The patients with HIV-associated neurocognitive disorder (HAND) are often accompanied by white matter structure damage. Diffusion tensor imaging (DTI) is an important tool to detect white matter structural damage. However, the changes in DTI values reported in many studies are diverse in different white matter fiber tracts and brain regions.Our research is dedicated to evaluating the consistency and difference of the correlation between HAND and DTI measures in different studies. Additionally, the value of DTI in HAND evaluation is used to obtain consensus and independent conclusions between studies.We searched PubMed and Web of Science to collect relevant studies using DTI for the diagnosis of HAND. After screening and evaluating the search results, meta-analysis is used for quantitative research on data. Articles that cannot collect data but meet the research relevance will be subjected to a system review.p < 0.0001) and higher mean diffusivity (standardized mean difference = 0.04 p < 0.0001) than the healthy control group in corpus callosum. In other white matter fibers, we found similar changes in fractional anisotropy (standardized mean difference = −1.18 p < 0.0001) and mean diffusivity (standardized mean difference = 0.69 p < 0.0001). However, the heterogeneity (represented by I2) between the studies is high . After subgroup analysis, the heterogeneity is obtained as 19.5, 40.7%  and 0, 0% .The meta-analysis shows that the HAND group has lower fractional anisotropy (standardized mean difference = −0.57 The changes in white matter fibers in patients with HAND are statistically significant at the observation level of DTI compared with healthy people. The differences between the studies are mainly derived from demographics, start and maintenance time of antiretroviral therapy, differences in nadir CD4+T cells, and the use of different neurocognitive function scales. As an effective method to detect the changes in white matter fibers, DTI is of great significance for the diagnosis of HAND, but there are still some shortcomings. In the absence of neurocognitive function scales, independent diagnosis remains difficult.Systematic Review Registration:https://inplasy.com/inplasy-2021-10-0079/. The emergence of combined antiretroviral therapy (cART) has resulted in a significant increase in the life expectancy of patients with acquired immunodeficiency syndrome (AIDS) in the past two decades . The incIn the diagnosis of cognitive impairment, both cognitive scales and imaging tests play an important role. The International HIV Dementia Scale (IHDS) is currently widely used, which includes attention, memory recall, and psychomotor speed. Compared with the Frascati standard, IHDS shows better sensitivity and specificity .in vivo (Diffusion tensor imaging uses the anisotropy of the dispersion of water molecules inside the white matter fibers (WMFs) and uses the average diffusion direction information of adjacent voxels through the continuous tracer fiber allocation algorithm to reconstruct the structure and shape of the WMF, and then, imaging method shows the three-dimensional distribution of white matter fiber bundles in vivo , 13. Amoin vivo –16. A main vivo –19 reporin vivo , 21. Corin vivo –25 have in vivo –28 showsin vivo , 30. Thein vivo , 32 repoThere are also differences in the application technology of DTI between different studies. The more common analysis methods of DTI are the traditional voxel-based analysis (VBA) method and the skeleton-based spatial statistics  method, and the latter is more widely used. Compared with the traditional voxel-based measurement method, Fixel-based analysis (FBA) , which hTherefore, based on the diversity of parameters, demographic application models, and outcomes of DTI in the diagnosis of HAND, we believe that it is meaningful to conduct a meta-analysis and system review of related studies. We will examine the correlations between DTI parameters, diagnostic criteria for cognitive impairment, and serum viral markers to obtain consensus and independent views between studies.To summarize the relevant research literature on the related application of DTI in HAND, we used an advanced search on the PubMed database and the Web of Science database on 30 September 2021, through use the term of “ (‘HIV-associated neurocognitve disorder' [MeSH Terms] OR ‘HAND' [All Fields] OR ‘HIV' [All Fields]) AND (‘Diffusion Tensor Imaging' [MeSH Terms] OR ‘DTI' [All Fields] OR ‘Magnetic Resonance Imaging' [All Fields] OR ‘neuroimaging' [All Fields]),” (((TS=(DTI) OR TS=(Diffusion Tensor Imaging) OR TS=(MRI) OR TS=(neuroimaging)) AND (TS=(HIV) OR TS=(HIV-associated neurocognitive disorder) OR TS=(HAND) OR TS=(cognitive impairment))). The search criteria are the documents from 2013 to 2021. The literature search produced a total of 104 records, by reading the abstract, of which 67 records were excluded due to the following reasons: (1) duplicate literature, (2) the study was conducted in mice or rhesus monkeys, (3) the records were case reports, and (4) the records were reviews, (5) the study has no control group, (6) the research participants are not infected with HIV virus, and (7) the literature topics and imaging examinations are less related.We retrieved a total of 37 eligible full-text articles, all of which belonged to cross-sectional studies or cohort studies. We read through the full text, and once again ruled out 15 articles due to the following reasons: 1. Research participants also suffer from neurodegenerative diseases such as Alzheimer's disease, Parkinson's disease, cerebrovascular disease. 2. Research participants also suffer from syphilis, hepatitis B, hepatitis C, and other diseases. 3. multi-modal research but incomplete experimental results involving DTI. 4. Research using resting state functional magnetic resonance imaging or 3D-T1 mapping and other sequences. 5. The main research direction is the aging of brain structure status. Of the remaining 22 articles, 12 articles can be collected with comprehensive and complete FA and MD values, including the CC, FX, anterior commissure (AC), association fibers, and projection fibers. We included these 12 articles in the meta-analysis. Due to the unique role of the CC in brain structure and cognitive function, the FA and MD values were separately extracted in the form of mean ± SDs. All data are from the table of the article. The remaining 10 articles cannot be extracted with complete data due to the following reasons: (1) The researcher only reported the FA value and MD value of the whole brain or a part of the brain area; (2) the researcher's main direction of study is the value of DTI parameters and serum sickness. There will be the correlation between the viral indicators and the test scores of each neurocognitive scale. We conducted a system review of these 10 articles .2 all indicated heterogeneity between studies, and the I2 result was more meaningful. I2 is used to evaluate the heterogeneity of the results and draw forest diagrams and funnel diagrams  refers to the number of variables that can take unlimited values when calculating a statistic. Test for overall effect is reflected by the p-value. When p is >0.05, the combined data are considered to be not statistically significant , including 7 indicators such as participant selection, exposure, and comparability control for important factor and for quality evaluation. We summarize all relevant research in inclusion analysis, including the statistical characteristics, research type, basic parameters of magnetic resonance, treatment or not, whether neuropsychology (NP) and cognitive function scale test, and region of interest (ROI) . Due to diagrams . It is gnificant , 61. DueFirst, we evaluated the included articles with the NOS, which confirmed to the quality evaluation standards of cross-sectional studies or cohort studies. Each item can be divided into three grades: excellent, ordinary, and not mentioned, corresponding to 2 points, 1 point, and 0 point, respectively. The eligibility standard for literature is 5 points or more. According to statistics, all the 22 documents included in the meta-analysis and system review meet the conditions.By pooling, these studies included 702 patients with HIV+/HAND and 346 healthy controls. The age range of the patient group was 4–77 years, with an average age of 48.52 years. The age range of the control group was 3–73 years, with an average age of 46.21. Of these studies, three were in adolescents and children, one was in young adults, and the rest were in middle-aged and elderly patients.Z = 1.86(p = 0.06), with high study heterogeneity  and I2 = 94% (variation in SMD attributable to heterogeneity). The Tau-squared of between-study variance was 0.12. Among the ten studies included in the analysis, five studies have a confidence intervals of zero.In the CC, patients with HAND and HIV-seropositive have a significant reduction in FA , test for overall effect: Z = 2.63 (p = 0.008), with high study heterogeneity  and I2 = 88% (variation in SMD attributable to heterogeneity). The Tau-squared of between-study variance was 0.00. Among the 10 studies included in the analysis, six studies have a confidence interval of zero.Also in the CC, patients with HAND and HIV-seropositive have an increase in MD , test for overall effect: Z = 3.67 (p = 0.0002), with high study heterogeneity  and I2 = 95% (variation in SMD attributable to heterogeneity). The Tau-squared of between-study variance WMF was 1.05. Among the 11 studies included in the analysis, six studies have a confidence interval of zero.Different from the CC, the FX, AC, association fibers, and projection fibers differ greatly in the image acquisition area and ROI selection in various studies. FA and MD values are not suitable for simply taking the arithmetic mean. In statistics, inverse-variance-weighting is a method of performing a weighted average of the measurements of a random variable. Each smaller ROI was weighted by the inverse of its variance in the random effects model of this study. This method minimizes the variance of the mean and makes the results more accurate. For studies with only the median, regardless of whether the samples meet the normal distribution or not , first pZ = 4.01 (p < 0.0001), with high study heterogeneity  and I2 = 81% (variation in SMD attributable to heterogeneity). The Tau-squared of between-study variance was 0.25. Among the 10 studies included in the analysis, five studies have a confidence interval of zero , test for overall effect:  of zero .2 = 19.5. MD in CC, test for subgroup differences: I2 = 40.7 . FA among others WMF test for subgroup differences: I2 = 0 . MD among other WMF, test for subgroup differences: I2 = 0 . The significant reduction in the heterogeneity of the subgroup analysis indicates the correctness of the subgroups. It also proves that the above grouping basis is the source of heterogeneity. The funnel plot showed that the asymmetry between studies was more pronounced in FA values than in MD values, because the two funnel plots associated with MD values have more studies with built-in confidence intervals than the two funnel plots associated with FA values, suggesting a greater publication bias. We used the cut-and-complement method to eliminate the studies with large deviations from the mean. We tried to exclude studies that were far from the confidence interval in the two analyses related to the FA value [FA in CC except , current CD4 count (range 230.4–980*106/L), cART duration (range 0–72 months), cognitive scale test . There is high heterogeneity in FA and MD values among the four groups of studies. These differences in white matter microstructures between groups may be caused by changes in the above-mentioned image acquisition parameters or biological variables.Although the main reason for the high heterogeneity was not found in the funnel chart, we still summarized the differences in acquisition parameters, demographics, serology, and treatment time between studies in the extraction stage before the included studies. The field strength (range 1.5T−3T), number of diffusion directions (range 6–64), age of participants (range 4–69 years), nadir CD4 count (range 33.5–221.8Z = 1.21(p = 0.22), with high study heterogeneity and I2 = 92%; MD value in CST , test for overall effect: Z = 6.99 (p < 0.00001), with low study heterogeneity  and I2 = 29%; FA value in SLF , test for overall effect: Z = 6.46 (p < 0.00001), with low study heterogeneity  and I2 = 23%; MD value in SLF , test for overall effect: Z = 6.45 (p < 0.00001), with low study heterogeneity  and I2 = 43%; FA value in IFOF , test for overall effect: Z = 7.29(p < 0.00001), with low study heterogeneity  and I2 = 0; MD value in IFOF , test for overall effect: Z = 4.95 (p < 0.00001), with low study heterogeneity  and I2 = 53%. The results revealed that the heterogeneity of FA values and MD values in the rest regions of interest was low, except for the higher heterogeneity of FA values in the CST region and the slightly higher MD values in the IFOF region. This suggests that although there are differences between studies in larger regions such as the CC or other projection fibers, associative fibers, the consistency of findings between the selected smaller regions of interest is high.Meta-analysis results of FA and MD values in CST, SLF, and IFOF show : FA valuDespite the studies included in the analysis have carried out tracing of WMF in the whole brain area, the differences in measurement parameters such as b value and diffusion directions have led to the white matter in different areas under the premise of similar biological conditions. Fiber DTI parameters still have high heterogeneity, which is unavoidable in subgroup analysis. In terms of the trend of this difference, the integrity of the CC is better than other commissural fibers, association fibers, and projection fibers. Therefore, except for the CC, our unified analysis of other WMF will minimize the differences between different studies due to different image acquisition parameters and then infer the main source of heterogeneity between studies. There is less heterogeneity between studies in smaller ROIs than in CCs or other larger white matter tracts, which may suggest that differences in subjects, parameters, and methods between studies have less effect on smaller ROIs, whereas such differences in CC would have additive effects, increasing heterogeneity between studies. Taking into account some regional differences in the measurement, the observed heterogeneity of the CC and other WMF between FA value and MD value groups may also be due to the sampling of different WMFs in different studies. To more closely study the changes in the CC of FA value and MD value that are related to the cognitive impairment status under HIV infection, we repeated the measurement several times and adopted the fixed-effects model and the random-effects model, respectively, and obtained higher levels in CC, FA value, and lower MD value. As far as the inside of the CC is concerned, the degree of change in the genu and body is higher than that of the splenium. In addition to the differences in DTI parameters between studies, neurocognitive function scales and age are decisive factors for high heterogeneity between studies, and factors such as cART drug selection and duration, and the number of CD4+ T cells also play an important role.Among the 10 articles excluded from the meta-analysis, eight studies suggested that the difference between FA value and or MD value between patients with HAND and the control group was statistically significant, and one study concluded that AD value at the ANI stage the reduction was limited to the left anterior thalamus the fronto-occipital lobe, and the left SLF, and the FA value, MD value, RD value, and AD value were not significant , 51, 64.A total of three studies involved follow-up and longitudinal studies. The participants included children, adolescents, and the elderly , 46. In There are two studies that quantitatively analyze the length and integrity of WMF. Woodruff measured the whole brain fiber length and the length of 6 white matter tracts on 135 patients with HIV-positive and 21 healthy controls and found that the whole brain fiber length was significantly reduced, but the average of the 6 white matter tract lengths was not significantly different . AlthougAll study participants are on antiretroviral therapy. Some studies have found that as the duration of antiretroviral therapy increases, the FA value will increase and the MD value will decrease compared to the acute infection period of HIV , 64. HowEmotional change is often one of the manifestations of cognitive impairment, and it is also a symptom that is relatively easy to find clinically. Some studies have taken a different approach . By condMeta-analysis results showed that compared with the control group, the DTI parameters of the whole brain of patients with HAND showed a trend of decreasing FA value and increasing MD value. The change value of the CC is more obvious than that of other fibers, which is also a strong evidence of the microstructure damage of white paper fibers –68. HoweA large number of studies have proved that the changes in DTI parameters of neurodegenerative diseases including HAND are mainly FA and MD values . The chaThe changes in DTI parameter values of patients with HAND in each stage are different. Cysique found that the DTI parameter value of the white matter fiber tracts of patients in the ANI stage was close to normal, and only the difference in the MD value of anterior limb of internal capsules (ALICs) was statistically significant . CompareUnlike common cognition, neurocognitive impairment caused by HIV infection can also occur in adolescents and children. Hoare found that among children aged 6–16, whether they experience cART or not, the integrity of WMF and neurocognitive functions is impaired, and a considerable number of people suffer from HIV-encephalopathy (HIVE). Compared with the uninfected group, patients in the infected group had higher MD values of bilateral EC, left FX, CC, and left former corona radiata area . CompareFor the elderly, the source of cognitive impairment in patients with HIV-positive not only comes from inflammation in the brain caused by viral infection, but may also come from other neurodegenerative diseases. This may be a huge blow to the cognitive function of the elderly , 85. UndPartial immune reconstitution is an inevitable process in patients with HIV undergoing antiretroviral therapy. However, some studies have suggested that partial immune reconstitution also seems to be one of the conditions that induce cognitive impairment. Zhu's research  suggestsThe neurocognitive scale is an important tool for evaluating cognitive impairment, and it cooperates with DTI to complete the diagnosis of HAND. Dreyer used 20 different methods to diagnose HAND on 148 HIV-positive participants and obtained patient's white matter and gray matter images. The accuracy of the 20 different methods was between 20 and 97%, and a single neurocognitive amount table assessment or DTI examination and the accuracy of reflecting the cognitive deficits of patients with HIV are relatively poor . The curCurrent researches believed that retinopathy is related to brain white matter fiber damage, so some research has taken a different approach , 94. BloSmoking or the abuse of other addictive drugs  may aggravate the cognitive impairment of patients with HAND, and more and more studies are now focusing on this , 97. LiaDiffusion tensor imaging is the most classic and clinically widely used diffusion imaging technique. It has good sensitivity for white matter microstructural abnormalities, but its specificity is not high enough. In DTI data interpretation, the most common misconceptions relate to scalar  results. In general, higher MD values and lower FA values indicate compromised fiber integrity due to increased diffusion in the main fiber direction and loss of fiber myelination . HoweverThrough meta-analysis and system review, we have obtained the changes in DTI parameter metrics of patients with HAND. Although there is still great heterogeneity between the studies, the changes occurred in parameter values  and cognition. There is a significant correlation with functional impairment, which is more obvious in the CC. The degree of cognitive impairment is also related to the factors such as cART duration, neurocognitive scale selection, serum viral load, and CD4+T cell level. DTI can be an important tool in the diagnosis of HAND, but it has disadvantages such as poor specificity, many artifacts, and susceptibility to cross-fiber interference. Moreover, HAND cannot be accurately diagnosed by DTI examination or neurocognitive scale test alone. It must be combined with other imaging methods and clinical laboratory tests to effectively evaluate cognitive impairment and structural changes in the brain in patients with HIV.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.JM is responsible for article writing and data collection. FX is responsible for finding references. XY is responsible for the use of meta-analysis methods. HL is responsible for guiding the ideas and writing directions of the article. All authors contributed to the article and approved the submitted version.This work was supported by the National Natural Science Foundation of China (Grant Nos. 81771806 and 61936013), the Beijing Natural Science Foundation (7212051), AI key R&D project of Beijing Municipal Science and Technology Commission (Z211100003521003), Ministry of Science and Technology International Cooperation Project (2020ZX100), and Key R&D chief project of the Ministry of Science and Technology (2020ZX178).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. 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Canada’s operation in Afghanistan has been unfolding during a critically important domestic political event, i.e., the federal elections of 2021. The election campaign had pooled the main attention and resources of the Canadian leadership, limiting its ability to act in Afghanistan. Despite the difficulties, the Liberal Government of Justin Trudeau has achieved a lot. Firstly, they have organized the evacuation of Canadians and of Afghans who worked with the Canadian Armed Forces during the US and NATO military mission. Secondly, Ottawa has defined its attitude towards the Taliban regime by refusing diplomatic recognition. Thirdly, the admission of Afghan refugees to Canada has begun. In each of these areas, the Liberal Government has successes and failures, which have caused acute controversy in the country. The 2021 election campaign in Canada coincided with two mutually related events having a strong international resonance: firstly, the seizure of power by the Taliban in Afghanistan and, secondly, the completion of the withdrawal of American troops from this country. Amid reports about the election battles, the Canadian media regularly published chilling accounts of desperate attempts by Afghan nationals to flee their country, conquered by the Taliban.Ottawa was directly involved in the Afghan events. Canadians took the terrorist attacks of September 11, 2001 in the United States as a blow to all Western democracies and to their country in particular, especially since over 30 Canadians died that day at the World Trade Center in New York. Political figures in Canada repeatedly raised the idea of retaliation for the dead by participating in the 2001–2011 Afghan mission.This operation has become Canada’s largest military campaign since the Korean War of 1950–1953. In terms of duration , this operation has exceeded the country’s participation in the First and Second World Wars combined .Canada was among the first countries to contribute its armed forces and civilian advisers in the fall of 2001 to support the US counterterrorism operation. In 2003–2004, Canada, along with the United States, played a decisive military role on this axis, and the Canadian contingent accounted for about 40% of all International Security Assistance Forces (ISAF) . The operation required large-scale financial resources. About CA$ 18.5 billion were spent on it . Grievous statistics should be given too: 165 Canadians died in that campaign and about 2000 were injured. Moreover, most of the Canadian military personnel were concentrated in Kandahar, the most dangerous province with the largest concentration of the Taliban.nation building in Afghanistan, taking the lead in education investment. It should be noted that in those years, Afghanistan was the main recipient of Canadian development assistance, $3.6 billion from 2001 to 2011 . The focus of Canadian assistance projects was on protecting women’s rights and promoting gender equality.In addition to military participation in the Afghan operation, Canada was one of the top five donors supporting the so-called The withdrawal of US troops from Afghanistan, which ended in August 2021, opened a new page in Canada–Afghanistan relations. The situation in Afghanistan required quick decisions from Ottawa, provoked controversy among the participants in election debates, and made the media headlines.By August 31, 2021, the armed forces of the United States and its allies left Afghanistan, drawing a line under their 20-year military presence in this country. The withdrawal of American troops began under President Barack Obama (2009–2017) and continued under Donald Trump (2017–2021). This operation was finally wound up under the administration of Joe Biden , who repeatedly announced the terms and conditions for ending the Afghan operation. Despite the lengthy process and the numerous tips-off from American officials, Canada found itself unprepared for the new challenges in the Afghan agenda of its foreign policy.The Taliban seized power on August 15, the day Canada announced federal elections to the parliament. Prime Minister Justin Trudeau faced the difficult task of working on two fronts: the Afghan and domestic political agenda. Each area required a large concentration of human, material, and organizational resources. Information was leaked to the press that Trudeau attempted to postpone the withdrawal of Canadian troops from Afghanistan but received a categorical refusal from Washington [10]. Canada had to act exactly according to the American timetable. At the request of the United States, Canada stopped the evacuation of civilians from Afghanistan the day before the official deadline to free up airspace for American aircraft.Observers also pointed out another fact. On the eve of the Group of Seven (G7) Summit in August 2021, Biden personally consulted on the Afghan issue with the leaders of the closest NATO allies: Britain, Germany, France, and Italy. Canada was not part of the discussions, another sign of its diminishing role in international affairs and in the US–Canada dialogue.The main issue Ottawa faced when the Taliban came to power in Afghanistan was the evacuation of Canadians and of those Afghan nationals who worked with Canadian military and civilian agencies. In a statement signed by three Canadian ministers—Foreign Affairs; National Defense; and Immigration, Refugees, and Citizenship—the government condemned the escalating violence in Afghanistan, especially against women, girls, and ethnic minorities. It also announced a suspension of the embassy’s operations and promised to ensure the admission and safety of the Afghans who cooperated with Canadian representatives [3]. The embassy staff immediately left Afghanistan.Trudeau signed the resolution adopted at the end of August 2021 by the heads of more than 90 countries worldwide on coordinated efforts to create conditions for the unhindered exit from Afghanistan of their countries’ nationals and of Afghan nationals of two categories: those who were part of the risk groups and those who assisted Western countries in fulfilling their mission. This classification set the framework for the Canadian admission policy for immigrants and refugees from Afghanistan.Unlike some other top public officials who considered the possibility of interaction with the Taliban, Trudeau immediately announced that his administration did not plan to recognize the new government of Afghanistan. He recalled that Canada refused to interact with the former Taliban regime, which was in power in 1996–2001, having declared their movement a terrorist organization [2].The Prime Minister’s stance caused a mixed response in Canada. Most of the political elite and the public supported the diplomatic boycott of the Taliban and objected to their removal from the list of terrorist organizations. However, advocates of a different approach also came forth. Thus, Maryam Monsef, a Canadian politician of Afghan origin, who held various positions in Trudeau’s cabinet, called the Taliban “our brothers” during an official briefing. Monsef has paid for her statement—many observers believe it was the real reason why she lost in her own constituency at the 2021 elections.Dissenting points of view also exist in the academic community. Some insist on working with the Taliban, including Colin Robertson, a former diplomat, now Vice President of the country’s leading think tank—the Canadian Global Affairs Institute. He believes that diplomatic recognition should not be seen as a “seal of approval” of the Taliban policies, but rather as a means to protect and advance Canada’s national interests. Firstly, Canada has invested heavily in Afghanistan in terms of material and human resources, and now, in tandem with the United States and other allies, Canada must help the new government maintain the achievements of the previous years and continue the unfolding reforms. Secondly, the evacuation from Afghanistan is not complete yet, and the success of this process hinges on the interactions with the Taliban. Thirdly, Ottawa needs to work with the Taliban to achieve its main foreign policy goal, i.e., restoring the role and influence of Canada on the world arena. One of its priorities is to expand Canada’s “presence on the ground” in different parts of the planet. Canada has experience in developing diplomatic relations with “unfriendly regimes,” e.g., the recognition of China in 1970 and the renunciation of the trade, economic, and diplomatic boycott of Cuba in 1961. After establishing relations with the Taliban, Canada should resume diplomatic relations with North Korea and Iran, sums up Robertson [12].The Canadian Air Force has finished its operation to evacuate people from Afghanistan, having performed 17 flights and bringing about 3700 Canadians and Afghans to the Canadian territory. The newcomers were provided accommodations in British Columbia, Alberta, Manitoba, Ontario, New Brunswick, and Prince Edward Island. In addition, Ottawa committed to take in 5000 Afghan refugees in the near future, who were evacuated by American aircraft to the United States or to US and NATO military bases in other countries. For reference: these bases are located in Qatar, Bahrain, Kuwait, the United Arab Emirates (UAE), Saudi Arabia, Germany, Spain, and Italy; at these locations, the Afghans go through security checks before being taken to the United States.There are two important promises made by Ottawa. In line with the “sunny ways” policy, based on humanitarian and liberal values, which was the hallmark of Trudeau’s course in previous years, the government declared commitment to accept 20 000 Afghan refugees. The Liberal Party’s platform mentioned 20 000 to 40 000 Afghan migrants. Marc Garneau, the Minister of Foreign Affairs of Canada, announced at the UN the finally agreed number of 40 000 people [1]. In addition, Ottawa provided $50 million in humanitarian aid [8].This humanitarian message won the approval of nongovernmental organizations involved in protecting the rights of immigrants and refugees. Meanwhile, the rushed campaign to evacuate civilians from Afghanistan, amid chaos and confusion, left many questions unanswered. One such question is how the repatriation of Canadian citizens remaining in Afghanistan will take place. According to official data, as of September 2021, more than 1200 Canadians, their families, and persons with a residence permit in Canada stayed on the territory of Afghanistan [8]. When questioned, officials got away with vague statements about coordinated efforts with their allies to ensure the security and safety of civilians and save the lives of Afghans.Assessing the results of the operation to evacuate civilians who were willing to leave Afghanistan, it should be noted that Canada was not among the leaders in terms of the number of evacuated civilians . According to Reuters [15], as of August 30, 2021, the United States was ranked first according this indicator by a wide margin (114 000). Qatar and the UAE helped evacuate, respectively, more than 40 000 and about 36 500 people. Among the G7 countries, Canada (3700) was ahead of only France (3000) and Japan (less than 500 people), falling behind Britain (315 000), Germany (5347), and Italy (5011).Let us revisit to the issues around the early parliamentary elections in Canada. It is known that Canadians, as one journalist put it figuratively, “vote with their wallets.” That is to say, they focus on the socio–economic and financial aspects of party programs, without taking much interest in their foreign policy aspects. The events in Afghanistan somewhat changed this unwritten rule. Although the COVID-19 pandemic remained the central theme of the election battles, foreign policy issues also played a prominent role. Together with Afghanistan, debates focused on the development prospects of Canada–China relations, the fight against global warming, environmental protection, and the protection of sovereignty in the Arctic.The Afghan operation stood as a separate issue during the debates of political party leaders in September 2021: Justin Trudeau , Erin O’Toole (Conservative Party), Jagmeet Singh (New Democratic Party), Yves-François Blanchet (Bloc Québécois), and Annamie Paul (Green Party). Unlike the 2015 elections, when the divide between the parties ran on the number of Syrian refugees being admitted, the 2021 debates centered on the lessons and shortcomings of the evacuation campaign itself. Understandably, Trudeau focused on the achievements of Canadian military and civilian personnel, who managed to save the lives of thousands of people.All other politicians unanimously criticized the government for the untimely elections. O’Toole accused Trudeau of “political selfishness” and unwillingness to abandon the power struggle for the sake of ending violence and ensuring the safety of the Afghans. Furthermore, O’Toole and Singh reproached the government for sluggishness, poor organization of the campaign, lack of coordination in the actions of the various ministries and departments, and bureaucratization of the refugee status application processing. Paul, the Green Party leader, pointed out shortcomings in the operations of the intelligence service, noting sarcastically: “It seems like we got better information on our smartphones than Mr. Trudeau got from our entire intelligence service” [4].Opinion polls indicated that Canadians were generally dissatisfied with the government’s efforts to evacuate civilians from Afghanistan. According to the Angus Reid Institute, the number of respondents who called the government’s actions “successful” was close to zero (2%); 37% considered the operation “a failure”; 20% restrained from judgment; and 41% of those surveyed said that the operation went “as well as can be expected.” This view was shared by the electorate of the Liberal Party, the New Democratic Party, and the Bloc Québécois, while 37% of Canadians supporting the Conservative Party called the operation “a failure.” An indicator of the generally negative attitude among the public towards government policy is the opinion expressed by half of the respondents that Canada should leave Afghanistan permanently [9].Dissatisfaction with the process and outcomes of the evacuation from Kabul was elicited in the results of another survey. It was conducted by Nanos Research and found that 45% of respondents rated the government performance “poor” or “very poor” . Men tend to be more disapproving of the country’s leadership than women; i.e., 52% of the men and 38% of women surveyed believe that the government did a “poor” or “very poor” job [11].Criticism and harsh judgments of Trudeau were undoubtedly justified. The evacuation campaign was indeed fraught with organizational blunders, strategic mistakes, and attempts to shift obligations to partners .However, it is also true that Trudeau has achieved much. First of all, in the number of people evacuated, i.e., a quantitative indicator of the operation performance, Canada was ahead of many NATO members, including, as mentioned above, two G7 members. Moreover, Canada operated in very difficult conditions. Firstly, it was one of the first countries to cease its participation in the NATO military operation in Afghanistan. After that, the ties between Canada and Afghanistan weakened, and the Afghan issue virtually disappeared from Ottawa’s political agenda. As a result, the Canadian military worked in an unfamiliar environment during the evacuation. Secondly, it so happened that the Afghan operation unfolded during a major domestic political event in Canada, i.e., federal elections. They pooled the main attention and resources of the Canadian leadership. All these factors should be taken into account when analyzing the achievements and costs of Trudeau’s mission in Afghanistan.The Ministry of Immigrants, Refugees, and Citizenship developed two programs to receive Afghan migrants. The first one was called the Immigration Program for Afghans Who Assisted the Government of Canada [6]. To be eligible, an applicant must meet the following criteria:persona non grata by the immigration authorities of Canada. Three reasons were listed: security reasons ; medical reasons; financial reasons (inability/unwillingness of the applicant to support him/herself and family members). “Committing a crime, including driving while under the influence of drugs or alcohol” was indicated separately as a reason for inadmissibility. The program also covered the applicant’s family members: a spouse or common-law partner; a dependent child (grandchild) who must not be married or in a common-law relationship. The age requirement for the dependents was under 22 years. As of November 17, 2021, Canadian immigration services had registered 14 520 applications under this program; of these, 5000 were approved, and another 3460 Afghans entered Canada with refugee status [13].Firstly, the applicant must be an Afghan national who worked with the Government of Canada  and had to be in Afghanistan on or after July 22, 2021, i.e., the date the immigration program started. However, it was indicated that even if this requirement was not observed, the applicant could still expect his/her documents to be processed. The applicant must also be admissible to Canada, and the program guidelines explained in detail when someone could be found The second program is humanitarian in nature as it provides an opportunity for certain categories of Afghan nationals to resettle in Canada [5]. It covers the following Afghan nationals outside of Afghanistan: women leaders, human rights activists, representatives of persecuted ethnic and religious minorities, LGBT communities, journalists, and people who assisted Canadian journalists. To be eligible for resettlement in Canada, the applicant must comply with many formalities. Potential settlers may enter Canada under a government program or a private sponsorship program, each of which is valid for a year. Contacting directly the Ministry of Immigrants, Refugees, and Citizenship is not allowed. The applicant must first register for refugee status with the United Nations High Commissioner for Refugees (UNHCR) or the Immigration Service of the host country. Then, his/her documents are sent to Canada by one of these agencies or by an authoritative international public organization with which the Canadian government cooperates. The document package submitted under the private sponsorship program must also include an agreement signed by the sponsor on his/her commitments, including an attachment with a thorough list of services and expenses provided by the sponsor. Not surprisingly, due to the bureaucratic obstacles, only 400 people have been able to resettle in Canada under the humanitarian program [13].The humanitarian component of the Afghan operation was a continuation of Trudeau’s government’s immigration policy of previous years. It was recognized by the international community and experts as one of the most successful areas of the government work. The Liberals in power amended the Canadian Citizenship Act to expand the rights of migrants and refugees and brought the illegal migration from the United States under control. In 2018, Canada accepted a record number of Syrian refugees—instead of the promised 25 000 migrants from Syria by 2021, Canada provided asylum to 75 000 people, ranking first in this indicator worldwide [7].Canadian private sponsorship programs are particularly well known. In 1979, Canada became the world’s first country to “partially privatize” the admission of refugees. Under Canadian law, individuals, families, or groups of people can sponsor refugees and personally integrate them. In doing so, the government takes into account the sponsors’ choice regarding refugees. The sponsors, in turn, get used to living and communicating with people that represent a different culture. This practice allows Canadians to feel involved in political and global processes, gives them the opportunity to control immigration, and helps them fulfill their life purpose. Private sponsorship has reached such a scale in Canada that it has actually pushed the relevant state programs into the background. In 2019, only a third of the migrants received state assistance. The rest settled through the support of individuals or public organizations. The Canadian model of using private sponsorship in refugee admission has been rated highly by the UNHCR Office and other international structures. This practice formed the core of similar or fully analogous projects developed by France, Germany, New Zealand, and Spain .The government policy of accepting Afghan refugees, as well as the evacuation campaign from Afghanistan, has not escaped criticism, which culminated in a letter from authoritative political and public figures of Canada, who addressed Trudeau and the ministers of the leading foreign affairs agencies. The letter was signed by well-known politicians such as the former Foreign Minister Lloyd Norman Axworthy and Senator Ratna Omidvar, prominent scholars (including Prof. Fen Hampson), and representatives of major human rights organizations. While recognizing the merits of the Afghan admission programs, the authors of the letter pointed to serious shortcomings and recommended measures to eliminate them. In particular, they proposed to (1) “clarify Canada’s policy by defining its terms” ; (2) “devote significant resources needed to get the job done,” including extra human resources for processing the applications submitted by Afghans; and (3) “waive the requirement of UNHCR recognition, and recognize the Afghan crisis as a prima facie refugee situation” [14]. The UN documents provide for such a procedure—in emergency circumstances when a group of migrants is granted refugee status, each member of this group automatically receives this status. The use of the prima facie approach instead of granting the refugee status on an individual basis makes it possible to eliminate many bureaucratic requirements and significantly reduce the time for processing applications.The Afghan agenda of Ottawa’s foreign policy became a national priority of Canada after the Taliban seized power in Kabul in August 2021. The situation in Afghanistan required urgent action from the government, which organized the evacuation of Canadians and of Afghans who assisted the Canadian Armed Forces during the US and NATO military missions. Ottawa defined its attitude towards the Taliban regime by refusing diplomatic recognition. Canada began to accept Afghan refugees on its territory. In each of these areas, Trudeau’s government had successes and failures, which caused acute controversy in Canada.The domestic political context associated with the events in Afghanistan was out of the ordinary for Canada since the Afghan campaign coincided with the early federal elections to the Parliament of Canada. This whole situation, along with Canada–China relations, was vigorously debated during the election campaign. Judging by the public opinion polls, the events in Afghanistan, i.e., the withdrawal of American and NATO forces and the lightning-fast victory of the Taliban over the Afghan regular army, had a significant impact on the course of the election campaign. Trudeau had to address all these issues when determining the necessary actions and developing a policy since the Afghan agenda highlighted Ottawa’s foreign policy shortcomings, i.e., the decline in Canada’s significance in the world arena and in the US–Canada dialogue. These are the issues to be addressed by the third government of Justin Trudeau, who won the 2021 elections.1. Address by the Honourable Marc Garneau at the General Debate of the 76th United Nations General Assembly – “In Our Hands,” Global Affairs Canada, Sep. 27 (2021). https://www.canada.ca/en/global-affairs/news/2021/09/address-by-the-honourable-marc-garneau-pc-mp-minister-of-foreign-affairs-of-canada-at-the-general-debate-of-the-76th-united-nations-general-assembl.html. Cited October 20, 2021.2. Bensadoun, E., Canada has ‘no plans’ to recognize Taliban as Afghanistan government, Trudeau says, Global News. Aug. 17 (2021). https://globalnews.ca/news/8118905/canada-will-not-recognize-taliban/. Cited September 20, 2021. 3. Canada temporarily suspends operations at Embassy of Canada to Afghanistan, Global Affairs Canada Statement, Aug. 15 (2021). https://www.canada.ca/en/global-affairs/news/2021/08/html. Cited August 21, 2021.4. Draper, S., Federal Election 2021: The unexpected role of foreign policy, National, Sep. 16 (2021). https://www.national.ca/en/perspectives/detail/federal-election-2021-the-unexpected-role-of-foreign-policy/. Cited October 16, 2021.5. Humanitarian program for Afghan nationals in need of resettlement. Government of Canada. https://www.canada.ca/en/afghanistan/special-measures/about-humanitarian-program.html. Cited October 20, 2021.6. Immigration program for Afghans who assisted the Government of Canada. Government of Canada. https://www.canada.ca/en/immigration-refugees-citizenship/services/refugees/afghanistan/special-measures/immigration-program.html. Cited November 24, 2021.7. Kalata N., Syrian refugees reflect on a decade of war and their new lives in the Toronto area, CBC News, Mar. 15 (2021). https://www.cbc.ca/news/1.5947946. Cited July 15, 2021.8. More than 3000 Evacuees Arrive in Canada from Afghanistan. Immigration, Refugees and Citizenship, Sep. 3 (2021). https://www.canada.ca/en/immigration-refugees-citizenship/news/2021/09/more-than-3000-evacuees-arrive-in-canada-from-afghanistan.html. Cited October 17, 2021.9. Most say Canada should accept at least 20 000 Afghan refugees. Angus Reid Institute, Aug. 30 (2021). https://angusreid.org/afghanistan-evacuation-federal-election. Cited October 1, 2021.10. View: Canada’s national humiliation in Afghanistan, National Post, Aug. 28 (2021). https://nationalpost.com/news/politics/election-2021/np-view-canadas-national-humiliation-in-afghanistan. Cited August 30, 2021.11. Neustaeter B., Nearly half of Canadians say Liberal government did a poor job on Afghanistan evacuations: Nanos, CTV News, Sep. 3 (2021). https://www.ctvnews.ca/politics/1.5573006. Cited September 23, 2021.12. Robertson C., Practicing good diplomacy will require Canada to recognize the Taliban in Afghanistan, The Globe and Mail, Aug. 31 (2021). 13. Supporting Afghan nationals: Key figures. Government of Canada. Nov. 17 (2021). https://www.canada.ca/en/immigration-refugees-citizenship/services/refugees/afghanistan/key-figures.html. Cited November 20, 2021.14. Urgent Call to action in response to the crisis in Afghanistan. Letter. Nov. 1 (2021). https://wrmcouncil.org/news/letter-news/urgent-call-to-action-in-response-to-the-crisis-in-afghanistan/. Cited November 25, 2021.15. Factbox: Evacuations from Afghanistan by country, Reuters, Aug. 30 (2021). https://www.reuters.com/world/evacuations-afghanistan-by-country-2021-08-26. Cited November 25, 2021.


Forests supply multiple ecosystem services and host a large proportion of the Earth's terrestrial biodiversity. In particular, they provide habitats for many taxonomic groups which can be threatened by forest unsustainable management practices. Type and intensity of forest management are widely recognized as the main drivers of structure and functions in forests ecosystems. However, to better understand the impacts and the benefits deriving from forest management, there is a big need to standardize procedures of field data collection and data analysis.sensu Council Directive 92/43/EEC. The dataset includes structural indicators commonly linked to old-growth forests in Europe, in particular the amount of standing and lying deadwood. We collected data on 32 plots  during spring and summer of 2022, in Val d'Agri . The dataset we provide follows the common national standard for field data collection in forest habitat types, published by ISPRA in 2016 with the aim to promote a greater homogeneity in assessment of habitat conservation status at Country and biogeographical level, as requested by the Habitats Directive.Here, we provide a georeferenced dataset of vertical and horizontal structure of forest types belonging to 4 habitat types,  Specifications Table•This dataset represents a monitoring baseline for the main forest habitat type in the Basilicata Region.•If integrated with other dataset, for example the one provided by Parisi et al •The release of this dataset promotes the collaboration among researchers, monitoring and management Institutions .•The active involvement of ARPA Basilicata in field data collection ensures future repeating assessments in the same localities, to evaluate the trends over time and space.•sensu art. 17 of the Directive 92/43/EEC (hereafter Habitats Directive).This dataset represents a first practical example of standardization and homogenization of forest stand structure data collection for Habitat Monitoring •Metadata will be used as a reference standard for Administrative Regions in our Country, since they derived from the National Handbook of Habitat Monitoring 1With the release of the dataset, ISPRA, in collaboration with ARPA Basilicata, decided to practically test on the field how Administrative Regions, which are responsible for habitat monitoring activities, can collect data on forests structure easily but efficiently. At the end of the project, ISPRA will produce practical indications for the correct application of the monitoring techniques recommended by the National Handbook of Habitat Monitoring 2The same information included in 32 and including some high ground, as Mount of Viggiano, Aquila Mount (1096 m a.s.l.) and Mount Calvarosa (1261 m a.s.l.), ends when the Agri river reaches the Pertusillo Lake (532 m a.s.l.), an artificial reservoir that dates 1957-1962.Dataset refers to the upper and middle valley of the Agri river, one of the main valleys of the Basilicata Region, located along the main axis of the Southern Apennines. The Agri river starts from Serra di Calvello, at 1567 m a.s.l., and flows between the Mount Calvelluzzo (1699 m), Mount Volturino (1835 m), and Mount of Viggiano (1727 m) on the left bank, and Maddalena Mountains (between 1300-1500 m a.s.l.) on the right bank, which represent the natural border between Campania and Basilicata. The investigated area, spreading for 260 kmQuercus cerris dominated forests, which is the most spread woods in Basilicata Region; in the South-Eastern part of the area, close to the Pertusillo Lake, the main ecosystems are represented by mixed oak forests ; Q. pubescens is relatively rare in the area and it is not associated to any habitat type. Fagus sylvatica forests (habitat 9210*) can only be found in Viggiano Mountain and Aquila Mountain. Among the azonal forests, two riverine woods can be identified, the first one dominated by Populus nigra and/or Salix alba (habitat 92A0), the second one characterized by Alnus glutinosa (belonging to the habitat 91E0) Along the slopes, area mainly hosts We used a random-stratified sampling design according to the different forest ecosystem types recognized in the Map of the Nature, a national project for land management and environmental protection produced by ISPRA for each administrative region. The Basilicata Map of the Nature was released in 2012 at a scale of 1:50.000 The selection of the location of the sample sites were spatially balanced by using the software QGis vers. 3.22 2) in zonal forests (Quercus or Fagus dominated forests); and rectangular shape  in azonal riparian forests . Shapes and dimensions, follow the standards of National and European Handbook for habitat monitoring activities Sample sites were located in the field by using GPS in order to identify the centre of the plot. Plots have square shape , the highest and average heights of trees, shrubs, and herbs layers. We also measured the DBH of living trees at individual level by using meter sticks. Finally, we recorded the number of standing dead trees, downed dead trees, stumps, snags, old trees, and trees with cavities per plot .Visual estimates are often applied in vegetation cover studies as they are relatively rapid and well established, although potentially less robust than other methods; to reduce the degree of subjectivity data were collected by a unit of only 4 researchers in a very short period (from May to July 2022).For future monitoring activities, we suggest the use of innovative technologies such as laser scanner, in order to provide more accurate measurements for the assessment at the national spatial scale.https://vegapp.de/), which allows to collect structural and vegetation data on the field, storing them directly in a georeferenced database.Concerning data collection, we use standardized field survey forms, and “VegApp”, a free application on Android platform . Forestry management plans still lack for some Municipalities. In this case, we indicated the type of management according to field survey observations.Lastly, in order to stress the importance of forests management plans to provide useful data for the assessment of conservation status of the habitat types The authors declare that the present work did not include experiments on human subjects and/or animals.E. Carli: Methodology, Writing – original draft, Investigation, Writing – review & editing. L. Casella: Conceptualization, Supervision, Writing – review & editing. G. Miraglia: Investigation, Data curation, Writing – review & editing. F. Pretto: Writing – original draft, Investigation, Data curation, Writing – review & editing. I. Prisco: Investigation, Writing – review & editing. G. Caricato: Conceptualization, Writing – review & editing. A. Palma: Conceptualization, Writing – review & editing. P. Angelini: Conceptualization, Supervision, Writing – review & editing.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


In developing nations like Ethiopia, the number of people suffering from work-related stress is rising at an alarming rate, and it is becoming a public health concerns.The goal of this study is to examine work-related stress and associated factors among health care professionals working in governmental and commercial health care facilities in Zone 1 of Ethiopia's Afar region in 2021.A comparative cross-sectional survey was done among 435 health professionals working at government and commercial health facilities in Zone 1, Afar, between April 1 and May 30, 2021. Self-administered structured questionnaires were employed to collect data, and multistage sampling was used to reach out to the study participants. To assess occupational stress, the Perceived Stress Scale was employed (PSS-10). To see if there is a difference in stress levels between government and private health practitioners, a chi-square test of independence was used. In multivariable logistic regression, a statistically significant relationship was found with a p-value of less than 0.05.This study had a total of 435 participants, with a 96.7 percent response rate. Work-related stress was reported by 67.5 percent of government and 47.2 percent of private health professionals, respectively, and overall stress was reported by 57.5 percent. A chi-square test revealed a significant difference in stress between health professionals working in government and private facilities, X2  = 18.19, p < 0.001. A monthly income of 4001–5500 ETB, being a male professional, working 40 h per week, having support and assistance at work, job satisfaction, and uncomfortable room temperature were all linked to work-related stress.Health practitioners in government facilities experienced more stress than those in the private sector. Moreover, the level of work-related stress was high. Effective programs and protocols are needed to maintain a healthy working environment. Work-related stress; Health professionals; Afar region; Ethiopia. GloballAround 59 million health workers worldwide are exposed to various health risks and hazards as a result of their unsafe working environment. The majority of these problems are caused by psychosocial hazards , as most health practitioners are regarded to be healthy persons .In developing countries, the number of people suffering from work-related stress or worsening their condition as a result of stress is increasing at an alarming rate, and it is becoming a public health concern . Even th22.1A comparative cross-sectional study was conducted among health professionals who work at both governmental and private health institutions found in Zone one (Awsi Rasu), afar region, from April 1 -May 30, 2021. Afar Region has an estimated population of 1.9 million people. Awsi Rasu is one of five zones found in the Afar region of Ethiopia, which is located 591 km far from the capital city of Ethiopia, Addis Ababa. From government institutions, there are 1 general hospital, 2 primary hospitals, 26 public health centers, 94 health posts, and from private facilities there are 5 primary clinics, 32 medium clinics, 2 specialty clinics, and 41 pharmacies, which are found within the zone. There are 1305 health professionals of which 907 of health professionals was from the government and 398 health professionals were from private health facilities.2.2The study's source population was health professionals in the Afar region. Health care professionals working in both private and public health facilities  in Zone 1, Afar region, who met the qualifying criteria, were included in this study as the study population. The criteria for participation were health care personnel who have worked for at least 6 months in both private and public health facilities .2.3Two population proportion formula was used to calculate the sample size. The previous study assessed the prevalence rate of job-related stress to be 68.2 percent for public health professionals and 50 percent for private health professionals (8). Using the assumptions of , Zβ , n1 = n2 , the calculated sample size was 214 (107 of each). Finally, by adding 5% for the non-response rate  and multiplying the sample size by two (2) for the design effect, the total sample size is 450.The researchers employed a multi-stage sampling technique. The health facilities were first classified as public or private, and then a lottery was used to select one primary hospital, eight health centers, and 36 clinics from each facility. After then, the proportional allocation was used to deal with the sample size. Finally, a simple random selection approach was used to pick the participants .Figure 12.4A structured, self-administered questionnaire was used to collect data. The questionnaire is divided into four sections: the first section contains socio-demographic data derived from the Ethiopian demographic health survey (EDHS), the second section contains workplace factors, and the third section contains the job satisfaction measurement instrument Satisfaction of Employees in Health Care (SEHC), and the fourth section contains the Perceived Stress Scale-10 (PSS-10). The Perceived Stress Scale (PSS) is a validated and reliable internationally accepted instrument that can be applied to a variety of situations . SEHC is2.5Work-related stress - Described as professionals who scored above the mean perceived stress scale to have work-related stress and score below the mean perceived stress scale shows no work-related stress  .Table 4SWorkload, job satisfaction, and an uncomfortable room temperature, on the other hand, were all linked to work-related stress. Health professionals who worked 40 h per week had a 70% lower risk of work-related stress than those who worked more than 50 h per week .Health professionals who work under Uncomfortable room temperature were more than 4 times more likely to be stressed  than the referent .Table 5WMoreover, satisfied health professionals with their jobs  were 65 % less likely to have work-related stress than those unsatisfied health professionals .Table 6I3.6.In governmental health facilities, the sex of the respondents was found to be significantly associated with work-related stress, where being male has a 66 %  less chance to have work-related stress than female professionals . SimilarMoreover, in governmental facilities satisfied health professionals were 74 % less likely to be stressed than unsatisfied professionals .) .In private facilities, health professionals who were getting enough support and assistance from other coworkers were found to be 78% less stressed  .Table 9I4The study's main goal was to determine the level of work-related stress (WRS), compare it between government and private facilities, and find associated factors with WRS among healthcare employees in both private and governmental health facilities in Afar's zone 1.Our study found that the magnitude of work-related stress among governmental institutions of health professionals was 67.5%, which is lower than a study report from Egypt . This might be due to the difference in objectives of the two studies , Saudi Arabia, and Nigeria , 20, 21;Furthermore, getting support and assistance in the workplace was a significant determinant of work stress among private facilities health professionals, accordingly, those who had enough support and assistance from other staff were 78% less likely to be stressed than those who didn’t have support and assistance. This could be due to the existence of a high workload and insufficient staff in private facilities and the exposure those health workers to long working hours , 20.Moreover, job satisfaction was found to be an important factor for work-related stress among both groups of health professionals; the more satisfying health professionals with their jobs will be less stressed. The finding of this study complements the result of the survey done in Mekelle and Addis Ababa , 22. The4.1By using a comparative study method, this study tries to identify the difference in work-related stress and associated factors among health professionals of the two study groups.4.2The cross-sectional nature of this study was unable to show the cause-effect relationship of independent variables and dependent variables (work stress), and some of the measurements used to assess work-related stress may not be accurate due to subjective responses. Moreover, even if we are under the era of a COVID-19 pandemic, and this is more likely to affect the overall stress and anxiety level of healthcare professionals, our study did not show the association and impacts of COVID-19 pandemic on healthcare professional's work-related stress in the current study area.5The prevalence of workplace stress was higher among health professionals both in governmental and private health facilities. Health professionals of governmental institutions were more exposed to work-related stress when compared to private institution professionals. The sex of the respondents and lack of support and assistance in the workplace were significant factors of work-related stress in governmental and private institutions respectively. While workload, job satisfaction, and uncomfortable room temperature were significant determinants of work-related stress in both governmental and private facilities.Therefore, policymakers, the ministry of health, and the regional health bureau should set different strategies and programs focusing on stress reduction management programs in health facilities, improve the health management system through the application of a health sector transformational plan, allocate more funds to recruit health professionals as per standard to reduce workload, and to buy artificial air conditioner (AC) for the facilities to create a comfortable working environment, improving their salary and providing competency training programs to improve employee performance and update their professional knowledge and skills to reduce stress and coping with stress.Motivational programs targeting female workers especially should have to be conducted routinely. Moreover, in a health facility setting, measures should be taken in create optimal organizational working hours, shifts, and rests based on the local situation, and establishing counseling centers with trained professionals to help health workers to cope with the stress.Sadat Mohammed Yesuf: Conceived and designed the experiments; Performed the experiments; Analyzed and interpreted the data; Contributed reagents, materials, analysis tools or data; Wrote the paper.Behailu Tariku Derseh: Conceived and designed the experiments; Analyzed and interpreted the data; Contributed reagents, materials, analysis tools or data; Wrote the paper.Daniel Girma: Conceived and designed the experiments; Contributed reagents, materials, analysis tools or data; Wrote the paper.Tadesse Mamo Dejene: Conceived and designed the experiments; Performed the experiments; Analyzed and interpreted the data; Wrote the paper.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Data will be made available on request.The authors declare no conflict of interest.No additional information is available for this paper.


Gestational hypertension (GH) is a common disease that seriously threatens the safety and health of pregnant women and their newborns. Physical exercise (PE) is widely recognized as a health maintenance method and it has numerous benefits. Studies on the association between PE and the risk of GH in obese and overweight pregnant women have generated controversial findings. This updated meta-analysis was performed to reassess the effects of PE on GH.I2 statistic. Risk ratios (RRs) and 95% confidence intervals (CI) were calculated through either random-effect or fixed-effect models. Subgroup analyses, sensitivity analyses, and publication bias diagnoses were also conducted.The articles from inception to April 2022, presenting studies investigating exercise intervention and pregnancy outcomes were explored across several online databases. Heterogeneity among the included studies was estimated and tested by Q test and P = 0.001; I2 = 24.3%). Subgroup analysis found significant trends amongst Eastern countries . Sensitivity analysis suggested the results were stable. No publication bias was detected based on Begg's test and Egger's test.Twelve with 1,649 subjects were included. PE was associated with a reduced risk of GH in obese and overweight pregnant women (Pooled RR = 0.58, 95% CI = 0.42–0.81, PE was associated with reduced risk of GH in obese and overweight pregnant women, especially in Eastern countries. More well-designed studies are still needed to further elaborate on these associations.CRD42022326183. Over the past few decades, the number of overweight and obese people has been increasing, especially among women of reproductive age –3. ApproGH is a common disease that seriously threatens the safety and health of pregnant women and their newborns . The incExercise is widely recognized as a health maintenance method and it has numerous benefits , 20. It The Preferred Reporting Items declared by the Systematic Review and Meta-Analysis (PRISMA) was utilized to conduct this updated meta-analysis .The articles from inception to April 2022, presenting studies investigating exercise intervention and pregnancy outcomes were explored across several online databases, including Web of Science, Cochrane Library, Embase, PubMed, China Biomedical Database (CBM), VIP (Chinese) database, China National Knowledge Infrastructure, and Wanfang Data. The searching terms used were as follows: (exercise OR training OR activity OR exercise intervention) AND (pregnancy OR pregnant woman OR delivery) AND  AND . The keywords used in the Chinese databases were replaced by the Chinese words with the same meaning as the English searching terms. For a comprehensive search to collect more qualified articles, studies were also collected through references from original published studies and relevant reviews. The records were processed with literature management software  to exclude duplicates and to further screen the literature.Studies could be included in this the subsequent analysis if the following inclusion criteria were fulfilled: (1) the subjects of the study were pregnant women; (2) the pregnant women were overweight or obese ; (3) the intervention was exercise (no limitation on the type of exercise); (4) The outcome of GH should be reported  (5) the study design was restricted to randomized controlled trial study. The exclusion criteria were also set: (1) Preclinical study; (2) observational studies; (3) reviews, case reports, meta-analysis, guidelines; (4) Duplicate articles; (5) Unable to extract data.Two authors (H. Tao and M. Liu) independently carried out the data extraction process using a pre-specified Excel form. Any dissonance was resolved with a senior supervisor (E. Xie) through discussion and consensus. Information extracted contents were listed as follows: (1) Basic information for the included articles . (2) Baseline characteristics of the subjects in the eligible literature . (3) Specific details of interventions (intervention measure and frequency). (4) The outcome indicators and outcome measures of interest .The quality of the included RCTs was assessed using the Jadad scoring scale for four indicators: literature random sequence generation, allocation concealment, blinding, and whether details of study participant withdrawal or dropout were described. Studies scoring 4–7 were considered of high quality and 1–3 were considered low-quality studies , 31.I2 statistic. Random-effects model would be applied if the test demonstrated a substantial level of heterogeneity (I2 > 50%), otherwise, a fixed-effects model would be applied (I2 < 50%)  was utilized in this meta-analysis. Since GH is a dichotomous variable, the results were combined using the Mantel-Haenszel method and expressed as the pooled RR with the corresponding 95% confidence interval (CI). Heterogeneity among the included studies was estimated and tested by Q test and 2 < 50%) , 33. Sub2 < 50%) . Funnel 2 < 50%) , 36. StaOf the 1,724 potentially relevant documents initially searched , 928 remained after excluding duplicates. After subsequent scanning of the titles and abstracts, 871 articles were eliminated, mainly for the irrelevance to the aim of this meta-analysis and non-conformity of the study type. Full texts of the 57 records that remained were scrutinized. Finally, 12 articles –46 that Twelve documents involving maternal outcomes in pregnant women were included in this meta-analysis. These studies were published between 2014 and 2021. Of all, five were conducted in China, three were from Italy, one was from Norway, one was from Spanish, one was from Denmark and the rest one was from New Zealand. More detailed characteristics and information were summarized in P = 0.001; I2 = 24.3%; Twelve articles –48 regarP = 0.033), while no statistically significant association was detected in Western countries . In terms of sample size, the outcomes were statistically significant in both the groups with sample size > 120 and ≤120 group . For Exercise intervention measures, seven studies with intervention of mixed physical exercise indicated a significant impact of exercise on reducing the risk of developing GH in in obese and overweight pregnant women RR = 0.38, 95% CI = 0.24–0.62, P = 0.001); however, in the five studies with intervention of walking only, the association between walking and incidence of GH was not statistically significant . In case of dietary interventions, the pooled RR for combining dietary interventions with PE was 0.55, , and the pooled RR for no dietary interventions was 0.74 . All these results of subgroup analyses were represented in In the subgroup analyses performed by geographic locations, a statistically significant association was observed in eastern countries , Egger's test  for GH showed that publication bias might not exist.After leaving an individual study out at a time, the fluctuation of the pooled RRs was found to be between 0.53 and 0.66 with an upper limit of 95% CI constantly remaining <1, and analysis . By chananalysis . Begg's Meta-analysis is considered an essential statistical tool to synthetically evaluate the effects of intervention for disease more precisely. Thus, we performed this updated meta-analysis, which identified a 0.58-fold decrease in the risk of developing GH in obese and overweight pregnant women. This finding was inconsistent with the previous meta-analysis by Muhammad et al.  and by DBesides, subgroup analysis confirmed the relevance between exercise and the decreased risk of GH, because the outcomes were statistically significant in both the groups with sample size > 120 and ≤120 groups. In terms of the geographic locations, a positive association was observed in eastern countries while studies in Western countries showed no such association. This might be explained by discrepancies in different ethnicities between Asian and Western countries. The different lifestyles and dietary habits of different regions cause differences in the characteristics of the general population, and therefore the characteristics of pregnant women, differ significantly from one another. A meta-analysis  using thThe exercise of pregnant women is greatly reduced and the intake of food is increased, so there are a lot of calories in the body that cannot be consumed, which is easy to lead to fat accumulation and obesity symptoms. These pregnant women are prone to GH due to abnormal lipid metabolism . It is kSeveral inherent limitations need to be cited when interpreting the results of this meta-analysis. First, the exercise duration and intensity were different across the included studies, and due to the limited number of the included studies, results cannot be stratified by these factors. Third, the majority of studies were conducted in Europe and Asia, with limited research in other regions. Last, it is not possible to conduct a stratified analysis based on pre-pregnancy BMI. Despite the limitations, the strength of this article should be highlighted. To begin with, compared with the previous meta-analysis, more studies were enrolled. The large sample size provided stronger statistical power. Second, more comprehensive subgroup analyses were performed in this study. Third, no obvious publication bias was detected.In conclusion, exercise is associated with a reduced risk of GH in overweight and/or obese pregnant women. Exercise is a convenient intervention in general life. Given the prevalence of GH is increasing, the effect of general exercise on GH in our study is promising. However, more well-designed studies are warranted to further elaborate on these associations.The original contributions presented in the study are included in the article/EX, CL, and QZ conceived and designed the research, provided critical opinions, and revised the manuscript. HT and ML designed the research, performed the statistical analysis, interpret data, and wrote the manuscript. All authors approved the final 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.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.


Stressed and hospitalized goats are at risk of developing abomasal (gastric) ulceration, but there is a paucity of pharmacokinetic studies for proton pump inhibiting drugs, such as, esomeprazole in goats.The objectives for this study were to estimate plasma pharmacokinetic parameters for esomeprazole in adult goats after intravenous (IV) and subcutaneous (SQ) administration. A secondary objective was to describe the plasma kinetics of the metabolite esomeprazole sulfone after IV and SC administration in goats.Esomeprazole was administered to 5 adult goats in a crossover study at doses of 1 mg/kg IV or 2 mg/kg SC. Plasma samples were collected over 36 h and analyzed via reverse phase HPLC to determine concentrations of esomeprazole and esomeprazole sulfone. Pharmacokinetic parameters were derived via non-compartmental analysis.Vz) of esomeprazole were estimated at 24.9 mL/min/kg, 6 min, 2.324 μg/mL, and 0.23 L/kg, respectively. After SC administration elimination half-life, maximum concentration (Cmax) and time to maximum concentration (Tmax) of esomeprazole were estimated at 29 min, 1.038 μg/mL, and 22 minutes respectively. Maximum concentrations of the sulfone metabolite were 32 and 18 ng/mL after IV and SC administration.Following IV administration, mean values for plasma clearance (Cl), elimination half-life [T1/2 (λz)], C0, and volume of distribution  acid suppression in goats and could include larger doses or additional routes of administration. Abomasal (gastric) ulceration is a multifactorial disease of many ruminant species, as well as a common cause of morbidity and mortality. Prevalence of abomasal ulcers varies substantially because of differences in populations, but abomasal ulcers can be found in ruminants of all ages and production systems –4. CliniProton pump inhibitors (PPIs) such as pantoprazole and omeprazole are routinely used by large animal clinicians to treat gastric ulceration in horses and many ruminant species, including sheep, goats, camelids, and cattle –10. HowePharmacokinetic studies of esomeprazole, the S-enantiomer of omeprazole, administered to human patients show that esomeprazole has a reduced first-pass hepatic metabolism, slower plasma clearance, and increased area under the curve (AUC) plasma concentration than that of omeprazole . EsomeprDespite the potential use of esomeprazole in ruminants, currently no studies report the pharmacokinetics in goats. Esomeprazole is proposed for investigation as a therapeutic to utilize in hospitals to prevent the development or perpetuation of abomasal ulceration. Esomeprazole is investigated as a medication that may have prolonged therapeutic concentrations in goats than other proton pump inhibitor medications. Based on previous work with pantoprazole in alpacas and goats, as well as comparative dosing, a similar dose was proposed for pharmacokinetic determination in goats. No short-term side effects have been associated with the use of the proton pump inhibitor class of drugs in small ruminants such as goats, but more studies are necessary to confirm this observation. The primary objective of this study was to determine the plasma pharmacokinetics of esomeprazole in healthy adult goats after single intravenous (IV) and subcutaneous (SC) administration. An additional, secondary objective of this study was to investigate the pharmacokinetics of the sulfone metabolite after IV and SC administration of esomeprazole in healthy adult goats.ad libitum grass hay. None of the animals had been medicated within the four weeks prior to the study and all were current on vaccination for Clostridium perfringens types C and D, as well as tetanus.The protocol was reviewed and approved by the Institutional Animal Care and Use Committee (IACUC) of the University of Tennessee, Knoxville (Protocol number: 2825-0221). Five healthy adult goats were utilized for this study. Three goats were pygmies and two were pygmy-crosses. The weights were 42.1 ± 6.1 kgs and ages of the goats were 3.2 ± 0.7 years. Two goats were castrated males and three of the goats were intact females. Goats were sourced from the teaching herd of goats maintained at the University of Tennessee's Veterinary Research and Education Center. Diet during the study consisted of Before enrollment for the study, all goats were deemed healthy based on physical examination by a board-certified large animal veterinary specialist. Prior to intravenous administration, all goats had intravenous jugular catheters aseptically placed as previously reported,  with one18  column with a 5 μm Symmetry C18 guard column . The mobile phase was a mixture of 20 mM ammonium acetate and acetonitrile (75:25). The flow rate was 1 mL/min and absorbance was measured at 290 nm.Analysis of esomeprazole and its metabolite in plasma samples was conducted using reverse phase high performance liquid chromatography (HPLC) method based on a method previously validated for pantoprazole in goat plasma . The sysEsomeprazole and its metabolite were extracted from plasma samples using a liquid-liquid extraction method. Samples that were previously frozen were thawed, vortex-mixed, and 100 μl of plasma was transferred to a 13 x 100 mm screw top tube followed by 10 μl of tinidazole  and 1 mL chloroform. The tubes were rocked for 10 min and then centrifuged for 10 min at 1,000 x g. The organic layer was transferred to a glass tube and evaporated to dryness with nitrogen gas. Samples were reconstituted in 225 μL of mobile phase and 100 μL was analyzed.Method validation was performed according to the FDA Bioanalytical Guidelines (FDA) . StandarThe pharmacokinetic parameters for esomeprazole in goats were determined from plasma time vs. concentration data as previously described for non-compartmental analysis , 9, 16. Standard PK parameters were generated for individual animals, as previously reported , 9:Maximum concentration extrapolated to time zero, C0 (esomeprazole).last and AUCinf.Area under esomeprazole concentration–time curve, AUCinf.Area under the moment curve, AUMCinf/AUCinf.Esomeprazole mean residence time, MRT = AUMCz)) = ln (2)/λz.Esomeprazole terminal half-life, T1/2  range. Pharmacokinetic parameters for the sulfone metabolite, were determined from plasma time vs. concentration data as previously described (Also reported: Volume of distributionand Bioavailability (F), with Bioavailability calculated as, AUCescribed , 17.During the duration of the study no adverse health effects were observed in any of the goats. Of the animals included in the study, no animal displayed inappetence or abnormal attitude or mentation. There was no evidence of the development of edema, injection site reactions or catheter site reactions. There was no evidence of anaphylactic reaction or adverse reactions throughout this study.Esomeprazole is the only optical isomer of omeprazole used in veterinary medicine, and although many proton pump inhibitors are reported in clinical practice, there is not enough literature about its pharmacokinetic or pharmacodynamic properties, especially in goats, to formulate treatment plans. In this study, concentrations of esomeprazole, when administered IV and SC, were not detected after 4 h in any animal. When a single dose of esomeprazole (1 mg/kg) is administered IV it is characterized by rapid elimination in goats compared to other veterinary species, and in comparison, to other proton pump inhibitors . The onlThis study utilized both IV and SC administration to investigate how the half-life and bioavailability are affected by route of administration. In a clinical setting, proton pump inhibitors are heavily utilized but highly variable in the amount of time they cause therapeutic effects. Due to previous pantoprazole studies on small ruminants, it was identified that SC administration had a significantly longer plasma half-life than IV administration . The resIn humans, patients with gastro-esophageal reflux disease are of interest for the investigation of esomeprazole. Esomeprazole has prolonged action within the body and rapid absorption in humans, along with lower inter-patient variability when compared to omeprazole. The most reported side effects of esomeprazole include headache, respiratory disease, diarrhea, abdominal pain and nausea . It is rIn a human study, there is a reported group of people that display poor metabolism of esomeprazole, resulting in decreased systemic clearance . This diA major limitation of this investigation is the small sample size of animals, but many pharmacokinetic studies of 4–6 animals are sufficient for describing necessary pharmacokinetic parameters . All goaFurther studies of the metabolism and pharmacodynamic effects of esomeprazole in goats will be needed to understand esomeprazole and the effects of its metabolites within small ruminant species. It is not currently known if there is a specific concentration of esomeprazole in circulation that needs to be reached for a certain period of time for desired effects. Future studies should investigate the efficacy of esomeprazole in goats to determine the potential for differenced in metabolic capacity of this drug within goats, as well as determine the effects of esomeprazole on the gastrointestinal tract, the ruminant gastrointestinal microbiome, and changes in abomasal acidity. The use of esomeprazole in small ruminants would be considered extra-label, which indicates that future studies involving the investigation and determination of withdrawal times would be necessary. Future studies could also investigate the effect of breed and gender on the pharmacokinetics of esomeprazole to determine what variation may be possible. Currently, it is also unknown if esomeprazole has any potential for epigenetic effects . FurtherIn conclusion, esomeprazole administered either intravenously or subcutaneously in goats appears to be very rapidly eliminated. Although rapidly eliminated, the administration of this drug is well tolerated. Elimination half-life and plasma clearance appear to be significantly faster than reported in canines. Esomeprazole sulfone, the metabolite of esomeprazole, was detectable in plasma for <4 h regardless of the route of administration. Esomeprazole was metabolized significantly faster than pantoprazole in small ruminants . A largeThe original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The animal study was reviewed and approved by Institutional Animal Care and Use Committee, University of Tennessee.RF, JS, AK, and SC developed the experimental design. RF, WS-G, RR, BF, OE, JG, JS, and LH contributed to logistical support, assessment of animal health, and data collection. SC and JB developed the analytical method for determination of concentration. JS performed the pharmacokinetic analysis. All authors contributed to manuscript construction. All authors contributed to the article and approved the submitted version.