Results showed that temporary mindfulness meditation training decreased the negative emotional experiences of happy and sad music and the positive emotional experiences of calm music during recognition and experience and promoted beautiful musical experiences in individuals with no musical training. Maintaining a state of mindfulness while listening to music enhanced body awareness and led to experiencing a faster passage of musical time. In addition, it was found that Chinese classical folk instrumental musical works effectively induced aesthetic emotion and produced multidimensional aesthetic experiences among non-musically trained adults. This study provides new insights into the relationship between mindfulness and music emotion.Mindfulness meditation is a form of self-regulatory training for the mind and the body. The relationship between mindfulness meditation and musical aesthetic emotion processing (MAEP) remains unclear. This study aimed to explore the effect of temporary mindfulness meditation on MAEP while listening to Chinese classical folk instrumental musical works. A 2  × 3  mixed experimental design and a convenience sample of university students were used to verify our hypotheses, which were based on the premise that temporary mindfulness meditation may affect MAEP (MMG vs. CG). Sixty-seven non-musically trained participants  were randomly assigned to two groups (MMG or CG). Participants in MMG were given a single 10-min recorded mindfulness meditation training before and when listening to music. The instruments for psychological measurement comprised of the Five Facet Mindfulness Questionnaire (FFMQ) and the Positive and Negative Affect Schedule (PANAS). Self-report results showed no significant between-group differences for PANAS and for the scores of four subscales of the FFMQ ( Music, as a temporal auditory art, tends to evoke aesthetic emotions Scherer, . The aesPrevious studies have shown that the processing of music aesthetic emotion involves the multidimensional measurement of both the psychological and the behavioral phenomena  without musical training were recruited through campus advertisements. They were required to abstain from taking substances or medications that could potentially influence their concentration. All participants reported that they received no training related to mindfulness meditation. In addition, they were required to disclose any history of major psychological disorders. All participants reported being right-handed, having normal hearing and speech, and a normal or a corrected-to-normal vision. This study was approved by the Southwest University Ethics Committee.Participants (www.xunjieshipin.com/download-audiorecorder). The duration of the audio was 10 min. It was recorded in MP3 format , which is a professional online music player application. These high-quality music clips included three emotion levels  with five excerpts for each level, categorized according to the emotional valence of music  from the Chinese classical folk instrumental musical works which were taken from commercially available “kugou” music software  and beauty ; liking was rated on a scale of 1 (extremely) to 6  in accordance with the preference of the participants. In order to ensure the ecology and integrity of music listening as much as possible, post-evaluation was conducted to assess the differences in MAEP.Based on previous studies, we modified the task to explore the effect of mindfulness on music aesthetics. Music aesthetic tasks include five items: recognition, experience, tension, beauty, and liking. Recognition was defined as emotions expressed by the music, while experience was defined as feelings felt by oneself   . Participants then performed the music aesthetic tasks based on the requirements of the mindfulness meditation state, which paid attention to the present moment and emphasized the attainment of consciousness that is non-judgmental/accepting. Finally, participants performed the post-measurement of body awareness and time perception and answered the FFMQ .not at all) to 5 (completely consistent). The higher the scores, the higher the mindfulness levels. In this study, Cronbach's alpha for the FFMQ was 0.80.The Chinese version of the FFMQ, which was revised by Deng et al. , has 39 very slightly or not at all) to 5 (extremely). Scores of the scale were totaled separately for the positive and the negative effects. As originally reported, Cronbach's alphas of positive affect ranged from 0.86 to 0.9, and Cronbach's alphas of negative affect ranged from 0.84 to 0.87  was used to verify our hypotheses. The between-subject design was used for the groups and the within-subject design was used for music emotion, which had three levels of music aesthetic emotion: calm, happy, and sad. All participants were randomly assigned to MMG or CG.t-tests were used to explore the between-group differences in age, sex, PANAS, FFMQ, body awareness, and time perception  The results of PANAS showed that there was no significant difference in the scores between the two groups (p > 0.05); (2) the post-test scores of body awareness showed that the scores of the MMG were lower than those of the CG ; (3) the post-test scores of musical time perception showed that the MMG experienced faster passage of time than the CG ; and (4) in the NJ scores, there was a significant but marginal difference between the two groups in the results of FFMQ , but there was no significant difference in the scores of the other four items .The demographic information and self-report results of the participants are shown in The behavioral results of MAEP of the participants at the three emotional levels are shown in F = 5.3, p = 0.02, η2 = 0.08. The post-hoc t-test showed that emotion recognition of all emotions when listening to music was lower among participants in the MMG than those in the CG. There was no main effect of music emotion levels and the interaction of group and music emotion levels .A repeated-measures ANOVA on emotion recognition showed the main effect of group, F = 10.04, p = 0.002, η2 = 0.13. The post-hoc t-test showed that the emotional experiences of the participants in the MMG were lower than that in the CG when listening to music, in all emotions. Results also showed the main effect of the music emotion levels, F = 4.64, p = 0.01, η2 = 0.07. The post-hoc t-test showed that the emotional experiences while listening to calm music were significantly more than that during happy music, p = 0.01. The emotional experiences while listening to sad music were marginally more than that during happy music, p = 0.07. There was no difference between calm and sad music. There was no interaction of group and music emotion levels .A repeated-measures ANOVA on the emotion experience showed the main effect of group, r = 0.64, p < 0.001; calm music, r = 0.77, p < 0.001; happy music, r = 0.76, p < 0.001).Pearson correlation analysis showed that emotion recognition was related to emotion experience  = 102.53, p < 0.001, η2 = 0.61, with ratings of tension in happy music > sad music > calm music. The score of happy music was significantly greater than that of sad music, and the score of sad music was significantly greater than that of calm music . There was no main effect of group and the interaction of group and music emotion levels .A repeated-measures ANOVA on tension showed the main effect of music emotion levels, F = 8.35, p = 0.005, η2 = 0.11. The post-hoc t-test showed that participants rated the beauty of music significantly higher in the MMG than in the CG for all three music emotions . Results also showed the main effect of music emotion levels, F = 18.92, p < 0.001, η2 = 0.37, with ratings of beauty in calm music > happy music and sad music. Meanwhile, there was no difference between happy music and sad music . There was no main interaction of group and music emotion levels .A repeated-measures ANOVA on beauty showed a main effect of the group, F = 37.61, p < 0.001, η2 = 0.37, with ratings of liking in calm music > happy music > sad music. There was no main effect of group and interaction of group and music emotion levels .A repeated-measures ANOVA on liking showed the main effect of music emotion levels, In our novel examination of the influence of temporary mindfulness meditation training on MAEP, the hypotheses were partially confirmed. In line with our expectations, significant differences in recognition, experience, and beauty between the two groups were influenced by temporary mindfulness meditation training. Temporary mindfulness meditation decreased the negative emotions  of happy and sad music and the positive emotions  of calm music during recognition and experience and improved the experience of beauty in MAEP. The post-test results showed that maintaining a state of mindfulness enhanced body awareness and led to experiencing a faster passage of musical time while listening to music. Although there were no statistically significant between-group differences in tension and liking, the scores of all aesthetic dimensions in the MMG were lower than those in the CG, which suggested that temporary mindfulness meditation training might affect music aesthetic emotion. Additionally, the GEMS findings showed that Chinese classical folk instrumental musical works induced aesthetic emotions and produced multidimensional emotional experiences.The behavioral results showed that the rating scores of emotion recognition, emotion experience, and evaluation of beauty and liking effectively measured the differences in the processing of music aesthetics in individuals with no musical training. Previous studies showed that temporary mindfulness meditation affected negative and positive emotion processing  or functional magnetic resonance imaging (fMRI). Finally, future research needs to explore the influence of individual music preference and different personality traits on music aesthetic processing based on temporary mindfulness meditation, and, further, provide relevant behavioral and neurophysiological evidence. As some researchers expect, future research on the medium- and long-term effects of aesthetic experience on physical and mental health, well-being, and cognitive function may benefit from regarding aesthetic emotion as an important variable. Music could thus certainly offer highly effective and pleasurable tools to further promote well-being and health (Vuilleumier and Trost, In conclusion, the findings of this study suggest, that whether during the recognition or the experience process, music emotions are multidimensional. Temporary mindfulness meditation decreases negative emotional experiences of happy and sad music and positive emotional experiences of calm music and promotes beautiful musical experiences in individuals with no musical training. Maintaining a state of mindfulness may enhance body awareness and lead to experiencing faster passage of musical time while listening to music. Mindfulness meditation, as a positive state of listening to music, provides a new avenue by which the beauty of music could be enjoyed. This is the first study exploring the effect of mindfulness on MAEP and provides new directions for the further studies of musical aesthetics.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by Research Project Ethical Review Application Form, Faculty of Psychology, Southwest University. The patients/participants provided their written informed consent to participate in this study.XL, YL, and HS conceptualized and designed this study and wrote the manuscript. MZ reviewed the manuscript. All authors have read and agreed to the published version of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Tursiops truncatus) between 2017 and 2020 at the Tiber estuary , a polluted major river supplying organic material to the Capitoline (Roman) coastal area and nearby regions. We identified 347 unique individuals, with different patterns of residency : 42 were labeled resident, 73 part-time, and 232 transient. Estimating a total population size of 529 individuals and highlighting the presence of animals with a strong site-fidelity, this study suggests developing conservation plans for this vulnerable top-predator species not only focused on areas close to the Tiber River mouths but also extended to cover a broader scale of area.Photo-identification is a non-invasive method of identifying individual animals from natural markings present on one or more parts of the body. The dorsal fin of a dolphin is the portion that contains individually distinctive marks and the most commonly visible when an animal surfaces to breathe. The camera captures an image of the dorsal fin whenever it is sighted and based on the number of times an image is captured, a statistical method called capture–recapture is used to estimate the site fidelity and the size of the population in a defined area. Here, we applied these methods to study the bottlenose dolphins (Tursiops truncatus) at the Tiber River estuary  between 2017 and 2020. We used photo-identification data and site-fidelity metrics to study the tendency of dolphins to remain in, or return to, the study area, and capture–recapture models to estimate the population abundance. In all, 347 unique individuals were identified. The hierarchical cluster analysis highlighted 3 clusters, labeled resident , part-time , and transient , each characterized by site-fidelity metrics. Open POPAN modeling estimated a population size of 529 individuals (95% CI: 456–614), showing that the Capitoline (Roman) coastal area and nearby regions surrounding the Tiber River estuary represent an important, suitable habitat for bottlenose dolphins, despite their proximity to one of the major urban centers in the world (the city of Rome). Given the high number of individuals in the area and the presence of resident individuals with strong site fidelity, we suggest that conservation plans should not be focused only close to the Tiber River mouths but extended to cover a broader scale of area.Periodic assessments of population status and trends to detect natural influences and human effects on coastal dolphin are often limited by lack of baseline information. Here, we investigated for the first time the site-fidelity patterns and estimated the population size of bottlenose dolphins ( Estimating the abundance of populations, and their spatiotemporal variability, is a key factor for ensuring biodiversity preservation and the maintenance of the integrity of the community structure and ecosystem processes . In the For the majority of delphinids, abundance estimates are particularly challenging. They are a highly mobile and often wide-ranging top-predator species, with often open-population structures, thus requiring robust analytical methods to prevent the potential of incorrect estimates associated with irregular sampling effort, variable probability of animal detection, and non-random movement patterns ,11. IndiTursiops truncatus) are key components of the inshore and coastal marine biodiversity worldwide, showing an irregular distribution dependent on the characteristics of the habitat, prey availability, and anthropogenic disturbance [Bottlenose dolphins  and of Fiumicino . The Tiber River is the main river in central Italy and the major supplier of organic material to the Capitoline (Roman) coastal area and nearby regions, contributing to the development of a rich marine community. However, crossing the city of Rome, it collects waste, organic material, and heavy metals, thus increasing the level of pollution when flowing into the sea [The study site  is locat the sea ,28.Posidonia oceanica meadows), which are included in the EU Natura 2000 network Sites of Community Importance (SCI). One of these sites, Secche di Tor Paterno, IT6000010, is also a marine protected area (MPA) of 1387 ha, protected since 2000. It is the only fully submerged Italian MPA and consists of a large rocky formation that extends from 18 m up to a maximum of 60 m depth. Human activities that may be dangerous or may represent a disturbance for marine species in the MPA are forbidden.The simultaneous presence of both fresh and salt waters, as well as the geomorphological action of sedimentation and erosion, generate different ecological gradients, making the area highly productive and rich in coastal biodiversity ,30,31,32On the banks of the Tiber close to the mouth, there are several shipyards, in addition to two touristic and fishing ports (Ostia and Fiumicino) that generate intense vessel traffic. In addition, 3 nautical miles from Fiumara Grande, there are two single-point moorings (SPMs) for the reception of crude oil and supply petroleum products ; navigation, anchoring, diving, and fishing activities at a distance of 750 m from each are prohibited. Such types of structures are known to be suitable habitats and aggregation points for demersal fish species and may be exploited by bottlenose dolphins as feeding sites ,33. In tBeneteau Oceanis 41.1 powered by a 55 hp Volvo diesel engine, in favorable weather conditions  to reduce the detection probability bias. More than 90% of the surveys occurred in sea state ≤2 and wave height ≤0.3 m. The sampling effort was conducted in 4- to 6-month sampling periods over 4 years (2017–2020), principally in spring, summer, and early autumn. Surveys were conducted from 08:30 to 16:30 h (depending on suitable conditions) by three to six observers alternating between 7 × 50 binoculars and the naked eye, at a steady speed of 4–6 knots. Survey track lines did not follow a standardized layout  but a random sampling procedure [Boat-based daily surveys were conducted onboard a sailing vessel  4 years 17–2020, rocedure  with resA group of dolphins was defined as two or more individuals with a relatively close spatial cohesion  involved in similar (or the same) behavioral activities . Upon siAt the location of each group, GPS  coordinates, time, direction, and the presence of concomitant anthropogenic activities  were recorded. Total group size and age class composition were estimated in the field, then corrected (if needed) via photo-identification analysis. Age class was defined as follows: adult = an individual generally of a length of about 2.8–3.0 m; juvenile = a poorly scarred and rarely nicked individual of about ⅔ the length of an adult; calf = an individual of about ½ the length of an adult, with often visible fetal folds, always swimming close to an adult in a position just behind the dorsal fin; and newborn = an individual of about ⅓ the length of an adult, with visible fetal folds, swimming uncoordinatedly always very close to an adult. Sex was determined whenever possible through photographs of the genital area or observations of constant adult–offspring associations during one or more encounters .When using photographic identification as the capture–mark–recapture method for abundance estimates, two possible main sources of bias have to be addressed: the heterogeneity in capture probability and individual misidentification ,39. The The occurrence and position of permanent natural markings (such as nicks and notches) on the leading and trailing edges of the dorsal fins (visible from both sides) were used to uniquely recognize individual dolphins ,42. The A hierarchical cluster analysis was used to describe the presence of possible dolphin groups according to their site-fidelity patterns in the surveyed area, with the aim of identifying resident, transient, and  part-time individuals considering their encounter histories. Clusters were characterized using different composite indices ,18 and tt1, . . . , nocct as the times of the occn capture occasions; we also labeled as kM, k = 1, . . . , mn and kY, k = 1, . . . , yn the sets of capture occasions belonging to the k-th month or year, respectively. We further defined dn as the number of identified dolphins and i = 1, . . . , dn, where ijc = 1 if dolphin i was captured on occasion j and 0 otherwise. Hence, the quantity i-th identified dolphin was captured. Then, we calculated the times of the first and last captures of each dolphin asi = 1, . . . , dn, respectively.To calculate the indices, we first defined Occurrence (Occ): The proportion of captures, determined by the number of times an individual was captured divided by the total number of capture occasions.We used these quantities to estimate three indices already reported and applied in other studies  aThis is different from the occurrence in  since alMonthly rate (MR): Monthly average number of sights.Yearly rate (YR): Yearly average number of sights.Resight rate (RR): The average number of recaptures over all the recapture occasions.after the first sight. The rationale behind this choice is that the individual may have entered the population after the first occasion.This is similar to the occurrence in , but thePeriodicity (P): The recurrence of an individual, determined by the inverse of the average time between successive recaptures.Relative span-time (RS): The portion of the whole observation time elapsed between the first and last captures of the individual.elbow rule for the total within-cluster sum of squares. Analysis was performed in RStudio 4.0.1 [All variables were standardized to make different metrics comparable in the cluster analysis. The Gower dissimilarity  was chosio 4.0.1  using faoccn = 99. These single-capture occasions were combined monthly, totaling mn = 20 capture occasions . The encounter history of each identified individual was then as i has been encountered at least once during the j-th month (0 if vice versa).The total number of sampling (capture) occasions analyzed in this study were p < 0.05; Otis Closure Test z-value = −13. 287, p < 0.05), we used the POPAN data type [superpopulation N, which represents the total number of individuals that are potentially available in the study area between the first and the last sampling occasion [Captures are independent across individuals and along time.jp  and survival probability jφ on each occasion are homogeneous among all individuals [Both capture probability ividuals .N enters the study area on occasion j with the same probability jβ; then, it stays in the study area as long as it survives, with no chance of re-entrance once it has exited.Each individual from the superpopulation To test whether the bottlenose dolphin population at the Tiber River estuary was closed or open, the CloseTest software  was usedata type , which uata type , to estiata type ,58,59. Toccasion ,61. The occasion ,62, whicφ represents the apparent survival probability.Thus, the parameters on which each capture history depends on are as follows:−Constant: It does not vary across groups or over time: φ.−Occasion: It does not vary across groups but can vary over time: tφ, t = 1, …, mn.−Group: It does not vary over time but can vary by group: gφ, g = 1, …, G.Survival probability between two subsequent sampling occasions:−Constant: It does not vary across groups or over time: p.−Log-effort: It does not vary over time but depends linearly on the logarithm of the effort: l e f fp, where l e f f = log(effort) and effort ∈ −Occasion: It does not vary across groups but can vary over time: tp, t = 1, …, mn.Detectability at each sampling occasion:−Constant: It does not vary across groups or over time: β.−Occasion: It does not vary across groups but can vary over time: βt, t = 1, …, mn.−Group: It does not vary over time but can vary by group: gβ, g = 1, …, G.Entry probability between two subsequent sampling occasions:The parameters may be constant or may vary over time, also depending on specific variables . Parameters’ estimation was carried out maximizing the likelihood of a multinomial distribution (as the observed data are represented by the capture histories), and the following models were obtained:Marks are not lost over time, and individuals are identified with no error .Sampling is simultaneous, and each individual is released just after.Captures do not affect the detectability and survival probability of the captured individuals after release.To avoid biases  and prod< 1) or overdispersion (> 1) displayed by the data. When L stands for the likelihood, n is the sample numerosity, and k is the number of parameters in the model. QAICc proves to be robust if N, which considers well-marked (WM), fairly marked (FM), and unmarked (UM) dolphins θ^=nWThe uncertainty was evaluated as suggested in , and conp < 0.05), the model does not adequately fit the data. All analyses were performed in RStudio 4.0.1 [The goodness-of-fit (GOF) test of the standard CJS model, which combines the hypothesis of equal capture and survival probabilities among the individuals (homogeneity) and of closeness of the population, was used. If the test is statistically significant . A total number of 104,781 images were selected for photo-identification out of the 263,703 pictures that were collected over the study period, identifying 347 unique individuals. The maximum number of re-sightings was 30 for a single individual, with 226 animals encountered only once or twice.A total of 137 surveys were conducted between august 2017 and november 2020, covering 4967 km in the study area , and a tG = 3 clusters  in the study area, but not necessarily on close sampling occasions. In particular, they were encountered at least five times, in three different months, over three distinct years. The number of encounters ranged from 5 to 30, with more than 50% of the individuals (24/42 dolphins) identified at least 15 times. None of the Resident dolphins were sighted all surveyed months, but 17 (40.4%) were regularly encountered over the 4-year study period. Overall, the maximum number of resident dolphins encountered per sighting was recorded in September (about 9.5 dolphins per sighting).The second cluster, accounting for 73 dolphins, was identified as the group of part-time dolphins. This cluster ranked second in all the site-fidelity metrics, except for periodicity. This means that individuals in this group were likely to be seen at distant occasions in time; they were encountered at least on two occasions in a month, in at least two different years. The number of encounters ranged from 2 to 14, with more than 50% of the individuals (47/73 dolphins) sighted fewer than five times. The number of months ranged from 1 up to 5, with about 50% of the individuals (37/73) encountered at least in three different months. Only 11 individuals (15.1%) were identified in three different years, and none of them in all surveyed years. Overall, the maximum number of part-time individuals encountered per sighting was recorded in October (about 5 dolphins per sighting).The third cluster was the most numerous, accounting for 232 dolphins, and showed the largest average periodicity but the lowest values for all the other site-fidelity metrics see . A largeAlthough the number of females was almost equally distributed among the three clusters , the relative contribution was higher for resident (43%) than for the other clusters . No new females were identified in 2020. We were only able to positively recognize one male, meaning that all other individuals in each cluster were classified as unknown.χ2 = 153.68; p < 0.05, df = 58), and this could bias estimates; hence, estimates were adjusted with the variation inflation factor  attained the lowest QAICc value . This model includes 18 parameters more than Model 2 , in which the detectability varies only as an effect of the effort. Negligible differences in terms of point and interval estimates between these two models emerged, and the ∆QAICc was only slightly larger than the threshold suggested in [The model with varying detectability by occasion, varying survival, and entry probability by group ), with 80 residents ), 114 part-time ), and 335 transients ).Given their evident inter-year variability, mark rates were used to adjust the yearly abundance estimates derived by the overall POPAN model see . The supCI0.95 = ) to 110 ) in 2017, from 100 ) to 117 ) in 2018, from 113 ) to 144 ) in 2019, and from 129 ) to 159 ) in 2020.Abundance estimates on each sampling occasion  show an The capture probability varies with the effort ; howeverCI0.95 = ) for transient, 0.987 ) for part-time, and 0.975 ) for resident. The probability of entering the superpopulation for the part-time dolphins is 3.5% and for the transient ones is 5.3%. It is obviously 0 for the resident.The apparent survival rate is 0.703  has a very localized distribution and a lower number of individuals compared to the transient and part-time groups, with almost 50% of them identified as females (the gender of the other 50% is unknown). Females that show strong site fidelity and limited movements have been reported as typical of bottlenose dolphin populations living close to estuaries ,76, as is grypus ; sperm wcephalus ; Indo-Pa aduncus ). HoweveThe inclusion of each individual in the resident, part-time, or transient group may change with additional data ; howeverThis study provides the first empirical estimates of abundance of bottlenose dolphins at the Tiber River estuary. The overall mark rate ), similar to that of the North Adriatic Sea [Under the parsimony principle in the POPAN model selection, our results indicate that bottlenose dolphins are abundant in the study area. The estimated abundance of the superpopulation is 529 individuals  and https://www.marinemammalhabitat.org/imma-eatlas/) (accessed on 25 February 2021) would be beneficial for the conservation of the ecology and genetic diversity of bottlenose dolphins in this region. In this potential scenario, information reported by the present work, focused both at population and individual levels, could support the evaluation of these proposals.The abundance estimates and the apparent survival rates assessed here  may


Introduction: Endometriosis has a negative effect on health-related quality of life (HRQoL), wellbeing and daily functioning. Endometriosis is an under-researched condition within non-western populations. Cultural representations are needed to understand the relative roles of societal norms, traditional factors, and religious sensitivities on the impact of endometriosis on HRQoL in various populations. In particular, there is a lack of emphasis placed in understanding the association of HRQoL on endometriosis in Arab women.Method: In this prospective case-control study, 2,610 Arab ancestry women in the United Arab Emirates were recruited to investigate the impact of endometriosis on HRQoL, diagnostic delay, psychological co-morbidities, work productivity, and physical activity. Participants completed the following standardized, validated questionnaires: Short Form-36 version 2 questionnaire, the World Endometriosis Research Foundation EPHect minimum clinical questionnaire version, and Work Productivity and Activity Impairment questionnaire. Translations to the Arabic language, validated using the forward-backward translation method, of the questionnaires were utilized.Results: HRQoL scores were significantly impaired in women with endometriosis, as demonstrated in the Physical Composite Scores and Mental Composite Scores in the symptomatic control group  and the asymptomatic control group . Susceptibility and severity of multiple pain syndromes and infertility in women with endometriosis was the main indicator of lower HRQoL. Anxiety (p = 0.007) and depression (p = 0.005) were significantly associated with endometriosis, in comparison to symptomatic controls. The average diagnostic delay was 11.61 years, however single women experience 15.81 years of diagnosis delay, with approximately 18% (n = 15) of the single women experiencing more than a 20-year delay in diagnosis. The intensity of physical activity was not associated with endometriosis, when compared to symptomatic (p = 0.405) or asymptomatic controls (p = 0.144).Conclusion: For the first time, we provide evidence from a combined hospital, clinic, and population-based study that Arab women with endometriosis experience significant impacts on HRQoL, substantial diagnostic delay after the onset of symptoms, significant association to psychological disorders (anxiety and depression), and a negative impact on work productivity. Future research must focus on understanding the personal and culturally centered beliefs of Arab women to ensure a positive HRQoL trajectory by improving diagnosis and management strategies. Endometriosis is a chronic gynecological condition that is characterized by endometrium-like tissue located outside the uterine cavity . Prevalep = 0.019), presenteeism (p = 0.033), and overall work productivity losses (p = 0.014) were reported more frequently by women with endometriosis when compared with symptomatic controls   in Middle Eastern women undergoing laparoscopy, for any indication . While tctively) .Polygamous marriages, strong patriarchal cultures, reticence in disclosing personal matters to the public, and reluctance in seeking care to limit community censorship and victimization is common in the Arab population. These cultural issues limit Arab women's autonomy and may contribute to reproductive and mental health disparities –22. In aThe Middle Eastern Women Research Association (MAR'A) Project is the first epidemiological study on women's health conditions and related co-morbidities in the Middle East that aims to develop a better understanding of cultural and regional women's health patterns. The findings presented in this study are based on the analyses of data collected within the MAR'A Project, which recruited Arab ancestry women from population and hospital-based settings in the United Arab Emirates (UAE). In this study, we investigated the impact of endometriosis on HRQoL, work productivity, activity impairment and physical activity in Arab ancestry women living in the UAE and evaluated symptoms that may significantly influence HRQoL, adopting the use of standardized, validated questionnaires. Furthermore, we estimated diagnostic delay of endometriosis from onset of symptoms to diagnosis by laparoscopy and prevalence of psychological co-morbidities.The Arab region consists of 22 countries located in the Middle East, a transcontinental region that includes the Gulf Cooperative Council region , the Levant region , and the North African region  . The AraThe UAE is situated in the Middle East, located at the southeastern Arabian Peninsula. Its pivotal geographic position allowed an influx of Arab tribes and foreign expats from the region, providing a representation of the middle eastern population . AdmixtuEthical approval was obtained from the research ethics committee within the University of Oxford (OXTREC: 25–18) and the Ministry of Health in the UAE (MOHAP/DXB-REC-25/2018). The study followed the General Data Protection Regulation, and adult participants provided written consent to participate in the study after reading the participant information sheet.The MAR'A Project is a prospective case-control study with multiple recruitment sites across the UAE, including: four hospitals and clinics , and six population-based sites . The participants were approached in the waiting room in the hospitals and clinics, or at the end of the public seminars, and asked if they were interested in learning more about this research study. Between August 2018 and August 2019, we recruited 2,610 participants, using the following criteria: 1) premenopausal women, 2) aged 18–50 years, 3) self-reported ethnically Arab, and 4) no previous diagnosis of endometriosis. Exclusion criteria were: 1) pregnant women, 2) women with special needs, and 3) women who were illiterate, and were unable to comprehend and provide informed consent. Participants who met the inclusion criteria were invited to participate in the study and given the consent form and participant information sheet in their preferred language (English or Arabic), which had been professionally translated using the forward-backward translation methods and approved by the ethics committee. The recruitment flow chart is demonstrated in The case group were incident endometriosis cases who attended the hospital scheduled to undergo a diagnostic and/or therapeutic laparoscopy or laparotomy for any indication  by visual confirmation as is the current golden standard , 34, andThe control group comprised three distinct groups: 1) hospital controls who had undergone laparoscopic surgery showing that they were endometriosis-free, 2) clinic controls who were screened using therapeutic/diagnostic tests , and 3) population controls recruited during organized public seminars. The control groups were sub-divided into symptomatic and asymptomatic controls , to explper se, and not the presence of symptoms. The asymptomatic control group allowed investigation of factors associated with symptoms with or without endometriosis. To quantify hidden bias, such as the possibility of undiagnosed endometriosis cases in the control group, sensitivity analysis was conducted between HRQoL dimensions from the symptomatic controls with surgical confirmation vs. symptomatic controls with no surgical confirmation.In analysis, comparisons were made between 1) women with endometriosis vs. symptomatic controls, and 2) women with endometriosis vs. asymptomatic controls. The symptomatic control group allowed us to investigate whether observed associations relate to endometriosis Participants completed the following standardized, validated questionnaires and instruments: Short Form-36 version 2 (SF36v2) , 41 quesData were collected and managed in a web-based research electronic data capture (REDCap)  databaseThe SF-36v2 questionnaire  , 48–51, Means and standard deviations for each of the eight-dimension scales are presented, ranging from 0 to 100, and two composite scores above the normative value (mean of 50 and a SD of 10) demonstrates a healthy QoL. The missing values in the SF-36 dimensions were imputed as recommended by the developer , 49: if The two-composite quality of life scores (PCS and MCS) were compared with pelvic pain severity, presence of endometriosis-associated symptoms, four grade classification based on the revised American Society for Reproductive Medicine (rASRM) , and lenDiagnostic delay of endometriosis was quantified by averaging the self-reported earliest age of symptom onset  and age of first contact seeking gynecological consultation, and then subtracting from this the age at surgically confirmed diagnosis of endometriosis. Due to societal norms that delay single women from seeking gynecological help, the diagnostic delay of the onset of pelvic pain symptoms was compared between single women and married women. Infertility was not included in the subtype analyses for marital status because single women are prohibited from seeking fertility services.The Work Productivity and Activity Impairment Questionnaire . Most endometriosis cases had rASRM stage I and II endometriosis at the time of their surgical diagnosis .Of the 2,610 women who participated in the study, 518 had surgically-confirmed endometriosis and 2,092 were controls. The recruitment population of the controls were , with a higher education  and were working , which aligns with the annual census data , and lower parity . Higher educational achievement and employment rate was not significant between endometriosis cases vs. symptomatic controls . Menstrual irregularity was not associated with endometriosis vs. symptomatic controls (p = 0.082); however, a significant difference was present for earlier age at menarche (p < 0.001) and longer duration of menstruation (p < 0.001). Women with endometriosis had a higher prevalence of being affected by chronic pelvic pain (p < 0.001), dysmenorrhea (p < 0.001), dysuria (p = 0.002), dyschezia (p < 0.001), and infertility (p = 0.001), in comparison to symptomatic controls. Even with a high prevalence of chronic pain symptoms among the endometriosis cases, the chief clinical complaint and primary reason for surgical investigation was infertility , with only 36.8% (n = 191) agreeing to surgical intervention due to their pain symptoms and 1.4% (n = 7) proceeding with tubal ligation.The mean age of participants was 34.18 (SD ± 7.77) and the mean body mass index (BMI) was 27.00 (SD ± 5.46). Most of the women were married , suggesting that results were not dependent on definition of symptomatic control group. Given that we found no change in our effect estimates, this suggests that the potential presence of undiagnosed cases in our symptomatic control group had little impact on the results of the analyses we present.Prior to investigating the impact of HRQoL on endometriosis, a sensitivity analysis was conducted to quantify hidden bias between the HRQoL dimensions of symptomatic controls with laparoscopic confirmation vs. symptomatic controls with no surgical confirmation. The assessment of robustness between the HRQoL dimensions for the two symptomatic controls  demonstrated no statistically significant differences in the HRQoL dimensions  and asymptomatic control group .Compared with symptomatic and asymptomatic women, mean HRQoL scores were significantly lower in the endometriosis case group in all eight dimensions and two composite scores . Using tp < 0.001) and MCS score  among endometriosis cases, and among symptomatic controls . However, endometriosis staging was not associated with physical (p = 0.815) or mental (p = 0.737) component scores, when stratified into the rASRM four-stage system.There was a significant negative correlation between the subjective NRS rating of pain severity and HRQoL, when conducting a Spearman correlation test. Severity of pelvic pain was inversely correlated with PCS score , which may be because women with endometriosis experience multiple pain symptoms with a greater severity that hinders their physical and daily activities.After stratifying endometriosis cases and symptomatic controls by pain symptoms  and infertility, and adjusting for demographic factors, all symptomatic women had impaired PCS and MCS, regardless of presence of endometriosis . EndometDysmenorrhea had the earliest symptom onset in the study population, and infertility the latest onset. The delay intervals from the onset of symptoms to first gynecological consultation, and intervals from first gynecological consultation to confirmed diagnosis are depicted in The delay from symptom onset to diagnosis varied from 7.32 years among women with infertility to 12.44 among those with pelvic pain. Arab women were more likely to seek surgical confirmation of endometriosis when they suffered from infertility, as opposed to pain, hence the shorter diagnostic delay when including infertility confirmation. This is also demonstrated when participants were asked for their chief clinical complaint and primary reason for surgical investigation .p > 0.001; MCS: correlation coefficient: −0.374, p < 0.001).When investigating the diagnostic delay of pain symptoms, married women experience 10.78 years of delay and single women experience 15.81 years of delay. There was a significant correlation between longer diagnostic delay of endometriosis and reduced HRQoL (PCS: correlation coefficient: −0.233. n = 145) reported anxiety, 21.9% (n = 292) of symptomatic controls and 6.0% (n = 46) of asymptomatic controls. For depression disorder the numbers were 26.3% (n = 136), 20.0% (n = 266), and 6.6% (n = 50), respectively. After adjustment for demographic factors, there was a significant association between endometriosis status both when comparing with symptomatic and asymptomatic controls , and those who did not work were mostly housewives or carers . Of the symptomatic women who were not in employment, approximately one in six  reported that they did not work because of the symptoms for which they underwent surgery. Work productivity was significantly impaired among women in the endometriosis group (p = 0.001), presenteeism (p = 0.006), and overall work productivity loss (p = 0.002). No significant difference (p = 0.059) of impact on non-work-related activities between the endometriosis cases and symptomatic controls was present.Participants were asked to rate the impact of their symptoms on work productivity and daily life using a 10-point scale in the WPAI questionnaire. Most women in the study population were employed  in the study.The intensity of physical activity was based on a MET score, measured to assess the amount of energy the body uses per minute, using the Compendium of Physical Activities . We did For the first time, we provide evidence from a combined hospital, clinic, and population-based study that Arab women with endometriosis experience significant impacts on HRQoL, substantial diagnostic delay after the onset of symptoms, significant association to psychological disorders (anxiety and depression), and a negative impact on work productivity.All women in the study population  had poorer mental HRQoL than the normative population. To interpret mental health and illness among Arab women, it is important to understand how Arab women perceive their role in their social, cultural, and religious context. The collectivist society emphasizes interdependence, where their role as custodians of community culture is to protect their family from any emotional harm. Emphasis is placed upon family privacy, reputation and solidarity, where women may feel reluctant to seek help due to shame and risk of harming the reputation and honor of the family , 63, 64.p = 0.001; p = 0.003, respectively) and asymptomatic control group . The effect of endometriosis on physical and mental HRQoL of women was substantial, with SF36v2 scores similar to those reported in Arab women with breast cancer  and MCS score (p < 0.0001). The lack of statistical significance in MCS score, when comparing the effect of HRQoL composite scores on endometriosis-associated symptoms, between endometriosis cases and symptomatic controls, demonstrates that the presence, duration and severity of the pain state might be a driving force in the development of sensitization  or mental (p = 0.737) component scores. This is consistent with previous studies where rASRM surgical staging was not associated with susceptibility or severity of pain or infertility of endometriosis  of the single women experiencing more than a 20-year delay in diagnosis due to chronic pain. Single Arab women were found to have fewer affirming attitudes toward seeking medical care, as they may endanger future marital prospects , mainly driven by the delay in seeking the first gynecological consultation from symptom onset (6 years among Arab women vs. 1 year in the GSWH study)  and depression (p = 0.005) were significantly associated with endometriosis, in comparison to symptomatic controls. The overlapping impacts of endometriosis on different aspects of life , as well as the early onset of symptoms and later diagnosis of the disease, collectively, have a considerable impact on mental health , presenteeism (p = 0.006) and overall work productivity loss (p = 0.002). However, no significant difference was observed in activity impairment between symptomatic women with and without endometriosis. Greater prevalence of empirical, over-the-counter medication usage by affected women leads to unsuccessful attempts to mitigate this pain, impacting their work productivity  due to the lack of access to healthcare, low standard of care, low accessibility to adequate medical supplies, lack of qualified medical staff, mental health impact and the lack of attention for women's health due to high mortality and morbidity directly due to war and conflict. In addition, while the study findings may not be generalisable to Arab women residing in countries outside the Middle Eastern region, because they are likely to encounter a different set of social and cultural factors, these findings could be used to make cross-cultural comparisons. For instance, investigating the quality of life of Arab women residing in Western societies can be compared with those in this study, to elucidate similarities and differences among cultures, as well as the genetic and non-genetic underpinnings on HRQoL outcomes. This will increase the likelihood of a positive HRQoL trajectory, improve health and wellness among Arab women, and tackle disparities in the representation of Arabs in endometriosis research, globally. This may also enable an exploration of geographical variations in healthcare provisions for women with endometriosis.It is important to acknowledge the influence of cultural sensitivities, traditions, and religious heterogeneity in different aspects of reproductive health disparities in healthcare that can act as barriers and directly impact Arab women. HRQoL associated with endometriosis is a growing concern, increasingly voiced by patients and health professionals. Women with endometriosis-associated symptoms should be referred to centers of expertise, led by those with training in complex benign gynecology and referred to a multi-disciplinary team that includes a psychologist, gynecology radiologist, pain specialist and with support from patient organizations. The significantly lower quality of life scores in women with endometriosis and symptomatic control group demonstrate that medical care should also address the emotional and social problems that come with endometriosis. Further research should identify symptom control strategies that target those pathways to improve the outlook for affected women. Our study will enable the establishment of communities for ongoing support and intends to build on the strength of women-centered networks for Arab women.The chronicity and severity of pain and infertility associated with endometriosis have a negative impact upon HRQoL, psychological wellbeing and daily functioning. To improve the quality of life in women affected by endometriosis, medical care should address emotional, social and well-being aspects of the disease. The scientific and medical professional need an informed understanding of the heterogenous array of religious beliefs, cultural norms, and traditional expectations in the community, to ensure they are providing culturally sensitive, comprehensive care. There is a need to conduct an in-depth understanding of the personal and culturally centered beliefs of Arab women within the realms of their lives as young adolescents and adults, and how their HRQoL is impacted with endometriosis. Such understanding will allow policymakers, stakeholders, and medical physicians to improve management and develop targeted health education awareness campaigns for Arab women that struggle with endometriosis, which will differ from the current, more western-centric approaches. Additional support is required to target younger Arab women in this region to advance their understanding of reproductive health literacy and increase awareness of the severe impact of this condition and associated symptoms.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Research Ethics Committee within the University of Oxford (OXTREC: 25-18) Ministry of Health in the UAE (MOHAP/DXB-REC-25/2018). The patients/participants provided their written informed consent to participate in this study.MM, NR, KZ, and CB were involved in all parts of the study conception, study design, analysis methods, interpretation, drafting of manuscript, and final approval. MA-J and HA were involved in study design, interpretation, reviewing of the manuscript, and final approval. All authors contributed to the article and approved the submitted version.This study was funded by The Sheikh Saud Bin Saqr Al Qasimi Foundation (MR-8180) doctoral grant.CB reports grant from Bayer AG, other from AbbVie Inc., grants from Volition Rx, grants from MDNA Life Sciences, grants from Roche Diagnostics Inc., non-financial support from Population Diagnostics Ltd., other from ObsEva, other from Flo Health, outside the submitted work. KZ reports grants from Bayer Healthcare, MDNA Life Sciences, Roche Diagnostics Inc., Volition Rx, and Evotec (Lab282-Partnership programme with Oxford University), all outside the submitted work; and is a Board member (Secretary) of the World Endometriosis Society and World Endometriosis Research Foundation. 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.


During the COVID-19 pandemic, many people had to shift their social and work life online. A few researchers and journalists described a new form of fatigue associated with a massive use of technology, including videoconferencing platforms. In this study, this type of fatigue was referred to as Online Fatigue. A new tool  was developed, and its psychometric properties were evaluated. This tool was used to assess Online Fatigue among Italian academics and to examine its associations with psychological and physical health.An online survey was conducted in December 2020 on a sample of Italian academics. Besides the Online Fatigue Scale (11 items) used to assess Online Fatigue, the survey was composed of questionnaires  focused on sociodemographic and job-related information, technostress creators, health status, psychological well-being, and COVID-related perceived distress. The psychometric properties of the Online Fatigue Scale were evaluated, and statistical analyses were conducted to examine the associations between Online Fatigue and all the other variables.Participants were 307 academics aged 24–70 years old . The Online Fatigue Scale showed good psychometric properties. Two subscales were identified: Off-Balance Fatigue and Virtual Relations Fatigue. High levels of Off-Balance Fatigue were associated with a greater use of technology, female gender, and presence of minor children. Participants with high scores on both subscales reported a greater frequency of psychosomatic symptoms, unhealthy habits, poorer psychological well-being, and greater Covid-related perceived distress.The Online Fatigue Scale can be considered a reliable tool to assess Online Fatigue, which was significantly detected in our sample of Italian academics, along with its negative effects on physical and psychological health. Being a woman and having young children represent important risk factors. Universities should promote the separation between work and private life by encouraging self-care activities. Since the very beginning of its outbreak, the COVID-19 pandemic and the containment measures taken by the governments (including lockdowns) involved shifting our social interactions and work life online , but at pandemic fatigue [As recently reported by the World Health Organization (WHO), people’s feelings of distress, complacency, alienation, and hopelessness, along with decreased motivation to engage in protective behaviors and information search, represent a normal reaction to the current sustained and unresolved crisis, which has been referred to as  fatigue . On the  fatigue . Moreove fatigue , and som fatigue . Due to  fatigue . Since t fatigue . Overall fatigue . All the fatigue .Overall, the available body of research on the psychological impact of the pandemic–either on the general population , 16 or oZoom fatigue and is characterized by feelings of stress, tiredness, anxiety and concerns, and even burnout due to overusing videoconferencing technology [Since early March 2020, a significant number of mass media outlets –but very few researchers–raised attention to a specific form of pandemic-related fatigue associated with the exponentially increased use of videoconferencing programs as a consequence of remote working , 20. Thichnology . At the chnology . ConsideThe biopsychosocial mechanisms associated with the mental and physical toll  of videoconferencing technology overuse remain unclear. Besides technical malfunctions, it has been suggested that minimal delays occurring in this type of communication, along with lack of mutual gaze, decreased nonverbal cues, and one’s overexposure to one’s own image, cause extra work to the brain to restore synchrony, as well as psychological fatigue .Overall, remote working involves an intense use of internet and technology on a daily basis, and for this reason one can speculate that workers’ experience of fatigue is related not only to videoconferencing, but more generally to the new work modalities imposed by the pandemic. In the current study, this specific type of pandemic-related fatigue, deriving from overusing internet and technology during homeworking, was referred to as Online Fatigue. Thus, Online fatigue can be conceived as a psychological fatigue exacerbated during COVID-19 pandemic that includes both what other authors called Zoom fatigue, such as the feeling of exhaustion associated to the overuse of a particular videoconferencing platform , and thetechnostress, i.e., “the stress that users experience as a result of application multitasking, constant connectivity, information overload, frequent system upgrades and consequent uncertainty, continual relearning and consequent job-related insecurities, and technical problems associated with the organizational use of Information and Communications Technology (ICT)” [The existence of a connection between new technologies and stress is well known in psychological literature, as indicated by the notion of y (ICT)” . This dey (ICT)” , who idey (ICT)” , technosy (ICT)” , 28, buty (ICT)” .In the current pandemic, many workers had to quickly learn to use new remote working tools and platforms, to find creative ways to combine their overlapping multiple roles and to live with the expectation of always being connected, available and operative . Higher S1 Dataset); (2) estimate the prevalence of Online Fatigue in the Italian academic staff; (3) identify the correlates of Online Fatigue in terms of mental health and psychosomatic symptoms.On these premises, we conducted the current study to: (1) provide a preliminary conceptual definition of Online Fatigue, as well as to develop and validate a specific assessment tool  through social media–i.e., Facebook, WhatsApp groups of academic staff, and LinkedIn–and institutional emails. The university teachers who had an interest to participate in the study could open a link and receive a detailed cover letter with electronic informed consent. The participants did not receive any form of compensation on participation in this study. Inclusion criteria were: (i) being part of the academic staff, (ii) working in Italy, and (iii) being fluent in Italian.A total of 322 individuals accessed the online questionnaire, and 307 individuals completed the full survey. The 15 participants who did not fully complete the survey answered less than 50% of the entire questionnaire, thus we decided to exclude them from the study, and only the responses provided by the remaining 307 participants were considered valid. Statistical analyses were carried out with IBM SPSS 25 (release 25.0.0.0).All the procedures conducted were approved by the Ethical Commission of the Department of Psychology of the Università Cattolica del Sacro Cuore of Milan. Informed consent was obtained electronically before data were collected from the participants.Some steps were taken to develop the Online Fatigue Scale. First, a scan of the scientific literature was conducted to identify all general scales measuring technology-related stress experience. This analysis led to the identification of two issues, that are the juxtaposition of private life and work-related duties work intensification deriving from the willingness of remote workers to invest greater work effort . In addiThe questionnaire included the following measures in the order in which they are presented.A background information sheet was used to collect participant demographic data , job-related information , and information about lifestyle behaviors over the past month.A pull of ad-hoc items was used to assess work-related technology usage over the past month. Moreover, Technostress creators were assessed through 11 items derived from the Italian validation of the Technostress Creators Scale : four itA checklist of psychosomatic symptoms, adapted from the Copenhagen Psychosocial Questionnaire  for thisThe Italian Mental Health Continuum-Short Form  consistFurthermore, the Perceived Stress Scale (PSS) was used to assess participants’ evaluation of stressful situations over the past month. The PSS is a global measure of stress that is simple to use, and there is an abundance of studies confirming its reliability and validity . SpecifiTo assess the level of emotional balance regarding the COVID-19 emergency we adopted the Patient Health Engagement Scale (PHE-s®) revised form . This meDescriptive statistics were computed for each item. Mean, median, and standard deviation, asymmetry and kurtosis have been checked. Values for asymmetry and kurtosis between -2 and +2 were considered acceptable to prove normal distribution .To evaluate the structural and psychometric properties of the Online Fatigue Scale, the sample of 307 participants was randomly divided into two subsamples. No significant differences were found between the two subsamples regarding sex, age and use of the technology. An Exploratory Factor Analysis (EFA) was performed on the first subsample  to evaluate the factorial structure of the scale, to estimate the factor loadings, to allow for greater accuracy of variable clustering and to minimize the covariance between elements on factors. For the factorial structure of each measure, the Kaiser–Mayer–Olkin measure of sampling adequacy, Bartlett’s test of sphericity , and factor loadings were evaluated. Since the sample was sufficiently large for the number of items, a principal axis method was selected for factor extraction with Promax rotations. Cronbach’s Alpha was calculated to evaluate the internal consistency of each dimension.Next, to check the adequacy of the items to the identified dimensions, a Confirmatory Factor Analysis (CFA) was run on the second subsample of n = 123 . The model was estimated using Maximum Likelihood with robust standard errors and evaluated using approximate fit statistics  to assess concurrent validity, and in relation to the PSS to assess convergent validity. To obtain a final scoring and to verify the difficulty of each item, a Partial Credit Rasch Model (PCM) was conducted. PCM allows sorting items by increasing difficulty or frequency. A more difficult item  indicates a situation less frequently experienced by the respondent. The sort of the items allows for an easier determination of the Online Fatigue Scale scoring. Moreover, two mean square statistics (Infit and Outfit Statistics) were computed to check whether the items fitted the expected model. If the data fitted the Rasch Model, the fit statistics should be between 0.5 and 1.5 .To assess the association between socio-demographic characteristics, technology and videoconferencing platform use, and different Online Fatigue levels, a series of contingency tables were computed. For each categorical variable, the row percentage distribution is presented. For each metric variable, mean and standard deviation in groups were calculated. Pearson’s chi-square was also carried out to reject the null hypothesis that data are randomly distributed across Online Fatigue levels.2 values were calculated.A series of univariate ANOVAs, with Online Fatigue dimensions as independent variables, were carried out to explore differences in the frequency of psychosomatic symptoms, behavioral habits, emotional, social and psychological well-being scores, Covid-related perceived distress, and General self-perceived health status among different Online Fatigue levels. P and η307 academics completed the full survey. Participants’ mean (SD) age was 40.7  years, and 72.6% were women. Regarding their academic position, 18.6% were PhD students, 15.6% Research Fellows, 25.0% Assistant Professors, 26.4% Associate or Full Professors, and 14.3% Adjunct Professors. For a more detailed description of the study sample, see Off-Balance Fatigue and Virtual Relations Fatigue, respectively. Scale scores on each factor were calculated for each respondent by summing ratings for each factor and then dividing by the number of items used to measure it. p<0.001).An EFA with Promax Rotation was performed on the first subsample. The analysis, based on an eigenvalue criterion of > 1.0, yielded two latent factors, with eigenvalues of 4.57 and 1.63 and with 56.32% of explained variance. The correlation matrix had good factorability, Bartlett’s test of sphericity showed that the chi-square was significant at the .0001 level  and the index of Kaiser-Mayer-Olkin measure of sampling adequacy was equal to 0.87. Factor 1 contains items 1, 2, 3, 4, 5, 6, 10 (α = 0.86), Factor 2 contains items 7, 8, 9 and 11 (α = 0.73). The two factors were named A CFA was then run on the second subsample. Results showed that the proposed solution provided an acceptable fit to the data, CFI = 0.951, TLI = 0.934, RMSEA = 0.072  and factor loadings ranging from 0.38 to 0.85, with median standardized loading = 0.71.The different choice of scoring between Off-Balance and Virtual Relations Fatigue subscales was due to the fact that the items included in the Virtual Relations Fatigue subscale were more difficult than the Off-Balance Fatigue items. Specifically, the least difficult items  according to the results of the Rasch Model were those included in the Off-Balance Fatigue subscale . On the other hand, the most difficult items  were those included in the Virtual Relations Fatigue subscale . Hence the reason for making different scorings for each subscale. This is also understandable if one considers that the situations presented in the Off-Balance Fatigue dimension  are more likely to be experienced in everyday life compared to the situations presented in the Virtual Relations Fatigue subscale .In view of the above, the Off-Balance Fatigue subscale was recoded into 3 levels: low , medium , and high . The Virtual Relations Fatigue subscale was recoded into 2 levels: low  and high .As regards Off-Balance Fatigue, 27.4% of the participants reported a low level, 38.4% a medium level, and 34.2% a high level. Regarding Virtual Relations Fatigue, 61.9% of the participants showed a low level and 38.1% a high level.The results of the contingency table to assess the association between socio-demographic characteristics, technology and use of communication platforms, and different Off-Balance and Virtual Relations Fatigue levels are reported in Tables Results showed a moderate significant association between a high level of Off-Balance Fatigue and the use of technology and videoconferencing platforms. A high level of Off-Balance Fatigue was reported by 45.3% of the participants who used technology more than 8 hours per day and by 44.8% of those who used videoconferencing platforms more than 4 hours per day. High levels of Off-Balance Fatigue were also more frequently experienced by women and people who had minor children, even if differences were not significant. Off-Balance Fatigue levels did not vary across different age and academic role.A high level of Virtual Relations Fatigue was reported by 43.9% of participants who lived alone and by 45.1% of those who were single / not cohabiting. However, these associations were not significant. In addition, Virtual Relations Fatigue levels did not vary across different age, academic role and gender profiles, as well as across different use of technology and videoconferencing platforms.Tables 2 values reported in Tables ANOVA results showed a significant main effect of Online Fatigue on all psychosomatic symptoms. In general, a high level of Off-Balance and Virtual Relations Fatigue were associated with a higher frequency of psychosomatic symptoms see Figs  and 2: eIn this cross-sectional study, we examined a new form of pandemic-related fatigue, referred to as Online Fatigue. We decided to examine Online Fatigue among Italian academics because they experienced a remarkable shift to homeworking, which involved a massive use of technologies for multiple activities (including work meetings and online teaching). Considering that the association between use of technology and stress has been demonstrated in several studies , 26, andThe conceptual definition of Online Fatigue was provided after careful review of the extant literature on technostress (including technostress measures), as well as of the published material (press release and very few articles) on the so called “Zoom fatigue” phenomenon. Based on this definition, we developed an 11-item assessment tool–the Online Fatigue Scale–that showed good psychometric properties. The first step of this study aimed to evaluate the structural and psychometric properties of the Online Fatigue Scale, and its association with concurrent and convergent measures.EFA and CFA conducted on two independent subsamples showed a two-factor structure, named Off-Balance Fatigue  and Virtual Relations Fatigue (related to a stressful experience linked to interacting with other using technology), with a good internal reliability as indicated by satisfactory Cronbach’s Alpha. The Rasch Analysis confirmed the importance (in terms of fitting) of each item of the scale by using the Infit and Outfit Statistics. Moreover, the Rasch Analysis allowed to rank the items based on their difficulty, which was useful for the scoring procedure.Finally, to assess the concurrent validity, the Online Fatigue Scale factor scores were evaluated in relation to two dimensions of the TCS scale (Techno-Overload and Techno-Invasion), because these dimensions refer to the feeling of being forced by ICTs to change work habits (work faster and longer), and to the subjective perception that ICTs blur the boundaries between work and private life. To assess convergent validity, the Online Fatigue Scale factor scores were evaluated in relation to the PSS Scale, as previous studies already demonstrated the positive association between these dimensions and behavioral strain, according to the transaction-based model of stress , showingOn the one hand, technology enabled the academic staff to work from home and continue doing their jobs despite stay-at-home orders . On the other hand, our results showed that, in our sample, Off-Balance Fatigue was associated with very frequent use of technology and communication platforms, especially in relation to being a woman and having minor children. These findings are understandable if one considers that, due to the COVID containment measures, work and private life bled into one another, with impaired balance between professional and home duties. In this regard, women and people with very young children may be particularly at risk of experiencing an “invasion” of technologies in their private life during homeworking.Academic work is not standardizable in terms of work hours, but all types of previous work-life balance arrangements might have been completely disrupted by the current pandemic. In these difficult times, universities should promote the separation between work and private life, for instance by planning periodic downtime to step away from technology, and invest in the psychological and physical health of the academic staff by encouraging self-care practices, including physical activities .During in-person meetings, people exchange either verbal or non-verbal information, and thus communicate implicit attitudes and feelings towards their colleagues, which are also related to the quality of interactions. Videoconferencing entails a greater effort to cognitively process non-verbal cues   and leadIn our study, both Off-Balance and Virtual Relations Fatigue were associated with a higher frequency of psychosomatic symptoms. In particular, irritability was a common symptom, whereas Off-Balance Fatigue was more associated with physical tension, as confirmed by the literature on the effects of technostress . On the Moreover, although the two Online Fatigue subscales were not associated with the participants’ general health status, they were significantly associated with Covid-related distress. These findings indicated that Online Fatigue is specifically related to the pandemic, an unprecedented global challenge that has been revolutionizing the private and work lives of many people.Our study contributed to detect the presence of Online Fatigue among Italian academics as a consequence of the new work conditions imposed by the pandemic. This complex situation needs to be addressed at different levels. On the one hand, greater attention should be paid to the balance between working and personal life, by defining spaces (even inside academic’s home) and working times, and thus sustaining an ethics of care . UniversS1 Dataset(SAV)Click here for additional data file.


Background: Traumatic hollow viscus injury (THVI) is one of the most difficult challenges in the trauma setting. Computed tomography (CT) is the most common modality used to diagnose THVI; however, various performance outcomes of CT have been reported. We conducted a systematic review and meta-analysis to analyze how precise and reliable CT is as a tool for the assessment of THVI. Method: A systematic review and meta-analysis were conducted on studies on the use of CT to diagnose THVI. Publications were retrieved by performing structured searches in databases, review articles and major textbooks. For the statistical analysis, summary receiver operating characteristic (SROC) curves were constructed using hierarchical models. Results: Sixteen studies enrolling 12,514 patients were eligible for the final analysis. The summary sensitivity and specificity of CT for the diagnosis of THVI were 0.678 (95% CI: 0.501–0.809) and 0.969 (95% CI: 0.920–0.989), respectively. The summary false positive rate was 0.031 (95% CI 0.011–0.071). Conclusion: In this meta-analysis, we found that CT had indeterminate sensitivity and excellent specificity for the diagnosis of THVI. Traumatic hollow viscus injury (THVI) is a difficult challenge in the trauma setting. THVI can induce active bleeding from disrupted mesenteric vessels or cause bowel discontinuity. Furthermore, discontinuity of the gastrointestinal (GI) tract causes spillage of the bowel contents, bacterial contamination, and a predisposition to sepsis ,2. UnlikComputed tomography (CT) is the first choice of an advanced evaluation tool for abdominal trauma ,10. CT iIn this study, we reviewed the available studies published in English to provide a thorough evaluation of the performance of CT with regard to the diagnosis of THVI. A meta-analysis was performed to highlight the strengths and weaknesses of emergency CT for the assessment of THVI.The systematic literature search was performed based on the 2019 Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement.A study was considered eligible if it evaluated CT as the only test used to diagnose THVI and determine the need for surgery in patients presenting to the ED with blunt-force trauma and presented the surgical findings with regard to the accuracy of that diagnosis.We tried to identify all published studies that reported the accuracy of CT for the diagnosis of TVHI due to blunt-force trauma. We searched the MEDLINE and EMBASE electronic databases. The search strategy restricted the language to English and the publication dates to between January 2000 and December 2019. The MEDLINE, EMBASE, Web of Science and Cochrane Library databases were searched using the following subject headings: “computed tomography”, “hollow viscus injury”, “intestinal trauma”, “intestinal injury”, “bowel injury”, “bowel trauma”, “free air”, “pneumoperitoneum”, “free fluid”, and “hemoperitoneum”. The details are provided in the Two independent reviewers (CC Hsia and CY Wang) independently screened the titles, abstracts, and, if there was insufficient information in the abstract, full-text publications to determine the suitability of the studies for inclusion in the analysis. Studies evaluating the performance of CT for the diagnosis of blunt-force THVI were eligible if they provided the data that could be used to calculate the sensitivity and specificity for the diagnosis of blunt-force THVI. No study was excluded based on the quality of the reference standard. Case reports, editorials, abstracts, conference proceedings, studies involving military patients and studies involving patients aged <18 years were excluded.Two independent reviewers (CC Hsia and CY Wang) independently extracted the study and patient characteristics, and the diagnostic accuracy of CT. Cohen’s kappa coefficient (κ) was calculated to assess the agreement between the review authors. No attempts to mask the authorship, journal name or institution were made here or in any other step of the review process. Any differences in opinion regarding inclusion were discussed with a third reviewer (CH Liao). Information about CT findings, surgical findings, true positives, true negatives, false positives, false negatives and study designs was collected. The Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) checklist was used by two reviewers to assess the quality of the included studies. Publication bias was evaluated by assessing the asymmetry in Deek’s funnel plot for the weighted regression with multiplicative dispersion.The primary objective of this systematic review was to assess the sensitivity and specificity of CT for the diagnosis of the need for surgical intervention in THVI patients. The accuracy of a diagnostic test is assessed by calculating the sum of all true-positive and true-negative findings divided by the sample size. The summary sensitivity and specificity, with 95% confidence intervals (95% CIs), and summary receiver operating characteristic (SROC) curves were generated using hierarchical SROC models.The statistical analyses were performed with Review Manager software, version 5.3 . The SROC parameters were determined with MetaDTA: Diagnostic Test Accuracy Meta-Analysis version 1.45  and R  and 0.969 (95% CI: 0.920–0.989), respectively. The summary false-positive rate was 0.031 (95%: CI 0.011–0.080). This systematic review summarizes the results of studies on the diagnostic performance of CT for THVIs. In this review, we found that the reported sensitivity of CT ranged from 63% to 95%, and the false-negative rate was 2.5%. However, the high specificity of CT for the diagnosis of THVI has been universally reported. The pooled analysis showed the summary sensitivity was 0.678 (0.501 to 0.809), and the summary specificity was 0.969 (0.920 to 0.989). THVIs occur in between 2% and 6% of patients with blunt-force abdominal trauma. CT is the first-line diagnostic modality for blunt-force abdominal trauma; it provides information about viscus organs that can be used to make treatment decisions. Although CT is highly specific for the diagnosis of THVI, the sensitivity is inadequate ,29. A shThe diagnostic signs and presentation on CT were also reported to be highly variable, which often led to the incorrect interpretation of the initial CT in patients with THVI ,35. The Free peritoneal air was the typical presentation if there was perforation or discontinuity of the intestinal tract. However, the proportion of patients with this presentation ranged from 0% to 83% in the included studies. Intestinal tract discontinuity is another specific sign indicating THVI. A similarly large range in the proportion of patients with intestinal tract discontinuity was reported 3–100%). Free peritoneal fluid is another typical presentation of THVI on CT; this sign is common and plays an important role in the diagnosis of THVI. Several studies have shown that it is a sensitive indicator of THVI that needs surgical management; 00%. Free however,The reason for the relatively low sensitivity of CT for the diagnosis of THVI is delayed perforation . Unlike This study is a systematic review of the diagnostic accuracy of CT for THVI. All available articles were reviewed to provide an overview of current clinical practice. There were some limitations. First, we did not collect studies published in languages other than English, which might have led to the omission of relevant articles. However, all available abstracts were evaluated by our reviewers; therefore, if an article published in a language other than English had an abstract written in English, we also included those data. Second, some manuscripts were published 20 years ago, and the technology and resolution of CT at that time does not reflect the current usefulness of CT as a diagnostic tool. Third, the protocol for evaluating trauma patients has changed in the past two decades. Whole-body CT is now performed for trauma patients, whereas CT was not often performed for trauma patients in the early 2000 s. The changes in the clinical protocol and the attitude of the physicians may have led to selection bias in this review. Furthermore, because we focus on the CT diagnostic accuracy in surgical significant cases, therefore, there are several articles that cannot offer the information clearly will be not included in this review, the selection bias cannot be completely excluded. Fourth, although the studies focusing on battlefield medicine have provided valuable evidence leading to advances in the treatment of trauma, we did not include military studies in the meta-analysis because of the differences in the complexity and etiology of injuries between the military and civilian populations. Fifth, we did not search the gray literature and did not evaluate heterogeneous patient populations/settings, which might be another limitation of this review.In conclusion, CT is an accurate tool for the diagnosis of THVI, with a false-negative rate of 2.5%. However, none of these signs can be used as a single predictor for delayed surgical management. To evaluate delayed THVI, well-designed prospective studies, including randomized allocation and comparison with open operations, are needed.


But for some people, gaming gets out of hand and can result in a Gaming Disorder (GD). Among others, high neuroticism and low conscientiousness are considered to play a role in the etiology of GD. Next to personality traits, environmental variables are debated such as the parental influence on children's gaming behavior. In detail, parental gaming behavior could have role model functions for children. Based on empirical observations and theoretical frameworks, it was hypothesized that higher tendencies to GD in children are associated with higher neuroticism, lower conscientiousness, and higher parental tendencies to GD. In an online survey N = 493 parents  rated their own and their children's  tendencies to GD by the Gaming Disorder Test (GDT) and their children's personality by the Big Five Inventory (BFI). Neuroticism was significantly correlated with the GDT scores of boys  and girls , while a significant correlation with conscientiousness was only present for boys . Parents' and children's general playing of computer and video games were interdependent ; hence, if parents reported to be gamers, their children were more likely gamers as well. The GDT scores of parents and children were positively correlated . The results indicate that already in children the personality traits neuroticism and conscientiousness are associated with tendencies toward GD. Moreover, as gaming of parents and children was related to each other, it is conceivable that parents influence their children's gaming behavior via their own gaming behavior. Therefore, parents should be aware of their exemplary function for children and may overthink their own gaming behavior. But it has to be mentioned that the correlational nature of the present work allows no insights regarding causal relations.Playing computer and video games (so-called  International Classification of Diseases (ICD-11)   . The dia(ICD-11) . Accordi(ICD-11) . However DSM-5) , which i , which interaction of certain predisposing person, affect, cognition, and execution variables is of high relevance to understand the etiogenesis of GD. In the context of the present study, the main focus is on one important person variable mentioned within the I-PACE model, namely personality (A prominent model to explain the development of GD (and other Internet and media-related use disorders) represents the I-PACE model . The modsonality . Personasonality . In the sonality . The thesonality , 9. A resonality . Howeversonality , 9. Nevesonality , 12. Howsonality . TherefoSocial Learning Theory  Higher neuroticism and lower conscientiousness are linked to higher GD tendencies in children.ii) Parents reporting to play computer and video games are more likely to have children who play computer and video games as well.iii) Tendencies to GD of parents and their children are positively correlated with each other.It has to be mentioned that the present work is part of a larger project, and first results were already presented in Wernicke and Montag  to the pvia a two-part parental online survey between February 2020 and June 2021. The study was advertised in schools, kindergartens, an online platform of pediatricians, and via different online media channels . In the first part of the survey, children's personality and gaming behavior were assessed; in the second part, parents' gaming behavior was of interest. Participation was anonymous. All participants provided electronic consent before filling in the survey. The present study was approved by the local Ethics Committee of Ulm University, Ulm, Germany, in August 2018 (253/18).Data were collected N = 493 German parents  participated in the present study. Inclusion criteria were a child's minimum age of 3 years, available data for both parts of the survey, and no double participation. Double participation was checked with a yes/no item “Did you participate in this study before?”. If former participation was stated with “yes”, the date of former participation was asked. If a date different from the recruiting phase of the study (February 2020 to June 2021) was stated, participants were included in the data analyses. Every parent filled in the survey for only one child. Parents of several children could decide themselves for which child they fill in the survey. Therefore, data of N = 493 children were available .In total, n = 249 parents and their children were already included in the paper by Wernicke and Montag  parents and for n = 247 (50.1%) children. The overlap of gaming parents and gaming children within the same family was n = 127. Tendencies toward GD were assessed by the Gaming Disorder Test (GDT) (n = 247), an external report with a German modified version of the GDT suitable for parents was used (2(2) = 83.191, p < 0.001; CFI = 0.817; TLI = 0.451; RMSEA = 0.405; SRMR = 0.102], but the factor loadings of all items were acceptable  and in accordance with the reported loadings by Pontes et al. (2(2) = 19.959, p < 0.001; CFI = 0.934; TLI = 0.802; RMSEA = 0.215; SRMR = 0.049], with factor loadings of λ1 = 0.687, λ2 = 0.774, λ3 = 0.779, and λ4 = 0.662.It was separately asked for children  and parents (self-report) if online and/or offline video/computer games were played at least occasionally within the last 12 months (yes/no question). That was the case for st (GDT) . For gamwas used . Both veBig Five Inventory (BFI) by John and Srivastava (2(892) = 2,871.060, p < 0.001; CFI = 0.763; TLI = 0.748; RMSEA = 0.067; SRMR = 0.091].Children's personality was assessed as an external report. To do so, a version of the ivastava  for pareivastava . The parParents' age as well as children's age and gender were considered as control variables. It was not possible to control for parents' gender due to the high number of participating mothers.2 test of independence, and Mann–Whitney U-tests. All significances were tested two-tailed. As parent's age, children's age, as well as children's gender were associated with some variables of interest, these variables were controlled in further analyses if this was possible. Associations between children's personality and GDT scores were analyzed via partial Spearman rank correlations (controlled for children's age), separately for boys and girls and for reasons of completeness also for boys and girls together. Given the directed hypothesis, correlations with neuroticism and conscientiousness were performed one-tailed; correlations with extraversion, agreeableness, and openness to experiences were performed two-tailed instead. With χ2 tests of independence, it was investigated if general parental and childhood gaming were independent of each other . While doing so, one χ2 test was conducted in the independent replication subsample of n = 244, which was not included in Wernicke and Montag . Again, correlation analyses were performed twice: once in the independent replication subsample, which was not included in Wernicke and Montag . All statistical analyses were conducted using SPSS 26 with the exception of the CFAs that were performed in R using the package lavaan . Children playing computer and video games had older parents  and were older themselves  than children who were not gaming. Furthermore, children's age correlated significantly with children's GDT score , with extraversion , and with neuroticism .Parents' age correlated significantly negatively with the parental GDT score  = 4.48, p = 0.034]. Boys had also significantly higher GDT scores than girls. On the contrary, boys had significantly lower scores for agreeableness, conscientiousness, and openness to experiences than girls. After Bonferroni correction for multiple testing to α of 0.007 (0.05/7), the gender difference for agreeableness was not statistically significant anymore. Results of Mann–Whitney U-tests regarding gender differences are presented in More boys than girls were playing computer and video games  as well as in the independent replication subsample of n = 244 . In detail, the χ2 tests of independence showed that more children were gamers when their parents were gamers, too, and vice versa, more children were non-gamers when their parents were non-gamers as well . This was also the case when performing the correlation analyses separately for gaming boys  and gaming girls .Furthermore, when considering the total sample the GDT scores of gaming parents and of their gaming children were positively correlated . This was also the case when correlation analyses were performed separately for gaming boys  and gaming girls . After Bonferroni correction for multiple testing to alpha of 0.008 (0.05/6), correlations of the independent replication subsample were not statistically significant.In the independent replication subsample the GDT scores of gaming parents and of their gaming children were also positively correlated , less empathic and cooperative (lower agreeableness), and more introverted (lower extraversion). As the present study is of correlative nature, it is not possible to determine if these manifestations of personality traits are a result of excessive gaming or if these provide a disposition toward GD. In line with the I-PACE model, we would expect the latter to be true ; hence, Social Learning Theory (Moreover, even though personality is of relevance to understand the etiogenesis of GD, it is only one relevant factor among many. In the present work, we therefore aimed to shed light on a further factor, namely parental gaming, while we especially focused on the relationship between parental and childhood gaming. We hypothesized parental and childhood gaming to be interdependent. The results support this hypothesis as gaming parents were more likely to report that their children are gaming as well. Additionally, the GDT scores of parents and their children were positively correlated with each other. The results replicate the findings by Wernicke and Montag  and otheg Theory , 21, it One strength of the present study is the investigation of three potential risk factors that might be related to children's tendencies to GD, namely high neuroticism, low conscientiousness, and parental gaming. Actually, these hypothesized relations were supported by the findings of the present work. This is an important contribution in understanding the etiology of GD. Furthermore, the replication of the findings by Wernicke and Montag  regardinvia self-report (But the present study also has some shortcomings. One limiting factor is that frequency and duration of gaming were not assessed, neither for children nor for parents. However, the amount of time spent gaming is not an indicator for GD but clearly accompanies a problematic gaming behavior . Moreovef-report . Anotherf-report . But perf-report . Also tef-report , 36 and f-report . TherefoGaming—hence playing computer and video games—is already popular in young children. But there is a risk that children develop an excessive or problematic gaming behavior. Therefore, the present study investigated the relationship between tendencies to GD and two of its possible vulnerability factors: children's personality traits and parental gaming. As in adolescents and adults, higher neuroticism and lower conscientiousness were related to higher GD tendencies in children. Additionally, associations of higher tendencies towards GD with lower extraversion, agreeableness, and openness to experiences were present. But these links of personality traits and GD need to be further investigated regarding their robustness in childhood as these relations were not hypothesized in the present work. Moreover, gaming behavior of parents was positively associated with children's gaming, too. The findings of the study add to the literature that already in children relations between personality traits and gaming behavior exist and that parents' gaming behavior can be a vulnerability factor for disordered gaming in children. In the future, research projects with a longitudinal design are of importance to understand the causality behind the reported findings.osf.io/ev93y.The raw data supporting the conclusions of this article is provided here: The studies involving human participants were reviewed and approved by Ethics Committee of Ulm University, Ulm, Germany. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.JW and CM designed the present study and drafted the present manuscript. JW conducted the data collection and performed the statistical analyses. The final version of the manuscript was approved by both authors.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.