found in other sources in dairy cattle farms. However, the difference in the prevalence of MRSA isolated from these two sample types was not significant. Moreover, MRSA transmission among cattle, humans, and the environment cannot be ruled out. Therefore, MRSA monitoring and prudent antimicrobial use in dairy cattle farms should be regularly implemented.In addition to cattle milk, MRSA has been isolated from farm workers, farm environments, and other cattle organs. The pooled prevalence of MRSA in milk samples was lower than that in other sample sources from dairy cattle farms. Most milk samples reported in the selected studies were quarter milk samples collected aseptically; therefore, MRSA detected in cattle milk is generally a representative pathogenic strain of MRSA associated with intramammary infection and/or mastitis in cattle. In contrast, MRSA isolated from other sample sources could be either pathogenic or non-pathogenic strains, or a mix of both. Our findings suggest that MRSA is higher prevalent among bovine mastitis-causing Regarding univariable and multivariable meta-regression, there was no significant association between the overall pooled prevalence of MRSA and any variable, suggesting that the source of heterogeneity could not be explained by the year of publication, continent, or sample type. It suggests that the heterogeneity of reported prevalence among included publications might be associated with other factors, such as the method of isolation, the sampling and sample handling procedure, and the history of MRSA infection or transmission in the farms. However, the information regarding those factors was not equally and well-explained in most of the included publications. Therefore, they were not extracted during the systematic review and included in the meta-analysis. A further study with a more specific hypothesis using different search strategies and inclusion and exclusion criteria should be performed to investigate the source of heterogeneity of the prevalence of MRSA in dairy cattle farms.Analysis of publication bias performed using the funnel plot and Egger's test revealed the bias of publications with small-study effects. Small-study effects are generally defined as a phenomenon in which studies with smaller sample size show different, and often larger, effects than studies with a larger sample size. This phenomenon can be due to the publication bias, when small studies reporting larger effects are more likely to be published compared to those reporting smaller effects. A funnel plot, showing the reported effects from small studies which are usually associated with high standard errors and large studies which are usually associated with low standard errors, can be used to illustrate the publication bias. According to the present study, the funnel plot clearly shows that small studies reporting low prevalence are missing which is illustrated as an area without any dots in the bottom left corner of the plot. Even though the small-study effect is a potential limitation of this study, all included publications were of fair to high quality. Moreover, using a sensitivity analysis, we showed that our meta-analysis was robust and stable. Other study limitations should also be concerned. First, only articles that were written in English were included. Second, the included studies were obtained from only three distinct databases. Third, the year of publication of several studies was not identical to the year of MRSA isolation, which may have influenced the misclassification and misinterpretation of the subgroup meta-analysis. Even though we successfully revealed the global prevalence of MRSA in dairy cattle farms, other knowledge such as the risk factors associated with the presence of MRSA and the antimicrobial use in dairy cattle farms was not described. This gap in knowledge is critical in controlling and monitoring MRSA in dairy cattle farms and needed to be further investigated in a future study.The global pooled prevalence of MRSA in dairy cattle farms has been minimal yet consistent over time. The pooled prevalence of MRSA in dairy cattle farms was the highest in Asia, followed by Africa and Europe. Cattle milk samples were found to harbor a higher prevalence of MRSA than other sample types. Therefore, following the results of this study, we recommend that appropriate levels of barn sanitation, personnel sanitation while handling animals and animal products, implementation of a continuous surveillance and monitoring program for evaluating animal health, and monitoring of antimicrobial resistance patterns at the farm level, be employed to control the spread of MRSA in dairy cattle farms.The original contributions presented in the study are included in the article/SB and NA designed this study. SB, SK, and NA performed the systematic review and meta-analysis. SB and SK prepared and revised the manuscript accordingly. All authors contributed to the article and approved the submitted version.This study was funded by the Center of Excellence in Veterinary Public Health, Faculty of Veterinary Medicine, and CMU Presidential scholarship, Chiang Mai University.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.


This review paper gives an insight into the microstructural, mechanical, biological, and corrosion resistance of spark plasma sintered magnesium (Mg) composites. Mg has a mechanical property similar to natural human bones as well as biodegradable and biocompatible properties. Furthermore, Mg is considered a potential material for structural and biomedical applications. However, its high affinity toward oxygen leads to oxidation of the material. Various researchers optimize the material composition, processing techniques, and surface modifications to overcome this issue. In this review, effort has been made to explore the role of process techniques, especially applying a typical powder metallurgy process and the sintering technique called spark plasma sintering (SPS) in the processing of Mg composites. The effect of reinforcement material on Mg composites is illustrated well. The reinforcement’s homogeneity, size, and shape affect the mechanical properties of Mg composites. The evidence shows that Mg composites exhibit better corrosion resistance, as the reinforcement act as a cathode in a Mg matrix. However, in most cases, a localized corrosion phenomenon is observed. The Mg composite’s high corrosion rate has adversely affected cell viability and promotes cytotoxicity. The reinforcement of bioactive material to the Mg matrix is a potential method to enhance the corrosion resistance and biocompatibility of the materials. However, the impact of SPS process parameters on the final quality of the Mg composite needs to be explored. Over decades, metallic implants have been used extensively in the human body for different functionalities. However, there are some common shortcomings, such as the stress shielding effect, the need for secondary surgery to remove the implant, and the release of toxic ions on prolonging implantation. It gives a scope of research in biomaterials to enhance functionality by reducing the medical difficulty and increasing the aesthetical comfort of the host . BiodegrAmong the biodegradable materials, magnesium has more significant potential, since it has mechanical properties similar to the natural bone, which helps avoid the stress shielding effect. Moreover, it does not release any harmful content and is biocompatible. The great difficulty in using Mg-related implants is because of their higher corrosion rate and decrease in mechanical integrity throughout healing ,8. The dMoreover, Mg exhibits a higher corrosion rate and less mechanical integrity in the host body throughout implantation ,15. Ther3AlC2 composite prepared through the SPS process shows a high relative density, but the addition of excessive reinforcement leads to agglomeration of the particle [2 and the ZrB2-SiCw-Cf system also shows relatively high density while adding nitrates [2-based composite allows the formation of in situ phases corresponding to significantly improving mechanical properties [The simultaneous application of pressure and electric field leads to a novel powder metallurgy technique called spark plasma sintering (SPS). The operating temperature of SPS is shallow compared to other conventional powder metallurgy (PM) processes. It helps to fabricate dissimilar materials with a homogenous structure without melting. The TiAl–Tiparticle ,20. SPS nitrates ,22. The operties ,25,26,27operties ,29. In roperties . To the 2 nanocomposite using a sinter less powder metallurgy technique followed by hot extrusion. The homogenous mixture is prepared using a ball milling process with a ball to powder ratio of 20:1. The powder blending is carried out at 200 RPM for 2 h without balls. The compaction is performed at 97 bar, and the sample is soaked for 1 h at 200 °C.Powder metallurgy is a manufacturing technique in which the final part can be obtained from a sequence of operations. In general, the sequence follows (i) the production of powder, (ii) compaction of powder, (iii) sintering of powder at an elevated temperature below the melting point, (iv) which is followed by post/secondary processing based on the requirement. Many researchers have been working on the fabrication of Mg composites to improve their functionality and properties. However, the optimal materials and process parameters must be maintained to attain a good response ,32,33. TThe hot extrusion is carried out at 200 °C, and the temperature is considerably lower than the eutectic transformation temperature ,36,37,38SPS is a novel manufacturing technique for developing materials with different compositions by using a direct electrical current to rapidly consolidate powders in a brief period, using relatively high sintering pressure . The higIn the scientific database, there is work that proves the presence of spark and plasma . Some woA particle is a basic powder unit with various shapes and may consist of grains and intermetallic phases. The characterization of the particle can be achieved by measuring various parameters with different techniques. The quantitative data of powder are as follows: “particle size and its distribution, particle shape and its variation with particle size, surface area, interparticle friction, flow and packing, the internal particle structure, and chemical gradients, surface films and admixed materials ”. Among The characteristics of Mg-based alloy powder can be measured using an optical microscope, SEM, and XRD techniques. The XRD pattern helps to reveal phases of the powder . XRD is The microstructure of any specimen can be analyzed using various instruments which are worked based on various techniques. SEM analysis reveals the microstructure of the sample and helps to investigate the surface details of the tested specimen. The porosity and Mg enrichment region is identified through BSE, as contrasts of the image are based on an atomic number of elements in the specimen . 2 composite with the absence of porosity, micropores, and voids [Energy-Dispersive Spectroscopy (EDS) helps identify the quantification of element distribution of the alloy or composite system. As for Mg in Ti-Mg alloy, initially, the strength of the alloy increases due to solid solution strengthening mechanisms, as the Mg dispersed in the Ti restricts the dislocation motion. A further increase in Mg content leads to a decrease in ductility, yield, and tensile strength due to the enrichment of Mg on Ti grain boundaries . Zn–Mg/Mnd voids . It alsond voids ,69,70. Ind voids . XRD results revealed the existence of magnesium oxide (MgO) and Mg because of SPS. Although the process occurs in vacuum conditions, oxidation happens because of the air between particles in the die, as shown in eMg41Nd5 phase from the intermediate β1Mg3RE phase in the gas-atomized powder along with Mg is identified. The Electron Backscatter Diffraction (EBSD) image shown in 4− and PO43− groups [In Mg–4Y–3Nd alloy, the formation of a stable β− groups ,73. The − groups . Hydroxyapatite (HAP) is one of the bioactive ceramics, which is highly recommended to use along with Mg to enhance its mechanical properties and bioactivity. The study shows that hardness increases with an increase in HAP percentage. The hardness of the Mg depends on the percentage of reinforcement ,76. The Furthermore, the relative density is the critical factor determining the SPS process’s effectiveness over conventional sintering processes. The conventional sintering process of Mg-xNb and Mg-xTa composites shows an average porosity of 2.5% (relative density of 97.5%) . On the 2/h and 28.87%, respectively [In general, the micro-galvanic coupling between cathodic and anodic areas leads to corrosion in Mg alloys in aqueous environments ,86,87. Tectively ,88. The ectively . The SPSectively . The corectively . The graectively . “Densifectively ,91,92,93ectively .The biodegradation behavior of implants tends to release metal ions in the surroundings, which would affect cell viability. The MTT assay of ZK61/β TCP is helping to perform cytotoxicity tests in L929 cells, and optical image of the tested sample is shown in 2+ and HPO42− from HAP [Moreover, cell morphologies such as diamond, flattened spindle, or polygon represent good cells’ spreading . The cytfrom HAP ,111. Thefrom HAP . Many stfrom HAP ,114. Thefrom HAP . “The cefrom HAP . Irrespefrom HAP ,118,119.The review article illustrates the various stages of the SPS process and its importance. It is evidenced that SPS is the practical process to attain full densification at the lower temperature range in a minimum time. It follows densification mechanisms such as particle rearrangement, localized deformation, bulk deformation, and neck growth. Compared to other powder metallurgy techniques, SPS helps produce good Mg composite products by the simultaneous application of pressure and temperature. However, it is also possible to achieve a higher heating rate, possibly reducing grain growth.Mg has more affinity toward oxygen, so the processing of Mg in atmospheric conditions or at high temperature directs to the formation of oxides of Mg. So, the researchers are establishing the SPS of Mg composites under vacuum or inert gas atmosphere, which reduces the oxidation of Mg to a greater extent. The mechanical properties can be enhanced by reinforcing bioactive ceramics. In addition, the SPS process parameters play an essential role in enhancing grain structure by restricting grain growth, which enriches the composite’s mechanical properties.The evolution of hydrogen gas can evaluate the corrosion rate of biodegradable Mg/Mg-related composite. For biomedical application, the amount of hydrogen should be within the following limit: “Ostwald solubility coefficient for hydrogen of whole blood in the human body is 0.018 (mL gas per mL medium)”. Therefore, this processing technique and percentage of reinforcement play a vital role in modifying the corrosion rate. Furthermore, it is required to correlate the in vitro study with the actual corrosion behavior of the implant. This challenge gives scope for future research.The studies show that the Mg composites have good biocompatibility behavior with enhanced bioactivity. The excellence of Mg composites is greatly influenced by their material composition , microstructure, and surface properties. Moreover, corrosion trends release metal ions, affecting cell viability. Although the Mg composites show promising results, there is a long way to use Mg composite as a bioimplant. The stages are as follows: (i) in vitro test; (ii) in vivo test; (iii) product shape formation; (iv) animal models; (v) human volunteers; and (vi) final product. It paves the way to work on Mg/Mg alloys/Mg composites for biomedical applications.Many studies show the effect of reinforcement on composites while processing through the SPS process. However, only a few studies show the effect of SPS process parameters on responses, which need to be explored.


The aims of this study were to examine the mediation effect of viral anxiety of healthcare workers on the influence of their intolerance of uncertainty on the adherence to physical distancing during the COVID-19 pandemic.An online survey was conducted among 329 healthcare workers  on November 29, 2021. Participants responded to questionnaires on adherence to physical distancing, health beliefs, and perceived social norms, and rating scales of the Stress and Anxiety to Viral Epidemics-6 items (SAVE-6), Patient Health Questionnaire-9 items (PHQ-9), and the Intolerance of Uncertainty-12 items (IUS-12) scale.p = 0.01), personal injunctive norms , SAVE-6 score , and IUS-12 score  . Viral anxiety mediated the association between intolerance of uncertainty and adherence to physical distancing but not the influence of perceived benefits and personal injunctive norms on adherence to physical distancing.Adherence to physical distancing of healthcare workers was predicted by perceived benefits of physical distancing (β = 0.13, We observed that viral anxiety of healthcare workers mediated the association between intolerance of uncertainty and adherence to physical distancing. During this pandemic, exploring adherence to physical distancing and its predicting factors will be helpful for the safety of healthcare workers and the patients for whom they care. Since the onset of the COVID-19 pandemic in 2020 ; howeverPhysical distancing has been one of most effective measures for preventing transmission of the COVID-19 virus , 6. HoweThroughout the COVID-19 pandemic, viral anxiety has been reported to be associated with adherence to or compliance with physical distancing. Anxiety may influence people's physical activity and time spent outdoors ; thus, iIntolerance of uncertainty, or the inability to successfully process and respond to information in uncertain contexts , 22, wasIn this study, we first aimed to explore the reliability and validity of the questionnaires on adherence to physical distancing and health beliefs model proposed by Gouin et al.  among heSecond, we aimed to examine the relationships among adherence to physical distancing, viral anxiety, depression, and intolerance of uncertainty in healthcare workers during the COVID-19 pandemic. We hypothesized that intolerance of uncertainty of healthcare workers may be associated with their adherence to physical distancing. Furthermore, we also explored whether viral anxiety of healthcare workers mediated the influence of intolerance of uncertainty on adherence to physical distancing.This online survey was conducted among healthcare workers at the ASAN Medical Center, University of Ulsan College of Medicine, Seoul, Korea on November 29, 2021. ASAN Medical Center is the largest tertiary hospital in South Korea, where a total of 9,216 workers  are employed. Nearly all of them are Korean nationals. We recruited participants via an advertisement posted on the hospital's intranet, which stated the study's objective, enrollment procedure, and reward for participation. The participants completed the survey voluntarily, and a gift-coupon worth approximately five US dollars was provided as a reward for participation. The study protocol was approved by the Institutional Review Board (IRB) of the ASAN Medical Center (2021-1682), and the requirement to obtain written informed consent was waived by IRB. The sample size was estimated to be 300 in total, based on the calculation that there would be 10 samples per cell, with a total of 10 cells. , and theAdherence to physical distancing was assessed using a questionnaire  developeTo assess psychosocial factors influencing adherence to physical distancing, participants completed a series of items assessing health beliefs about COVID-19 as well as perceived social norms related to physical distancing. Health beliefs includes three items for perceived susceptibility of being infected, three items for perceived severity of viral infection, three items of perceived benefit of physical distancing, and four items of barriers of following physical distancing, and one item of self-efficacy. Perceived social norms subscale contains single items assessing descriptive social norms, personal injunctive norms or moral norms, and social injunctive norms. These items were originally developed by Gouin et al. , and we never) to 4 . In this study, we used the original Korean version of the SAVE-6 scale rather than SAVE-9, because we tried to explore the effect of viral anxiety of healthcare workers on adherence to physical distancing. The Cronbach's alpha among this sample was 0.805.The SAVE-6 scale is a self-rating scale for measuring one's viral anxiety , and wasnot at all) to 3 (nearly every day). In this study, we used the Korean version of the PHQ-9  based on Kaiser-Meyer-Olkin (KMO) value and Bartlett's test of sphericity. Before running the EFA, we performed parallel analysis and scree plot to identify the number of factors to retain for subsequent rotation. In EFA, principal component analysis (PCA) was utilized. We warranted oblique rotation to assess the correlations between extracted factors. As all the correlations between factors were significant except one, we retained this oblique (oblimin) rotation method. In this study, we explore the appropriate model of questionnaire on adherence to physical distancing using seven items and health beliefs using 13 items . The single self-efficacy item was excluded in this model, as single items could not be included for the factor analysis. In addition, since the three items in the social norms subcategory measure different types of social norms as a single measurement, we did not include those in the final model. The reliability  was examined using the Cronbach's alpha and McDonald's omega. The convergent validity was examined based on a Pearson's correlation analysis with other rating scales.p < 0.05. Continuous variables were analyzed using a student's t-test, and categorical variables were analyzed using a Chi-square test. A linear regression analysis was performed to reveal the predicting variables for adherence to physical distancing. The bootstrap method with 2,000 resamples was implemented to examine the mediation effect. We used SPSS version 21.0, AMOS version 27 for Windows , and JASP version 0.14.1 to perform the statistical analysis.Second, we explored the association of Adherence to Physical Distancing Scale with other rating scales. Demographic characteristics and rating scales scores are summarized as mean ± standard deviation. The level of significance for the analyses were defined as two-tailed at values of A total of 330 healthcare workers participated in this survey. All except one agreed to allow their responses to be used for the study purposes. Hence, 329 responses were analyzed after excluding the response of the worker who did not agree for their response to be used in the study .p < 0.001). Parallel analysis which suggested four factors in the health beliefs and two factors in the adherence to physical distancing. Next, a scree plot and EFA with oblimin rotation advised the four factors model of health beliefs , and two factors model of adherence to physical distancing . Factor loading of items in each scale are presented in The normality assumption for items in both the adherence to physical distancing and health beliefs questionnaires were checked based on the skewness and kurtosis within the range of ± 2 . CorrelaThe questionnaire on adherence to physical distancing showed good reliability, when we tested for all items . Cronbach's alpha of each factor was good (0.868 for distancing factor I and 0.781 for distancing factor II). The Cronbach's alphas if the dropped items were measured were 0.703–0.899 . The conp < 0.01), perceived benefits , personal injunctive norms , SAVE-6 score , and IUS-12 score .p = 0.03), personal injunctive norms , SAVE-6 score , and IUS-12 score . Furthermore, the results also revealed that adherence to physical distancing among healthcare workers was predicted by perceived benefits of physical distancing  was relatively low (0.342) among this sample. In this sample, 48.0% of participants responded “not at all” to this item  unlike tThe reliability tests results showed that the Korean version of questionnaires on adherence to physical distancing and health beliefs can be applied to healthcare workers. It also showed good convergent validity with pre-existing rating scale for viral anxiety. Components of the questionnaires were significantly positively correlated with high level of viral anxiety  of the Asan Medical Center (2021-1682) and the requirement to obtain written informed consent was waived by IRB. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.SC and WS: conceptualization. SC, TL, and YH: data curation. SC, OA, J-PG, and WS: formal analysis. SC and TL: investigations. SC, J-PG, and YH: methodology. SC: project administration. YH, OA, and TL: visualization. SC, TL, OA, WS, YH, and J-PG: writing—original draft. All authors: writing—review and editing. All authors contributed to the article and approved the submitted version.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.