Interest in sustainable food consumption has gradually increased over the previous third decades. Despite substantial studies addressing various topics connected to sustainable food consumption, little research systematically evaluates which factors influence consumers’ purchase of sustainable food. We aim to integrate preliminary findings, compare four original and extended models of the theory of planned behavior (TPB) in the context of sustainable food consumption, and identify measurement and situational moderators using a meta-analytic structural equation modeling approach. The results show that attitude (ATT), subjective norms (SN), and perceived behavioral control (PBC) were most strongly positively correlated with a purchase intention (PI) of sustainable food. Furthermore, the analysis of the moderating effects revealed significant differences in the relationship between PBC and purchase behavior (PB) and between SN and PI in developing and developed countries. In addition, by comparing four original and extended TPB models, this study proposes a theoretical framework to affect customers’ PI of sustainable food. The findings of this study can be used as a foundation for company marketing and government environmental protection promotion. Humanity confronts various environmental concerns, such as global warming, resource depletion, and the accelerating extinction of species. To overcome these concerns, international and interdisciplinary efforts must identify the key drivers and processes underlying the behavior causing these challenges, forecast their evolution over time, and ultimately change the system enough to mitigate negative consequences. The United Nations, in particular, has identified sustainable consumption as one of its primary objectives for achieving environmental sustainability . Food suTechnological advancement and government regulation play a significant role in food sustainability. However, the contribution of individuals’ behavior should not be overlooked. Consumers are paying more and more attention to the environment, which directly impacts the changes in individual lifestyles and values. As consumers become increasingly concerned about environmental, nutritional, and health-related problems, the demand for sustainable foods and beverages is rising . This riDespite the considerable evidence, the determinants of sustainable purchasing behavior remain uncertain, as studies have reached different conclusions based on different scenarios. The theory of planned behavior (TPB)  is a robThis study aims to integrate preliminary findings, compare four original and extended models of the TPB in the context of sustainable food consumption, and identify measurement and situational moderators using a meta-analytic structural equation modelling approach .Specifically, we explore the relationship between ATT, SN, PBC, and PI and the effect of behavioral intention on actual behavior based on 42 previous empirical studies’ effect size of the TPB model of sustainable food consumption. Therefore, the first research question proposed in this paper is: in the empirical research of planned behavior theory on sustainable food consumption, how strong is the relationship between ATT, SN, PBC, and PI, and how strong is the effect of PI on actual behavior?Second, we advance the existing meta-analyses –18 by stThird, we intend to go beyond the classic framework of the TPB by analyzing a series of relationships rarely studied in the literature on sustainable consumer behavior and comparing different models from the original TPB to explore other mediating effects: 1) SN-ATT-PI-PB; 2) SN-PBC-PI-PB; 3) SN-PBC-PB; 4) SN-PI-PB.The remainder of this paper is organized as follows: Section 2 outlines the conceptual model developed for the present study and includes a literature review; Section 3 explains the research methodology, which provides for the concept of meta-analysis, selection criteria related to the empirical studies, and how the data collected for the analysis; Section 4 describes the empirical results of overall estimates, moderators analysis, a test of models and mediating analysis; Section 5 discusses of results and implications; Section 6 provides conclusions and includes research limitations and suggestions for future work.The TPB has been used successfully in food selection –22.Attitude is a psychological construct that conveys an individual’s global positive/negative assessment of a particular behavior; the more positive the attitude, the stronger the intention to express that behavior . Some stSubjective norms are associated with the social influence or pressure on people to engage or refrain from a specific action . The TPBPerceived behavioral control refers to an individual’s impression of the elements that may promote or obstruct the manifestation of behavior . AccordiScholars’ research on the relationship between ATT, SN, and PBC and sustainable food purchase intention and actual consumption is limited by sample space. They cannot comprehensively and deeply explore the influence of potential regulatory variables, resulting in inconsistent research conclusions. With the help of a meta-analysis method, this study examines the relationship between ATT, SN, and PBC and sustainable food purchase intention and actual consumption based on a large sample across space and time. The study discusses the potential moderating effects of relevant variables, including measurement factors (sampling area) and situational factors .There are differences in consumption views of people in different countries or regions with different levels of economic development. Consumers in today’s world are increasingly concerned and aware of consuming eco-friendly food. According to previous research, sustainable food is healthier, more nutritious, and tastes better , 34. As Attitudes, subjective norms, perceived behavioral control, and the relationship between behavioral intention and actual behavior may differ across cultural contexts, resulting in inconsistent relationships across study variables. Hofstede  proposedThe Web of Science and SCOPUS databases were searched for this study. The following terms and combinations are used as research keywords for titles, keywords, and abstracts:  AND (“theory of planned behav*” OR “planned behav*” OR “Ajzen”). The results are extracted from online search engines and recorded in a comprehensive database. Studies with duplicate entries or basic missing information were excluded. A total of 5,223 studies were retrieved due to the wide range of keywords used. To avoid omission, many relevant studies are covered, and references to reviews and related articles are manually searched. The literature retrieval of this study will be completed on the 31st of July 2021.In the retrieval process of articles, the literature is first screened to check whether the title and abstract meet the specific requirements. A total of 453 initial articles are obtained after initial screening. Based on the concept of the meta-analysis method and the principle of the structural equation model, the criteria for inclusion in the MASEM study are (1) empirical papers using survey data or secondary data. (2) All studies adopt a quantitative approach to Ajzen’s theoretical model of planned behavior and follow Ajzen’s original operational definition , 36. (3)After screening according to the eligibility above criteria, the final database for meta-analysis comprised 42 publications, providing 50 different studies with 23,947 participants. All authors agreed on the definition of each dimension/variable before coding the literature. Authors coded independently and discussed and solved the ambiguity generated in the coding process. Specifically, the documents included in the meta-analysis are coded as follows: Literature information (author name and literature publication time), sample size, output results, correlation statistics , sampling region, national culture, data source, etc. The correlation coefficient r of the effect size in the literature is coded as an effect size value for each article as an independent sample. A complete list of the studies considered in the current review and the related classifications based on the above variables, is available in To test the strengths of the correlations between the components of the theory of planned behavior regarding the purchase and consumption of sustainable food products, a meta-analytical structural equation model (MASEM) was used as a complementary advantage of meta-analysis and the structural equation model. This was accomplished using meta-analytical approaches that pooled the multiple correlation matrices accessible in the research before analyzing the results with structural equation models.The meta-analysis in this study is performed using the professional software Comprehensive Meta-Analysis (CMA) 3.0. The Pearson correlation coefficient was chosen as the effect size in this investigation. Cohen  developeThe fixed-effects model or random-effects model is mainly used in meta-analysis. Fixed effects models assume that all studies share the actual effect size, while random effects models believe that different studies have different effect sizes. According to Field and Gillett , researc2 test and the Q test. Values above 75% of I2 are given high heterogeneity, while values below 25% are assumed to be low heterogeneity. The null hypothesis of the Q test assumes complete homogeneity [Then, the Heterogeneity test was performed to confirm the rationality of the random effect model selection. Heterogeneity test methods mainly include the Iogeneity ; we can While conducting a meta-analysis, there may be publication bias; that is, articles with significant research results are more likely to be published. As a result of publication bias, the published literature cannot represent the entire state of finished research on the subject in a systematic and comprehensive manner . PublicaAfter meta-analysis, the joint correlation coefficient matrix between variables is obtained, and metaSEM R package  is used Model A  is the oData are analyzed according to the above process, and the main effect is tested first. The results are shown in First, the lower limit of the 95% confidence interval of the corresponding test results of each relational variable is greater than 0, indicating that these effect values have good reliability. The relationship between ATT, SN, PBC and PI is then investigated. The correlation coefficient between ATT and PI was the strongest (r = 0.578***). The correlation between SN and PI is slightly lower but still large (r = 0.489***). The correlation coefficient between PBC and the PI was the smallest (r = 0.438***). Similarly, there are similar results in examining the relationship between the antecedent variable of PI and PB. The correlation between ATT and PB was the strongest (r = 0.399***), followed by SN and PB (r = 0.362***), and finally, PBC and PB (r = 0.345***). In addition, there was a strong correlation between PI and PB (r = 0.511***).Interestingly, the correlation between ATT, SN, and PBC also showed different magnitude. On the one hand, ATT (r = 0.369***) and SN (r = 0.330***) were equally strongly correlated with PBC. On the other hand, there was a moderate correlation between ATT and SN (r = 0.431***). The latter results appear to be of particular interest since, as shown in the following, they might suggest an indirect relationship between SN and PI mediated by ATT.2 and Q test values: I2 values ranged from 94.23% to a maximum of 97.84% in the test correlation, thus indicating a very high overall heterogeneity between studies  on the relationship between ATT, SN, PBC, PI and PB, the relationship between PBC and PB is significantly different at the significance level α = 0.01 . Although there was a high positive correlation between PBC and PB in both developed and developing countries (0.276 (P <0.001) and 0.478 (P <0.001) respectively), the effect was more significant in developing countries. Besides, the relationship between SN and PI is significantly different at the significance level α = 0.01 . Although there was a high positive correlation between SN and PI in both developed and developing countries 0.535 (P <0.001) and 0.408 (P <0.001) respectively), the effect was more significant in developing countries. However, the moderating effects of other relationships were not significant.Unfortunately, the moderating effects of national culture (high uncertainty avoidance vs. low uncertainty avoidance) on the relationship between ATT, SN, PBC, PI, and PB were insignificant for each connection.χ2 (2) = 5.988, p < 0.001; RMSEA = 0.009, SRMR = 0.000; TLI = 0.990; CFI = 0.998). These findings imply that TPB is very helpful in predicting sustainable food consumption behavior. R2 values for intention and behavior of sustainable food consumption were 0.572 and 0.687, respectively, indicating that the model accounts for approximately 57.2% of the explanation power in predicting intention and approximately 68.7% of the explanation power in predicting behavior of sustainable food consumption. The results suggest that ATT had the greatest impact on PI , followed by SN  and PBC . The effect of PI on PB is very high .Four TPB models, both original and modified, were assessed. Results and fit indexes are summarized in χ2 (3) = 57.790, p < 0.001; RMSEA = 0.028, SRMR = 0.071; TLI = 0.904; CFI = 0.971. R2 on intention and behavior of sustainable food consumption demonstrates a significant explanatory power on sustainable food consumption intention and behavior . The order of strength of effect on intention for model B is different with that of model A, leading by attitude , following by PBC  and then SN . The influence of intention on behavior of sustainable food consumption is the largest , followed by the influence of PBC on sustainable food consumption behavior .Model B was an extension of model A that included the direct influence of SN on ATT. For the sample of 50 studies , the indices reveal excellent fit: χ2 (3) = 58.421, p < 0.001; RMSEA = 0.028, SRMR = 0.072; TLI = 0.903; CFI = 0.971) were assessed using 50 studies . R2 on intention and behavior of sustainable food consumption show the strong explanation power on intention and behavior of sustainable food consumption . Similar with model B, the order of strength of effect first is attitude , following by PBC  and then SN . The impact of PI on PB of sustainable food consumption is the strongest , followed by the influence of PBC on PB of sustainable food consumption .Model C was a modified version of model A that had a direct link between SN and PBC. The goodness-of-fit indexes (model C: χ2 (3) = 58.470, p < 0.001; RMSEA = 0.028, SRMR = 0.072; TLI = 0.903; CFI = 0.971) were assessed using 50 studies . R2 on intention and behavior of sustainable food consumption demonstrates a significant explanatory power on sustainable food consumption intention and behavior . Similar with model B, the order of strength of effect first is attitude , following by PBC  and then SN . The effect of PI on PB of sustainable food consumption is the strongest , followed by the effect of PBC on PB of sustainable food consumption .Model D was a hybrid of models B and C. The goodness-of-fit indexes  is near the reasonable limit of the predictive utility suggested by Ajzen . FurtherThe study also shows that the relationship between PI and PB is stronger than the relationship between ATT, SN, PBC, and PB. On the one hand, this indicates that PI is the most significant predictor of PB. Still, it also supports the idea of the intention-behavior gap, which states that even the most potent intents may not convert into commensurate behaviors . Few stuTwo additional moderators were explored to capture the roles of the sample area and national culture. Interestingly, the results confirmed the significant role of these dimensions. Specifically, the moderator role of the sample area dimension was found in the relationship between PBC and PB in consuming sustainable food. This study shows that developing countries have a much stronger effect of PBC on PB to consume sustainable food. This implies that increased education on the benefits of sustainable food in developing countries could increase the consumption of sustainable food by developing country residents. We also found the role of economic status in moderating the influence of SN on the intention to consume sustainable food. This means that SN is important for PI in both developed and developing countries which is in accordance with Chu . And theThe final section of the analysis examines different TPB models and investigates the many correlations between their aspects using a MASEM. Among the four TPB models , our empirical results show that the original TPB seems to provide reasonable support in predicting PB of sustainable food with goodness-of-fit indices and strong explanation power on PI and PB of sustainable food. First, the finding related to the mediating effect of attitude toward sustainable foods on the relationship between SN and PI to purchase sustainable foods is statistically significant. This result is consistent with the empirical findings of Chu  and FariBased on earlier research, this study uses a MASEM to examine the factors influencing consumers’ sustainable food purchase intentions. According to the theory of planned behavior, the elements influencing consumers’ sustainable buy intention fall into three constructs: ATT, SN, and PBC. The results show that ATT, SN, and PBC were most strongly positively correlated with a PI of sustainable food. The findings of this study add to the theoretical foundation for understanding consumers’ buy intentions for sustainable products and new methodologies and ideas for investigating the influencing elements of sustainable product purchasing intention. Furthermore, the analysis of the moderating effects revealed significant differences in the relationship between PBC and PB and between SN and PI in developing and developed countries, with the connection being more robust in developing countries. In addition, by comparing four original and expanded TPB models, this study proposes a theoretical framework to affect customers’ PI of sustainable food. The findings of this study can be used as a foundation for company marketing and government environmental protection promotion. Enterprise marketers may make greater use of the study’s findings to develop marketing strategies; government agencies can highlight the benefits of sustainable products and assist consumers in practicing environmental stewardship.There are still some limitations in this study. First, because of the significant heterogeneity of the results, the accuracy of random effect size was reduced, and the small datasets added to the study limited our ability to investigate moderators that may assist the analysis. The second is in the process of literature collection; this paper chose between the quantity and quality of literature. Strict standards and high quality were selected to screen the literature to ensure the reliability of experimental data. As a result, some literature was not included in the meta-analysis. The third one is that this paper only explained the differences in existing research results from the sampling region and country culture due to the limited number of studies. There may still be other moderating variables that have an impact, which is worthy of further research.We believe that at least three issues have emerged: first, the need for a more robust methodological exploration of the dimensions in future literature; second, the importance of determining whether the relationship between perceived behavioral control and actual behavior holds in the current context; and third, investigate whether the function of attitudes in mediating the relationship between subjective norms and behavioral intentions extends to other similar green items, such as locally produced food , fairtrade products, and even eco-friendly technological gadgets. Paul et al.  also conS1 Checklist(PDF)Click here for additional data file.


To investigate the association between fatigue and sleep habits of pregnant women to further explore the effect of sleep duration and bedtime on fatigue during the third trimester.A total of 465 Chinese Han pregnant women in the third trimester (after 28 weeks) with a singleton gestation were recruited. Sleep habits  and the 14-item Fatigue Scale scores  were collected.The effects of sleep duration and bedtime on FS-14 physical and total scores were significant. FS-14 physical scores and total scores of the participants in the group of sleep before 23 o’clock (SBC) of short sleep duration (<7 h) were significantly higher as compared to the participants in the group of SBC of normal sleep duration, and those of the participants in the group of SBC of normal sleep duration were significantly lower than the participants in the group of sleep after 23 o’clock of normal sleep duration. There were negative correlations of sleep duration with FS-14 physical score and total score in the SBC of short sleep duration group.Sleep less than 7 h or bedtime after 23 o’clock was associated with increased fatigue levels of pregnant women in the third trimester. Therefore, it is necessary to develop good sleep habits (enough sleep duration and early bedtime) to keep fatigue at a low level for pregnant women in the third trimester. Fatigue as a common discomfort symptom during pregnancy may not only reduce the quality of life but also contribute to severe outcomes, such as severe labor pain, postpartum depression, and cesarean deliveries , 2, and It has been reported that short sleep duration during the third trimester was associated with intense fatigue in Chinese women , while CApproximately 60% of pregnant women during the third trimester report being fatigued . Total sFatigue, as one symptom of the delayed sleep phase, is consistent with insufficient sleep . While lIn modern society, late bedtime and insufficient sleep remain both common and it is difficult to disentangle the independent effects of sleep duration and bedtime on fatigue, as short sleep duration can frequently be linked to a delay in bedtime . MoreoveA total of 465 Chinese Han pregnant women in the third trimester (after 28 weeks) with a singleton gestation were recruited. Participants’ sleep was assessed after 28 weeks.The inclusion criteria were as follows: healthy pregnant women aged >20 years old, in the third trimester, and experiencing no pregnancy complications. Gestational age was determined from the last menstrual cycle and was verified using ultrasound scan measurements. According to medical records and self-reported data, women who worked night shifts, those who had been diagnosed with depression, those with major longstanding sleep issues and diagnosed with sleep disorders, or those who took medications and healthcare products known to affect sleep patterns were excluded. The exclusion criteria also included no history of any substance abuse or dependence and any diagnosed neurological and psychiatric disorders.Sociodemographic data, such as age, years of education, occupation, prepregnacy details, and current body mass index (BMI), were collected. Clinical data, such as the history of substance abuse and dependence, were obtained according to medical records and self-reports and confirmed by the next of kin and family members. Sleep habits, such as drinking coffee or tea at night, bedtime, sleep onset latency, and night sleep duration, were recorded.n = 163) and those who had a sleep duration of more than 7 h were designed for the normal sleep duration group (n = 302). Participants who sleep before 23 o’clock and who sleep after 23 o’clock were grouped into the sleep before 23 o’clock (SBC) group and the sleep after 23 o’clock (SAC) group, respectively. Of participants in the short sleep duration group, 106 participants were included in the SBC group and 57 participants in the SAC group. Of participants in the normal sleep duration group, 245 participants were included in the SBC group and 57 participants in the SAC group.Participants who had a sleep duration of no more than 7 h were designed for the short sleep duration group  was used to assess fatigue . FS-14 cThe data of high-density lipoprotein, low-density lipoprotein, alanine aminotransferase test, cholesterol, triglyceride, gamma-glutamyl transferase, and aspartate aminotransferase were obtained from routine tests of the subjects to evaluate the physical condition in the third trimester (36 weeks ± 7days). Sleep duration, sleep habit, and FS-14 were collected after the peripheral metabolic marker levels were measured on the same morning.p > 0.05). Therefore, the Mann-Whitney rank-sum test is used in p > 0.05); consequently, an analysis of covariance (ANCOVA) is used to compare differences in sleep duration and FS-14 between groups in via tolerance and variance inflation factor (VIF) as the cutoff recommended thresholds for tolerance <0.1 and VIF >10 (Continuous variables were summarized using means and standard deviations (SDs). The normality of all the variables was performed using the Shapiro-Wilk test, and only the distribution of high-density lipoprotein was normally distributed  were applied to test the significance of the interaction between sleep duration and bedtime and their effect on FS-14 scores. Age, education, and current BMI were included as cofactors in all models. The model was compared and tested using an F-statistic.p < 0.05.All statistical analyses were performed using IBM SPSS Statistics for Windows, Version 22.0 . Figures were created using GraphPad Prism version 8 (GraphPad Software Inc.). All tests were two-sided and the significance threshold was set at No participants were engaged in shift work or drank coffee/tea at night. All participants reported a sleep onset latency of fewer than 5 min.p < 0.05), except for high-density lipoprotein. The Mann-Whitney rank-sum tests are used in The homogeneity of variance using Levene’s test was performed for sociodemographic and clinical variables , while no difference was observed in other sociodemographic and clinical characteristics between two groups .p > 0.05). Stepwise multiple regression analyses of age, education, and current BMI showed that no variable was removed from models . Therefore, ANCOVA was used to compare differences in sleep duration and FS-14 scores between different groups , and FS-14 physical and total scores in SBC of short sleep duration were significantly higher than those in SBC of normal sleep duration .The homoscedasticity of residuals of sleep duration and FS-14 was verified by Levene’s test, and the results showed that the residuals of age, education years, and current BMI were contained in equal distribution , and those of the participants in SBC of normal sleep duration were significantly lower than the participants in SAC of normal sleep duration , no variable was removed from the models. Therefore, a partial correlation analysis was performed to test the correlation between FS-14 scores and sleep duration in each group after being adjusted for age, years of education, and current BMI. There was a negative correlation of sleep duration with FS-14 physical score and total score in SBC of short sleep duration  to keep fatigue at a low level for pregnant women in the third trimester.huihli@pku.edu.cn.The data that support the findings of this study are available from the corresponding authors. Requests to access these datasets should be directed to HL, The studies involving human participants were reviewed and approved by the Institutional Review Board of the Second Affiliated Hospital of Xiamen Medical College. The patients/participants provided their written informed consent to participate in this study.HL and FW designed the study. YK, DW, FW, and HL secured funding for the study. HL, DM, and DW led the drafting of the manuscript. HL led the statistical analyses. DM, HC, and LS collected the clinical data. YK, CS, and YL input the data. All authors approved the final manuscript for submission.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Women achieving a pregnancy had a significantly higher EFI score than others (p < 0.05). No significant differences were observed concerning the #Enzian score. In conclusion, the revised #Enzian score is not correlated with pregnancy achievement; EFI score is the only score significantly associated with the pregnancy outcome in women affected by endometriosis.This study’s objective was to compare the predictive validity of the three most utilized classification scores for endometriosis, #Enzian, EFI, and rASRM, in achieving a spontaneous pregnancy or pregnancy via assisted reproductive technology (ART) after surgery for endometriosis. The monocentric retrospective study was carried out from January 2012 to December 2021 at the gynaecology department of the cantonal hospital of Fribourg. Patients consulting for infertility and operated on for endometriosis with histological confirmation were included. The predictive value of #Enzian, rASRM, and EFI was evaluated and compared concerning the prediction of fertility after surgery, both spontaneous and ART, during the following 12 months. A total of 58 women (mean age 33.1 ± 4.57 years) were included. Overall, 30 women achieved a pregnancy, seven spontaneously. Among all women who achieved a pregnancy, there was a lower prevalence of rASRM stage III–IV (16.67% vs. 39.29%,  Endometriosis is one of the most frequent benign pathologies affecting women of reproductive age. The estimated incidence is currently around 6–10%, a value, however, which remains highly variable and imprecise due to the difficulty of diagnosis as well as its correlation to the type of population considered . Since tThe first classification was published in 1979 by the American Fertility Society (AFS), then it was revised twice, to revised American Fertility Society (rAFS) in 1985 and to revised American Society of Reproductive Medicin (rASRM) in 1997 ,7. It haRecently, a revised version of the Enzian classification (#Enzian) was proposed, including evaluation of the above-mentioned anatomical structures that are pivotal in female fertility . This waThis was a retrospective monocentric study conducted at the local university hospital, HFR Fribourg, between January 2012 and December 2020.The study considered all patients having consulted for infertility and having been operated on by laparoscopy or laparotomy with a histologically confirmed diagnosis of endometriosis. Patients were excluded from the study in case of: non-desire for pregnancy; diagnosis of endometriosis not retained by surgical explorations or histological examination; a lack of information or documentation in the patient’s medical records; refusal of informed consent to participate to the study.This project has been accepted by the Local Ethic Commission (CER-VD number 2021-00258). An informed consent was obtained for each patient included in the study.Our study was based on the patient files established during the specialist consultation for infertility in the gynaecology department of the HFR, as well as on the operating protocol, which preceded the start of treatments. We took some relevant data from these files, grouped into different categories: obstetrical anamnesis, gynaecological anamnesis, endometriosis anamnesis, ART anamnesis, pre- and post-operative therapy, and operating protocol, as well as the outcome of spontaneous pregnancy vs. pregnancy after ART. Through the operating protocol, the scores based on the rASRM, #Enzian, and EFI classifications were retrospectively calculated by one of the authors in order to assess their predictivity for a spontaneous pregnancy or pregnancy by ART. In case of uncertainty, an independent revision process of a second author was provided. A pooling of the scores of the #Enzian compartments in the form of a median of scores was also calculated. The mean of the sum of the rASRM stages was also calculated.Pregnancy was considered for the main outcome if it was observed within 12 months post-operation for a spontaneous pregnancy, as well as 12 months after the ART method was started for pregnancy by ART.p-value < 0.05 (two-sided). Pregnancy was achieved in 30 women, and a minimum of 21 women without pregnancy were required to detect a large effect size (0.8) in comparing the proportions of the analysed variables with a power of 80% and significance level of 0.05 (two-sided) [Data were analysed by R (version 4.2.0), considering a significant o-sided) . Moreoveo-sided) . We presA total of 58 women were scored during the study period. The mean age was 33.1 years (±4.57); 41.38% (24/58) had a previous pregnancy, and three had at least one previous delivery. Extra-uterine pregnancies were diagnosed in six women; four underwent salpingectomies, and two salpingotomies. Thirty women had a pregnancy during the 1-year follow-up time. Seven of them had a spontaneous conception. Twenty-four conceived through an ART technique, and one of these women also conceived once spontaneously. The pregnancy was evolutive in three out of the seven women (42.85%) who conceived spontaneously, and in 19 out of the 24 patients (79.17%) who conceived through ART. The study population is described in The majority of cases were found to be classified according to rASRM as stage I , followed by stage II , and stage IV . The median rASRM stage was 2 (IQR 1–3). The median EFI score was 8 (IQR 6–9), and the median sum of Enzian scores was 3 (IQR 1–3); meanwhile, the median of the Enzian score sum considering only peritoneal, ovarian, and tubal endometriosis was 1 (IQR 1–2).p = 0.054). Women achieving pregnancy had a significantly higher EFI score than others (p < 0.05). As shown in p < 0.05) (p = 0.079). These three cases were located: one in the diaphragm, one in the cervix, and one in the ureter. No other differences were observed in this sub-analysis.Considering only the seven cases in which pregnancy was achieved spontaneously, we found a higher EFI median score in the spontaneous pregnancy group than in other women  . FurtherAccording to our results, the #Enzian classification did not show any prognostic association with subsequent female fertility, either for cumulative pregnancies, or for pregnancies after ART or spontaneous ones. The rASRM classification also did not show any prognostic correlation to later fertility. Conversely, the EFI index showed a significant association with pregnancy outcome, for both assisted reproduction and spontaneous pregnancies.In terms of pregnancies achieved, our results show that seven spontaneous pregnancies were obtained in the 58 patients (12.07%). A systematic review dating from 2020 combines three different studies, and evaluates in particular the number of women with a pregnancy confirmed by ultrasound at 9 months or 18 months following laparoscopy with ablation and excision of the endometriosis . The spop = 0.079) to a spontaneous pregnancy. This result can be explained, in part, by the extra-pelvic location of some of these lesions. However, it should be taken with a grain of salt, as it is based on the presence of endometriosis in the F compartment in three out of seven women with a spontaneous pregnancy, this number being very low. In addition, the presence of endometriosis in the ureter for one of the three patients should rather demonstrate severe endometriosis. This trend should therefore be verified with a larger sample.Concerning ART and the chances of achieving a pregnancy after surgery for endometriosis, a recent literature review and meta-analysis demonstrated the same chance of achieving clinical pregnancy and live birth as do women with other causes of infertility . ConversDue to the novelty of #Enzian, we found no study evaluating its prognostic value concerning female fertility and pregnancy rate. Similarly, there are few data concerning the non-revised Enzian classification, as this previous classification was not conceived for studying this outcome . A recenp = 0.054) lower prevalence of pregnancies among stages III–IV, and no other significant association with the other stages and with the mean of the sum of the stages of this classification. The association between infertility and higher rASRM stages is not surprising, even though this difference was not significant. Zeng et al. found similar results, showing a significant difference between stage IV rASRM and lower grades in cumulative pregnancy rate after 1 year. However, the overall data showed that rASRM does not predict endometriosis-associated infertility [With regard to the rASRM classification, we found a non-significantly , influencing the reliability of the calculation of the various scores.Although the #Enzian classification was developed with the intent to improve the assessment of female reproductive organs, in our preliminary assessment, we found no association with pregnancy achievement. Meanwhile, the only score significantly associated with the pregnancy outcome in women affected by endometriosis is the EFI score. Additional and larger-scale studies should be performed in order to be able to draw valid conclusions.


To examine the longitudinal associations between cannabis use and risks of short (<7 days), medium (7-28 days), and long (>28 days) sickness absences at one-year follow-up.87,273 participants aged 18-65 years from the French CONSTANCES cohort reported their frequency of cannabis use at inclusion between 2012 and 2018. Sickness absences occurring during one year of follow-up were collected from national medico-administrative registries. Multivariable generalized linear regressions were used to compute the Odds Ratios (OR) with their 95% Confidence Intervals (CI) of having at least one sickness absence at follow-up compared to no sickness absence, while controlling for sociodemographic factors, chronic conditions and occupational factors.p-for-trend <0.001). In stratified analyses, cannabis use was associated with an increased risk of sickness absences in older individuals, men, participants with good self-rated health, living or having lived as a couple, and having an open-ended contract.Cannabis use more than once a month was associated with an increased risk of short  and medium (1.29 [1.07–1.54]) sickness absences at one-year follow-up, with dose-dependent relationships for short sickness absences (1.13 [1.08–1.18], Cannabis use prospectively increased the risk of short and medium sickness absences, even from once a month and with a dose-dependent relationship for short sickness absences. These findings should be considered in information and prevention public health campaigns to alert the general population and workers to this increased risk. CannIn addition to detrimental health consequences, cannabis use could also have deleterious social and occupational consequences. Indeed, both acute and long-term effects of cannabis use may alter occupational life, at least through the alteration of interpersonal relationships promoted by cannabis-induced psychiatric disorders. These effects might even lead to job loss whereas substance users could be more affected by socioeconomic crises than the general population . FurtherThe French CONSTANCES cohort offers a unique opportunity to examine the prospective relationships between cannabis use and the risk of sickness absence while taking into account a broad range of sociodemographic factors, chronic conditions and occupational factors. Indeed, CONSTANCES is a national population-based cohort including a randomized sample of the French population from various occupational status types and sociodemographic factors . In addiCONSTANCES is a French national population-based cohort that included more than 220,000 volunteers living in metropolitan France and aged 18 to 69 years at inclusion . ParticiAmong the 182,022 volunteers included from 2012 to 2018, 119,562 participants were employed at inclusion. After excluding 8,292 independent workers and 453 participants older than 65 years, we made the linkage with the National Health Data System—NHDS  that was feasible for 99,058 participants. Among them, 89,063 (89.9%) reported their cannabis use at inclusion. Finally, information regarding the type of employment contract  was provided for 87,273 participants (98.0%). All of these participants were included in the present study .Commission Nationale de l'Informatique et des Libertés—CNIL, no. 910486) and was approved by the Institutional Review Board of the National Institute for Medical Research—INSERM (no. 01–011). Written informed consent was received from all subjects in the cohort.The CONSTANCES cohort has obtained the authorization of the National Data Protection Authority  never used, (2) no use in the last 12 months, (3) less than once a month in the last 12 months, (4) once a month or more in the last 12 months.Système National des Données de Santé—SNDS) provides access to objective and exhaustive data regarding duration and date of occurrence of sickness absences, from January 2009 to December 2019 at the time of study , gender (men or women), marital status , household income in euros per month  and occupational grade , as categorical variables. Education level was based on the International Standard Classification of Education as follows: levels 0 to 4 (up to upper secondary education or post-secondary non-tertiary education), levels 5 and 6 , and levels 7 and 8  . TobaccoThree different dependent variables were considered for all the analyses, i.e., the number of short, medium and long sickness absences at one-year of follow-up. In the main analyses, these dependent variables were used as binary outcomes, i.e., no sickness absence vs. at least one sickness absence. The independent variable  was used as an ordered categorical variable in the main analysis.p for trend.Univariable generalized linear regression models were used to study the risk of sickness absence at one year according to the frequency of cannabis use at baseline. The results were presented as Odds Ratios (OR) with their 95% Confidence Intervals (CI). Multivariable generalized linear regression models were then performed by introducing in the models the following covariables: sociodemographic, chronic conditions and occupational factors. Three levels of adjustment were performed. Since age and gender are strongly linked to both cannabis use and sickness absences, the first level of adjustment was for age and gender. Then, the second one was additionally adjusted for tobacco consumption in order to study the specific role of cannabis and not tobacco as it is frequently associated. Finally, the last level of adjustment included also all the other potential covariables in order to examine their potential confounding and/or moderating roles. Covariables were studied as potential moderators by testing their interactions with cannabis use in order to identify at-risk subgroups. In case of significant interaction, stratified analyses were performed. Stratified analyses for age, gender and smoking status were conducted whatever the significance of the interactions between cannabis use and these variables, as the magnitude of the associations between cannabis and sickness absences may differ between different strata of the population. Finally, we searched for dose-dependent relationships between the frequency of cannabis use and the risk of sickness absence by introducing the frequency of cannabis use as a continuous variable in the models instead of introducing it as a categorical variable in order to compute a In sensitivity analyses, stratification for sickness absences in the 3 years before inclusion, i.e., zero sickness absence vs. at least one sickness absence, was performed. We also examined whether the associations could remain similar while performing a negative binomial regression with count data for the dependent variables.Non-response biases were examined by comparing participants who reported their cannabis use at baseline with those who did not.We had complete data for the outcomes  since data from the National Health Data System (NHDS) are exhaustively registered. We didn't have missing data for the independent variable of interest as we selected only the participants who reported their frequency of cannabis use. Regarding the covariables, we had missing data with a mean percentage of 6.1%. Assuming that these data were randomly missing, multiple imputations were preferred to restricted analysis to complete data in order to limit selection biases .Statistical significance was determined using a conservative two-sided alpha a priori set at 0.05 and statistical analyses were performed with RStudio, version 1.3 (R foundation).n = 8,448; 59.4%) never used cannabis, more than a third  experienced cannabis more than one year ago, 219 (1.5%) used cannabis less than once a month in the last 12 months and 340 (2.4%) used cannabis once a month or more in the last 12 months.Among the 87,273 participants, 14,219 (16.3%) experienced at least one sickness absence at one-year of follow-up. The majority of these participants  and self-rated health (p = 0.043). Men were at higher risk of sickness absence compared to women , d model] .In univariable analysis, cannabis use more than once a month was positively associated with medium sickness absences . In the p < 0.001), tobacco consumption (p = 0.024), marital status (p = 0.023) and type of work contract (p = 0.003). After stratifying for marital status and type of work contract, cannabis use remained significantly associated with medium sickness absences in the following strata: married or in a civil partnership participants, separated, divorced or widowed participants, and open-ended contract  and tobacco consumption (p = 0.035) ] and men [OR = 1.58 ], with a significant interaction for gender (= 0.035) .In sensitivity analyses, positive associations between cannabis use more than once a month and short sickness absences at one-year of follow-up remained significant for participants without any prior sickness absence in the last 3 years . MoreoveWhen considering sickness absences as a count variable rather than a binary one, all the associations from the fully-adjusted models remained significant and with similar effect sizes . FinallyOur main objective was to examine the prospective associations between cannabis use and the risk of short, medium and long sickness absences at one-year of follow-up in a large population-based cohort. We found that cannabis use more than once a month was associated with an increased risk of subsequent short and medium sickness absences, even after adjusting for sociodemographic, chronic conditions and occupational factors. Dose-dependent relationships were also found regarding short sickness absences. Stratified analyses showed that these associations may be more prevalent among older participants, men, and those with a good self-rated health, living with a partner, and having an open-ended work contract –24.To our knowledge, this is the first study to examine the prospective associations of cannabis use and sickness absences in a wide national population-based cohort with participants from various sociodemographic and occupational backgrounds. The systematic linkage with administrative medical registries provides an assessment of outcomes based on objective and exhaustive data. Moreover, thanks to the large sample, we have sufficient statistical power to take into account a great number of potential confounders and to examine further moderating effects. This study has also limitations. First, although CONSTANCES participants were recruited randomly, participants in epidemiological cohorts usually differ from the general population . Thus, rOverall, our results are in accordance with our a priori hypotheses as we found evidence that consuming cannabis increased the risk of sickness absences. Our results were primarily concerned with the risk of short sickness absences. The acute effects of cannabis, such as reduced cognitive performance , symptoms of intoxication  and withdrawal symptoms  could be particularly harmful to the ability to fulfill professional obligations and lead to short sickness absences. As cannabis is an illicit substance whose use is punishable by law in France, some people showing visible signs of use might consider taking a short sickness absence to avoid professional misconduct. The chronic effects of cannabis such as induced psychiatric disorders  and somatic pathologies  require long-term medical treatment and could therefore lead to longer sickness absences. Regarding the stronger associations in men, they tend to consume larger quantities of cannabis than women and its use is more frequently accompanied by other behaviors harmful to health , leading to an increase in risks and damage after a certain duration of exposure , 26. MorAssociations between cannabis and long sickness absences were only significant in men and in participants aged 35–50 years. One might hypothesize that participants from these groups had a lower likelihood of experiencing a shorter sickness absence during the follow-up period because they were more frequently on long sickness absence. However, subgroups analyses revealed significant associations among men and across all age groups for short sickness absences. Long sickness absences tend to occur in sicker people, suggesting that cannabis is not the major factor involved for this outcome, especially after the age of 50 . The conIn conclusion, the present study showed that cannabis use more than once a month was associated with an increased risk of subsequent short and medium sickness absences, even after adjusting for sociodemographic factors, chronic conditions and occupational factors, and with dose-dependent relationships regarding short sickness absences. These findings could be used in prevention public health campaigns to better inform on the harm associated with cannabis use. The innovative nature of this awareness-raising message, which focuses on occupational damage of cannabis use, could constitute an important motivational tool for workers to reduce their cannabis use. Moreover, sickness absences are linked to an increase in morbidity and mortality, partially in relation with a deterioration in health behaviors during these absences. Thus, preventing from detrimental health behaviors that could promote sickness absences could be of paramount interest, because such detrimental behaviors tend to increase while being in sickness absence . From a rf.mresni@sniz.eiram) and MG (rf.mresni@grebdlog.lecram).The datasets presented in this article are not readily available because personal health data underlying the findings of our study are not publicly available due to legal reasons related to data privacy protection. However, the data are available upon request to all interested researchers after authorization of the French “Commission Nationale de l'Informatique et des Libertés”. Requests to access the datasets should be directed to MZ  and Institutional Review Board of the National Institute for Medical Research—INSERM (No. 01–011). The patients/participants provided their written informed consent to participate in this study.AD: conceptualization, methodology, software, and writing—original draft. GA: conceptualization, methodology, writing—review and editing, resources, supervision, and validation. MZ: writing—review and editing, project administration, data curation, resources, supervision, and validation. YR and CL: writing—review and editing, supervision, and validation. MG: writing—review and editing, project administration, data curation, supervision, and validation. AL: methodology, writing—review and editing, supervision, and validation. All authors contributed to the article and approved the submitted version.GA declares consultant and/or speaker fees from Pfizer, Zentiva, Pierre Fabre, and Lundbeck. CL declares consultant and/or speaker fees from Boehringer Ingelheim, Janssen-Cilag, Lundbeck, and Otsuka Pharmaceutical outside the submitted work. The CONSTANCES cohort benefits from grant ANR-11-INBS-0002 from the French National Research Agency. CONSTANCES was supported by the Caisse Nationale d'Assurance Maladie, the French Ministry of Health, the Ministry of Research, the Institut National de la Sante et de la Recherche Medicale (INSERM). CONSTANCES is also partly funded by AstraZeneca, Lundbeck, L'Oréal, and Merck Sharp & Dohme Corp managed by INSERM-Transfert. This study was supported by the MILDECA . The funders had no role in the design and conduct of the study, collection, management, analysis, and interpretation of the data, preparation, review, or approval of the manuscript, and decision to submit the manuscript for publication. The remaining 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.


Fecal calprotectin (FC) levels correlate with the disease activity of inflammatory bowel diseases (IBD); however, the utility of FC in predicting IBD relapse remains to be determined. We aim to evaluate the efficacy of fecal calprotectin in predicting the relapse of inflammatory bowel disease. We searched Pubmed (MEDLINE), Embase, Web of Science, and the Cochrane library databases up to 7 July 2021. Our study estimated the pooled sensitivity and specificity, summary receiver operating characteristic (SROC) curve, and the optimal cut-off value for predicting IBD relapse using a multiple threshold model. A total of 24 prospective studies were included in the meta-analysis. The optimal FC cut-off value was 152 μg/g. The pooled sensitivity and specificity of FC was 0.720 (0.528 to 0.856) and 0.740 (0.618 to 0.834), respectively. FC is a useful, non-invasive, and inexpensive biomarker for the early prediction of IBD relapse. An FC value of 152 μg/g is an ideal threshold to identify patients with a high relapse probability. Inflammatory bowel diseases (IBD) are chronic gastrointestinal disorders with a remitting and relapsing course and are associated with multiple complications. IBD incidence has increased in industrialized countries with increased healthcare expenditure and poor quality of life . UlceratEndoscopy plays an essential role in the diagnosis, management, prognosis, and surveillance of IBD ,5. HowevFC is an excellent marker of intestinal inflammation. Calprotectin is a calcium and zinc-binding protein formed by a heteromeric complex of two subunits, S100A8 and S100A9. It is derived from human neutrophils and monocytes and represents around 60% of soluble cytosol proteins in human neutrophil granulocytes . In addiFC is currently incorporated as a routine test to aid in diagnosing and monitoring IBD . Though The meta-analysis followed the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) . We searThe eligible articles were initially screened independently by three reviewers  based on their titles and abstracts. Full manuscripts of the potentially eligible articles were reviewed while removing the duplicates. Three reviewers  independently assessed articles if they met the including criteria: ① diagnostic cohort studies, ② prospective studies using FC to predict IBD relapse, ③ FC level was measured at baseline, ④ patient’s baseline status was in remission, ⑤ sufficient data to reconstruct 2 × 2 table, ⑥ relapse was confirmed by clinical symptoms and endoscopic results, and ⑦ studies conducted on adult’s patients with IBD. All disagreements were resolved through discussion with the authors (HG and HGX). Studies that did not meet our prespecified criteria were excluded.Three reviewers  extracted the following characteristics from each article independently: name of the study, country, authors, publication year, age, gender, FC cut-off value, data for the construction of 2 × 2 table, follow-up time, type of FC assay, reference standard, medical treatment, and funding sources. The quality of included articles was assessed by JX using the QUADAS-2  . All disTo obtain the summary receiver operating characteristic (SROC) curve and an optimal cut-off for predicting IBD relapse, we applied the multiple thresholds model, which included multiple cut-off values with the results of true positive, true negative, false positive, and false negative. The multiple threshold model is a new approach for the meta-analysis of diagnostic test accuracy studies where several studies reported more than one threshold and the corresponding sensitivity and specificity values. The approach is based on the idea of estimating the distribution functions of the biomarker with the nondiseased and diseased individuals using a common parametric assumption  for the distribution of a continuous biomarker. This was achieved using a mixed effects model with the study as a random factor . The optTo explore the clinical utility of FC for the prediction of the relapse of IBD, we performed a Fagan nomogram. The relationship between the prior probability, the likelihood ratio, and the posterior test probability is portrayed graphically by comparing 25, 50, and 75% prior probabilities . The likAdditionally, we calculated the positive predictive values (PPVs) and negative predictive values (NPVs) related to different cut-off values under varying levels of relapse rate by using a linear mixed-effects model for multiple thresholds model .Although a funnel plot is the basic graphical method to detect publication bias, it is not recommended to be used in the diagnostic meta-analysis because of the multiple thresholds, so we did not explore publication bias .As the thresholds can vary for each study, it was essential to see how close the observed results are to the receiver operating characteristic (ROC) curve rather than how dispersed they are in the ROC space . The magAll data analyses were performed using STATA version 15, “DIAGMETA” package of R language for windows  and MetaDisc version 1.4 ,19,23.Our initial search yielded 3209 papers. Additionally, we added 30 papers from the review of relevant literature references. After removing duplicates and screening titles and abstracts, 396 studies were selected for full-text review. Of these, 356 were initially excluded. After data extraction and discussion, another 16 studies were excluded. The reasons for the exclusion of each study were listed in the Overall, the quality of the included studies was good , 0.78 (0.73 to 0.82), and 0.85 (0.82 to 0.88), respectively. The SROC for the bivariate model can be found in In clinical practice, there is a need to understand the probability that a patient with quiescent IBD will relapse or not when an FC test result exceeds a certain threshold. The PPV and NPV varied for various relapse rates of IBD because these are related to the disease prevalence. Therefore, it was addressed with a multiple thresholds model, with a calculation of PPVs and NPVs related to the optimal and other common cut-off values for different levels of relapse rate . Employi® ELISA, Calprest® or Human Calprotectin ELISA Kit, Cell Sciences Inc., Newburyport, MA, USA) were sources of heterogeneity, we performed subgroup analyses. Analyses showed similar summary performance for all subgroups (In order to determine whether disease types (CD or UC), follow-up time (<1 year or ≥1 year), reference standard (clinic or endoscopy), and FC-assay . It was found that the pooled sensitivity of FC is 0.720 (95% CI 0.528–0.856) and the pooled specificity is 0.740 (0.618–0.834) with an AUC of 0.794 at the cut-off value of 152 μg/g. The estimated DOR is 14, indicating that FC is a useful biomarker in predicting the relapse of IBD.Heida A et al.  suggesteWe used the comprehensive GRADE approach  to examiIn a hypothetical population of 100 IBD adults in remission , eighteen patients should increase the frequency of FC testing. Additionally, they need to be monitored continuously and, if necessary, endoscopically examined to confirm recurrence. Fifty-six percent of patients have a low risk of recurrence in the future and only need to be observed according to the original plan. FC testing reduces the psychological burden of those patients. Seven patients will be missed. A false negative FC result can delay determining the patient’s risk of recurrence and delay treatment. Nineteen percent will be diagnosed as false positives, which results in inconvenience and unnecessary financial expense. There will also be a certain amount of stress on the mental side. We also hope that when determining whether the FC results are reliable, the factors that will produce false positives and false negatives should be excluded . Based oPrevious meta-analyses have evaluated the performance of FC for relapse in patients with IBD ,65,66,67Additionally, the diagnostic performance results obtained by the multiple threshold model would be a little lower but more realistic than by traditional approaches. This is because the multiple threshold model uses all the available information and results in an estimation of the performance of the biomarker, which avoids the drawback of using a single cut-off value. Previous meta-analyses only used one pair of sensitivity and specificity per study, which may lead to an overestimation of the SROC curve because there would be cut-off selection bias, and the ‘optimal’ point would be generally chosen .We would also like to report some of the limitations of this study. The reference standard for the diagnosis of IBD relapse is still controversial; however, the reference standards used in the included studies are currently recommended. Also, QUADAS-2 is not a quality assessment method for prognostic tests, but it is still the most suitable method. We have deleted some items that are not applicable, which may lead to some deviation in the results. Additionally, due to the lack of data, we could not perform a subgroup analysis of medications used in these patients. The threshold may vary slightly when faced with different patients, and sometimes clinicians need to consider the extent of involvement and past history of the patient on the basis of the given threshold. In addition, a recent study reported that FC may increase with age, even 3–4 times , which rIn conclusion, regularly measuring FC levels in IBD remission is a useful tool for the early prediction of relapse. The FC value of 152 μg/g is an ideal threshold for identifying patients with a high probability of relapse, suggesting careful follow-up and adjusting medications. Moreover, this noninvasive monitoring method will be better received by the patients without any preparation for colonoscopies and with high sensitivity and specificity. Further prospective high-quality trials are needed to determine the optimal FC measurement interval and cut-off value for the FC trend. In addition, it will also be useful to study further the predictive performance of combining markers, such as CRP and FC, for the relapse of patients with IBD.


Substance use has been a serious public safety issue. It not only affects the users’ physical and mental health but is also detrimental to social stability. To improve our understanding of this issue, the present study looked to examine the factors influencing substance use craving and develop interventions to reduce craving and relapse among substance users.T-test, Pearson correlation analysis, and multiple linear regression analysis, as appropriate.A total of 502 substance users were included in this study. Socio-demographic characteristics and substance use-related characteristics were recorded using self-developed forms. With regard to psychological traits, we used the self-esteem scale, the experience of shame scale, and the revised Cheek and Buss shyness scale to assess the self-esteem, shame, and shyness of substance users, respectively. The degree of substance use craving of substance users was assessed using the visual analog scale (VAS). Data were analyzed using independent samples P < 0.001), times of substance rehabilitation , shyness , and shame , and negatively associated with self-esteem .The majority of the substance users were unmarried, employed, and with lower education levels. For substance use-related characteristics, the age of first use was 27.52 ± 8.30 years and the duration of substance use was 12.29 ± 7.72 years. The scores of their self-esteem, shame, and shyness were 25.65 ± 3.19, 57.26 ± 7.82, and 37.8 ± 7.13, respectively. All substance users rated the intensity of their substance use cravings using the VAS, which showed that the mean score was 2.83 ± 1.87. Multiple linear regression analysis showed that substance use craving was positively associated with the frequency of substance use (β = 0.186, Factors and psychological traits related to substance use are important to account for substance use craving and relapse. Thus, our findings are helpful for a better understanding of the extent of substance use cravings among users and the selection of appropriate interventions to control the craving and relapse. Substance use is a serious public safety problem, which not only harms users physically and psychologically , 2 but aTo achieve the above goals, several studies have analyzed the factors affecting substance use and found that substance use craving plays an important role in post-cessation relapse and substance dependence –8. CraviPrevious studies exploring substance use craving-related factors suggested that substance use craving are positively associated with education degree , duratioThis cross-sectional study included all newly admitted substance users from two compulsory isolation centers in Hunan Province, China, from March to July 2019. The inclusion criteria were: (1) meeting the diagnostic criteria for substance-related and substance use disorders in the DSM-5; (2) able to understand the purpose of this study and sign the informed consent form. Subjects who met the DSM-5 diagnostic criteria for schizophrenia spectrum and other psychotic disorders, bipolar disorder and related disorders, depression, and other psychiatric disorders, as well as those who refused to participate in this study, were excluded. The study was approved by the Ethical Committees of the Second Xiangya Hospital of Central South University, the Lushan Compulsory Isolation and Rehabilitation Center, and the Baimalong Compulsory Isolation and Rehabilitation Center in Hunan Province, China.The general demographic information including gender, age, level of education, marital status, employment status, and residence was recorded for all the included participants. The level of education was divided into a low level  and a high level of education .The participants were assessed on the categories of reasons, the answers were mainly divided into (1) blind curiosity, the pursuit of pleasure and excitement, and (2) other reasons. With regard to the frequency of substance use, a frequency of <4 times per week is defined as low, and ≥4 times per week is defined as high.An open-ended question was used to obtain the types of drugs used by the subjects. All the drugs used by the subjects were categorized into new types of drugs  and traditional types of drugs (mainly referred to opium and heroin). The substance users were also divided into two categories based on the type of drugs they used: (1) users of traditional or new drugs and (2) users of mixed categories of drugs.The times of drug rehabilitation (including the current admission) refer to the times of compulsory isolation and rehabilitation decided by the public security agency and executed by the judicial administrative agency. This variable was described using two categories: (1) once and (2) twice or more times.The degree of substance use craving was assessed using the visual analog scale (VAS) , with 0 The subjects’ overall self-esteem was evaluated using the self-esteem scale (SES), a 10-item questionnaire compiled by Rosenberg in 1965 . It has Experience of shame scale (ESS) was used to assess the shame experienced by the participants. The scale was jointly compiled and revised by Dr. Bernice Andrews from the Department of Psychology at Holloway College, University of London, and professor Qian Mingyi from the Department of Psychology, Peking University in 2002 . Each itRevised Cheek and Buss shyness scale (RCBS) was used to evaluate the shyness of the participants. The 13-item scale was originally compiled by Cheek and Buss, and the Chinese version was tested for reliability and validity by Xiang et al. , which sT-test. The correlation between some variables and substance use craving was analyzed using Pearson correlation analysis. Multiple linear regression analysis was used to examine the factors influencing substance use craving. All the variables with a p-value of <0.05 in the t-test and Pearson correlation analysis were included as independent variables in the multiple linear regression model.SPSS 23.0 software was used for statistical analysis. Continuous variables were presented as mean ± standard deviation, and categorical variables were presented as a number of cases and percentage. The degree of substance use craving was compared between categories using the independent samples A total of 534 new substance users were initially recruited, but 17 of them refused to participate in the study, and 15 were excluded due to the lack of data. Thus, a total of 502 participants  were included in this study . The parThis study found that the average age of first substance use was 27.52 ± 8.30 years and the average duration of substance use was 12.29 ± 7.72 years. The main reason for substance use was blind curiosity and the pursuit of pleasure and excitement , and most of them  used substance at a higher frequency (≥4 days/week), accounting for. By the time of this study, 42.8% of the substance users were admitted for compulsory isolated detoxification for the first time.With regard to psychological features, we found that the average scores for self-esteem, shame, and shyness were 25.65 ± 3.19, 57.26 ± 7.82, and 37.85 ± 7.13, respectively.t = –2.256, P = 0.025), had lower education degree , lower frequency of substance use , and higher time of drug rehabilitation  had higher substance use craving score , shame , and shyness  were positively correlated with substance use cravings, while self-esteem  was negatively correlated with substance use cravings. The correlations between continuous variables and the substance use cravings are presented in This study found that the duration of substance use (P < 0.001), times of substance rehabilitation , shyness  and shame , and negatively associated with self-esteem   .In contrast to other studies, the present study assessed multiple aspects that might affect substance use cravings, i.e., socio-demographic characteristics, substance use-related characteristics, and psychological traits. Eventually, we found that the frequency of substance use, times of drug rehabilitation, shyness, and shame were positively correlated with substance use cravings, while self-esteem was negatively correlated with substance use craving.With regard to substance use-related characteristics, the frequency of substance use and times of substance rehabilitation were found to be factors affecting substance use craving, with higher frequency of substance use and more times of substance rehabilitation associated with stronger craving. This is consistent with previous studies . As we hConcerning psychological traits, shyness, self-esteem, and shame were found to be associated with substance use cravings. Shyness refers to an uncomfortable emotional and behavioral tendency to feel nervous, worried, or embarrassed due to excessive concern for oneself in interpersonal interactions and the fear of being judged by others. There are few studies on the correlation between substance use craving and shyness, while more studies have focused on the relationship between substance use and shyness, which showed opposite findings with the help of data from different populations. Studies involving high school students found that boys with a higher level of shyness used illicit substances more often than those with a lower level of shyness , 29, In Shame refers to an overall negative feeling about some inappropriate behaviors or shortcomings of oneself. The present study indicated that the subjects’ shame was positively correlated with their substance use cravings. However, few studies have been conducted on the relationship between substance use craving and shame. A study found that the tendency of shame was generally positively associated with substance use problems among college undergraduates and jail inmates . This miSelf-esteem is an emotional experience of self-love and the need to gain respect from others and the society based on self-evaluation. Structurally, it can be divided into global self-esteem and contingent self-esteem. Global self-esteem refers to a global judgment of one’s self-worth, while contingent self-esteem refers to the satisfaction people show when their performance meets a certain standard or fulfills certain interpersonal expectations. The present study found that lower self-esteem was associated with stronger substance use cravings, which is in line with a study by Kavas . FurtherThe present study showed no association between socio-demographic variables and substance use craving. However, several prior studies have found that some demographic variables are related to substance use craving, such as education and age. Generally, people with a higher level of education are more aware of the dangers of substance abuse, which might be why subjects with higher educational attainment only accounted for a small proportion in this study. However, a study found a significant positive relationship between the level of education and induced substance craving ; accordiDespite the strengths of the present study, there are several limitations. First, this study is a cross-sectional study, which precluded us from following up the subjects for a longer period. Second, all the substance users included in this study were adults, and adolescents can be included in future studies for better investigation of the influence of age. Third, the factors examined in the present study are still limited, and more dimensions may be included in future studies.Substance use-related factors and psychological traits are also important factors affecting substance use craving. Our findings in the present study are helpful for a better understanding of substance use craving as well as the selection and development of appropriate intervention strategies to control cravings and reduce relapse.The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.The studies involving human participants were reviewed and approved by the Ethical Committees of The Second Xiangya Hospital of Central South University. The patients/participants provided their written informed consent to participate in this study.HG conceived the study, performed data analyses, and drafted the manuscript. JW helped with data collection, performed data analysis, and drafted the manuscript. SW helped with data collection and performed data analysis. XW and JZ conceived, planned, and designed the study and revised the manuscript. All authors contributed to the article and approved the submitted version.


The survival rate of breast cancer patients is closely related to the pathological stage of cancer. The earlier the pathological stage, the higher the survival rate. Breast ultrasound is a commonly used breast cancer screening or diagnosis method, with simple operation, no ionizing radiation, and real-time imaging. However, ultrasound also has the disadvantages of high noise, strong artifacts, low contrast between tissue structures, which affect the effective screening of breast cancer. Therefore, we propose a deep learning based breast ultrasound detection system to assist doctors in the diagnosis of breast cancer. The system implements the automatic localization of breast cancer lesions and the diagnosis of benign and malignant lesions. The method consists of two steps: 1. Contrast enhancement of breast ultrasound images using segmentation-based enhancement methods. 2. An anchor-free network was used to detect and classify breast lesions. Our proposed method achieves a mean average precision (mAP) of 0.902 on the datasets used in our experiment. In detecting benign and malignant tumors, precision is 0.917 and 0.888, and recall is 0.980 and 0.963, respectively. Our proposed method outperforms other image enhancement methods and an anchor-based detection method. We propose a breast ultrasound image detection system for breast cancer detection. The system can locate and diagnose benign and malignant breast lesions. The test results on single dataset and mixed dataset show that the proposed method has good performance. Meanwhile, breast cancer incidence in developed countries is high, while the relative mortality in the less developed countries is the highest2. Clinical reports show that early detection and breast cancer treatment can significantly improve the survival rate3.Breast cancer is one of the most prevalent type of cancer in women. According to the global cancer epidemic statistics released by the International Agency for Research on Cancer of the World Health Organization, there are approximately 2.89 million new female breast cancer cases worldwide each year, accounting for 24.2% of the total female cancer cases, ranking first4. Radioactivity causes health risks for patients, high cost increases the financial burden of patients, and low specificity (65–85%) leads to unnecessary biopsy operation4. DBT also has the disadvantages of high cost and radioactivity. In contrast, ultrasound imaging has the advantages of real-time imaging, no ionizing radiation, and low cost, and is commonly used in breast cancer screening or diagnosis. However, the diagnosis of ultrasound image is highly dependent on the skill level of the technician. Doctors with different training and different clinical experiences may make different diagnosis results5. Moreover, ultrasound images have high noise, significant artifacts, and low contrast between tissue structures. Therefore, it is desirable to develop a computer-aided breast cancer diagnosis system that can assist doctors in diagnosis.Mammography, digital breast tomosynthesis (DBT) and ultrasound imaging are three common imaging methods in clinical examination of breast cancer. However, mammography has the disadvantages of low specificity, high cost, and radioactivity7. For example, Drucker et al.8 first used radial gradient index filtering to detect the initial points of a region, examined the candidate areas from the background by maximizing the regional average radial gradient index of detection point growth, and classified the lesions using Bayesian neural networks. Finally, it achieved sensitivity of 87% at 0.76 false positive detection. As the most popular machine learning method, deep learning (DL) has gained a good reputation in computer vision and pattern recognition. In the medical field, many researchers have successfully applied DL to breast cancer detection13. Cao et al.14 comprehensively compared five object detection networks based on deep learning 17, YOLO V318, and single shot multibox detector (SSD)19), and demonstrated that SSD achieved the best performance in terms of precision and recall. In a study on breast lesion detection, Yap et al.20 used Faster R-CNN as their deep learning network. To reduce the impact of small sample datasets on the experiment, they applied transfer learning. At the same time, they proposed a three-channel fusion method, the original image, the sharpened image, and the contrast enhanced image (three single-channel images), are merged into a new three-channel image. However, the limitations of the prior work include: (1) they did not explore the impact of image preprocessing on experimental results; (2) their datasets20 are not publicly available and other researchers can not conduct comparative experiments; and (3) they all used anchor-based object detection networks and they did not examine the impact of anchor size settings on the experimental results. Therefore, we address the above issues by proposing an anchor-free object detection method for breast cancer detection. In addition, a segmentation-based enhancement (SBE) method is proposed for the detection performance improvement. The system flow chart is shown in Fig. We designed a segmentation-based ultrasound image contrast enhancement method.We explore the use of an anchor-free object detection network to detect breast cancer, avoiding the complex calculations of the anchor-based detection network.We propose a method of making object detection label by using lesion shape label.Many researchers have studied the ultrasound diagnosis of breast cancer. Previous researches mainly applied traditional digital image processing techniques and machine learning technique to implement breast cancer detectionThe remainder of this paper is as follows, “We evaluated the performance of our breast lesion detection system using various datasets. We also compared with many different enhancement methods and detection networks. The performance metrics and experimental results are described bellow.21, breast ultrasound image dataset (BUSI)22, and breast ultrasound image segmentation dataset (BUSIS)23. BUS was collected from the UDIAT Diagnostic Centre of the Parc Tauli Corporation, Sabadell (Spain). BUS contains 163 breast ultrasound images, of which 109 are benign and 54 are malignant. BUSI was collected from Baheya Hospital for Early Detection and Treatment of Women’s Cancer, Cairo, Egypt. The breast ultrasound images were collected from 600 female patients between 25 and 75 years old. BUSI contains 437 benign images, 210 malignant images, and 133 normal breast images, for a total of 730 breast ultrasound images. BUSIS was collected from the Second Affiliated Hospital of Harbin Medical University, the Affiliated Hospital of Qingdao University, and the Second Hospital of Hebei Medical University. BUSIS contains 562 images among women between 26 and 78 years old. These datasets contain multiple images for the same patient. The specific information of the datasets are shown in Table In this study, we used three public datasets, namely breast ultrasound (BUS)w equal h equal w, h and lesion category as the label for breast lesion detection. However, in BUSIS dataset, because the lesion category is not given, it can not be used as the breast lesion detection data. Therefore, we use BUSIS in the image preprocessing step and we will introduce the use of BUSIS dataset in detail in the next section.The task of breast lesion detection is to identify and locate the exact localization of the lesion. Identification is to classify benign and malignant lesions and location is to give localization information of the lesion area. In BUS and BUSI datasets, the category labels of the lesions have been given, but there is no coordinate information of the lesions. We propose a method to obtain the lesion coordinates according to the lesion shape labels. As shown in Fig. entclass1pt{minima24) to detect the breast lesion.Our system consists of two parts, the image preprocessing part and the breast lesion detection part. First, in the image preprocessing part, we use a new image enhancement method named segmentation-based enhancement (SBE). A deep learning method is used to segment the breast lesion region, and the segmented image is multiplied with the original image to obtain an enhanced image. Second, we input the enhanced image to an anchor-free object detection network IoU, in medical image analysis, IoU is also known as Jaccard Similarity Index or Jaccard Index. The IoU is defined by: Confidence Probability of each class prediction.True positives (TP) The prediction BBox with False positives (FP) The prediction BBox with False negatives (FP)According to the above parameters, we haveN is the total number of categories of class.We used Precision, Recall, and mean average precision (mAP) as the performance metrics in our experiments. The calculation of Precision, Recall, and mAP depends on the following parameters.25, Attention U-Net26, and traditional method contrast limited adaptive histogram equalization (CLAHE)27) and tested them based on both single dataset and composite dataset (BUS+BUSI). The experimental results are shown in Tables We used different enhancement methods U-Net25, 28 in 2020. This method used YOLO V3 as the detection network and maked two changes to the original YOLO V3. First, Ref.28 adopted the K-Means++ algorithm and K-Mediods algorithm to optimize the original K-Means algorithm to set the anchor size. Second, the residual structure in the original YOLO V3 was changed, and a new residual network based on ResNet and DenseNet29 was constructed. We implement the method proposed by Ref.28 using our dataset for experimentation. We have obtained three different anchor size through K-Means++ and K-Mediods, and named the network that changed the anchor size as YOLO V3-anchor. Three sets of anchors The sizes are , , , , , , , ,  for BUS+BUSI; , , , , , , , ,  for BUSI; , , , , , , , ,  for BUS. We reproduced a new residual structure according to the method proposed by Ref.28 and named it as YOLO V3-res. The experimental results are shown in Table To further verify the performance of our proposed method , we compared it with a breast cancer ultrasound detection method proposed by Mo et al.zes are 3, 45, . We also propose a segmentation-based ultrasound image enhancement method to improve the breast cancer detection method’s performance. We use three public datasets, which are obtained from 8 different ultrasound acquisition devices, to compare our proposed method with anchor-basde method. Our proposed method can reach an mAP of 0.902, which demonstrates that our proposed method has good generalization ability and high clinical application value.This section covers image preprocessing methods of breast ultrasound images, an anchor-free detection network, and implementation process of our experiment.In this study, we used data from three publicly available datasets, and our study is carried out in accordance with relevant guidelines and regulations.Due to the low contrast of ultrasound images and a large amount of speckle noise, appropriate preprocessing methods are essencial for subsequent image analysis. In this study, the preprocessing of ultrasound images consists of three steps. The first is to use traditional methods to enhance the contrast of the image and then denoise. Finally, we use our SBE method to further enhance the image’s contrast.We use CLAHE to enhance the image. The algorithm of CLAHE is as follows.Step I First, divide the original picture into K of the subregion. Set a threshold T, cut off the part of K is greater than T, and evenly distribute it to the original image histogram to obtain a new histogram. Simultaneously, to avoid the blocking effect caused by the block operation, the bilinear interpolation method needs to be used to reconstruct each pixel’s gray value.Take the derivative of Step II The original image’s noise is enhanced for the ultrasound image calculated by CLAHE and the image needs to be denoised. Anisotropic diffusion30 is a denoising method based on partial differential equations, which can preserve image details while denoising.p the coordinate of the sampled pixel, p, Let k be the gradient threshold, then Let n, gradient threshold k, and diffusion strength Anisotropic diffusion needs to set the number of iterations After CLAHE and anisotropic diffusion, we obtain the contrast-enhanced image, as shown in Fig. We integrated R2U-Net and Attention U-Net and designed R2AttU-Net. The downsampling part of R2AttU-Net is from R2U-Net, and the upsampling part is from Attention U-Net. R2AttU-Net network structure is shown in Fig. Through the steps described above, we have obtained the enhanced image. In this section, we will introduce the last step of the whole breast lesion detection process.We adopted an anchor-free detection network, FCOS, as the detection network for breast lesions. FCOS outputs five sizes of heads to facilitate object detection of different sizes. Three loss functions  are used to calculate the loss of the object category, center point, and bounding-box size, respectively. Compared with anchor-based object detection networks , anchor-free networks do not need to set anchor boxes in advance, so that can significantly reduce the number of parameters and reduce the large number of calculations due to anchor boxes  calculation and matching of anchor boxes and ground-truth boxes in training). These advantages over anchor-based object detection networks lead to faster detection and simpler training process in FCOS.The overall experimental steps of this study is shown in Fig. 31. Using ResNet5032 as a backbone of FCOS, a total of 300 epochs are trained. The FCOS output detection box coordinates are mapped to the original breast ultrasound image and the final output result is obtained. We feedback/map the detection boxes to the original image, rather than the enhanced image, to avoid the segmentation results from interfering with the doctor’s diagnosis. The hyperparameters of the R2AttU-Net used in the image preprocessing stage and the FCOS used in the breast lesion detection stage are shown in Table We used FCOS based on the mmdetection object detection toolbox


Strict quarantines can prevent the spread of the COVID-19 pandemic, but also increase the risk of mental illness. This study examined whether the people who have experienced repeated home quarantine performance more negative emotions such as anxiety, depression, and post-traumatic stress disorder (PTSD) in a Chinese population.We collected data from 2,514 participants in Pi County, Chengdu City, and stratified them into two groups. Group 1 comprised 1,214 individuals who were quarantined only once in early 2020, while Group 2 comprised 1,300 individuals who were quarantined in early 2020 and again in late 2020. Both groups were from the same community. The GAD-7, PHQ-9, and PCL-C scales were used to assess symptoms of anxiety, depression, and PTSD between the two groups.p < 0.001) and the quarantine times and age are independent predictors of symptoms of depression (p < 0.001). The two groups did not differ significantly in total GAD-7 or PCL-C scores.Analyses showed that total PHQ-9 scores were significantly higher in Group 2 than in Group 1 (Increasing quarantine times was associated with moderate to severe depression symptoms, but not with an increase in symptoms of anxiety or PTSD. A study of 10 countries with the highest number of reported deaths, suggests that the total number of infections is expected to reach 16 millions by July 2020 , and those who had been quarantined both in early and late 2020 (Group 2). Each quarantine period lasted 14 days. Both groups were from the same community and living environment and other basic circumstances were roughly similar.We included only those who hadn't been diagnosed with SARS-CoV-2 infection previously and were at least 18 years old and under 65 years old in December 2019. We excluded participants with a history of anxiety, depression, PTSD, or other uncontrolled psychosis that had been diagnosed before quarantine, as well as those who were unable to read or understand the questionnaire.This survey-based study was approved by the Ethics Committee of Sichuan University , and participants gave informed consent.via WeChat.Between 31 April 2020 and 01 March 2021, we conducted a cross-sectional network survey to collect data on symptoms of depression, anxiety, and PTSD experienced by the participants during quarantine. The study was performed based on the strategy of online sampling survey, and a custom-designed questionnaire was distributed to participants Apart from relevant data on psychological status, we collected information on age, sex, number of years of education, marital status, and time spent in quarantine. Previous studies have shown that age  and leveIn the present study, these three scales were used to assess negative emotions and evaluate whether the two groups of participants differed significantly in symptoms related to anxiety, depression, or PTSD. The higher the scores on each scale, the more serious the symptoms.The General Anxiety Disorder Scale-7 (GAD-7), the Patient Health Questionnaire (PHQ-9), and the PTSD Checklist-Civilian version (PCL-C) are widely used to evaluate anxiety, depression, and PTSD.For the purpose of our study, the anxiety assessment scale was translated into Chinese and revised based on the GAD-7 scale before being incorporated into the questionnaire. The GAD-7 scale consists of seven items, and anxiety is scored as follows: minimum, 0–4; mild, 5–9; moderate, 10–14; and severe 15–21 . Respondents answer items on a four-point Likert scale from 0  to 3 . Based on the total score, the severity of depression symptoms is categorized as follows: few symptoms of depression, 0–4; have symptoms of depression, >4 .The PCL-C scale was developed according to the DSM-IV. This scale is based on 17 items, for which responses can range from 1  to 5 (“extreme”). Based on the total score, patients are categorized as showing no obvious PTSD symptoms, 17–37; PTSD symptoms present to a certain extent, 38–49; and obvious symptoms that could lead to a diagnosis of PTSD .t-tests and chi-squared tests. Multivariate logistic regression was used to independently analyze the factors associated with anxiety, depression, and PTSD. The multivariate model comprised variables that had a significant association with psychological status (p < 0.1) in the univariate analysis. All tests were bilateral, and the significance level was set at 0.01.Statistical analyses were performed using SPSS 23.0 . We tested the effects of demographic factors such as age, sex, number of years of education, marital status, and exposure history on the psychological status of participants. Inter-group differences were assessed for significance using Student's Of 2,651 questionnaires submitted, 137 were excluded because participants did not meet the age criteria, reported a history of mental illness, or failed to complete all items on the questionnaires. The remaining 2,514 questionnaires were retained in the final analysis and were submitted by individuals who had been quarantined at home in 2020.Group 1 comprised 1,214 individuals who had experienced only one home quarantine, while Group 2 comprised 1,300 individuals who had experienced home quarantine twice. While the first 14-days quarantine between February and March took place nationwide, the second quarantine ranging from December 8, 2020 to December 22, 2020 took place only in Pi County. A large proportion of participants in Group 2 were ≥30 years old (87.8%), higher percentage of people with <12 years of education (51.5%) and married 79.3%; , reflectt-tests showed no significant differences between the two groups in symptoms of anxiety  or PTSD  . PositivOne study, conducted under controlled conditions, found that though it couldn't allay the painful distress symptoms, a 30 min of weekly talking could lead to post-traumatic growth . In addiAll of these characteristics mentioned above can be used as the current psychological intervention targets for repeated quarantine populations.Our findings must be considered with caution in the light of certain limitations. First, due to the pandemic and the quarantine situation, we were restricted to using a strategy of online sampling survey to collect data. Since our sample was limited to individuals who used the WeChat platform, cared about their mental health, and were willing to participate in a questionnaire survey, we cannot rule out sampling bias. Indeed, we included only individuals who were >18 and <65 years old. Future work should include a wider range of demographic characteristics, such as household income and size of household population in order to provide a better understanding of the potential risk factors associated with anxiety, depression, and PTSD. Second, since this is a cross-sectional study, our analysis could not capture potential changes in the variables that we measured, or in their relationships with symptoms of depression, anxiety or stress. Future research should longitudinally examine the effects of quarantine on mental well-being, and the sample should also include children, adolescents, and the elderly. Third, our research cannot explain why family support in home quarantine reduce anxiety but not depression. This is also a limitation of our research.The results of this study show that increasing the times of quarantine during the COVID-19 pandemic can increase the prevalence and severity of depression, without affecting anxiety or PTSD-related symptoms. Therefore, public health officials and clinicians should focus more on developing effective interventions for individuals with depression, especially in areas affected by epidemics.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.QT was a major contributor in writing the manuscript. YW mainly responsible for data collection. JL provided guidance to the study design. DL mainly responsible for data analysis. JX and XH mainly responsible for directing and revising the writing of manuscript. All authors read and approved the final manuscript.This study was funded by Sichuan Provincial Science and Technology Support Program (Grant ID: 2019YFS0218) and (Grant ID: 2020YFS0587).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.