Background and objectives: Chronic tension-type headache (TTH) is the type of headache with the highest prevalence. The involvement of musculoskeletal structures in TTH is supported by evidence in the scientific literature. Among these, deep cervical muscle strength appears to be related to the function of the cervical spine and the clinical characteristics of TTH. This study aimed to correlate anatomical, functional, and psychological variables in patients with TTH. Materials and methods: An observational descriptive study was carried out with 22 participants diagnosed with TTH for at least six months. The characteristics of headaches, including ultrasound-based deep neck flexor and extensor muscle thickness, range of motion (ROM), and pressure pain threshold (PPT), were recorded. We also conducted the Pain Vigilance and Awareness Questionnaire (PVAQ) and the Craniocervical Flexion Test (CCFT). Results: Moderate–large negative correlations were found between the PVAQ and the muscle thickness of right deep flexors contracted , left multifidus contracted , right multifidus at rest , and right multifidus contracted . Moderate–large positive correlations were found between the CCFT score and the left cervical rotation ROM , right cervical rotation ROM , muscle thickness of left multifidus contracted , and muscle thickness of right multifidus at rest . The muscle thickness of the contracted right deep cervical flexors showed a moderate negative correlation with headache intensity . No correlations were found between PPT and the rest of the variables analyzed. Conclusions: In patients with TTH, a higher thickness of deep cervical muscles was associated with higher ROM and higher scores in the CCFT. In turn, the thickness of deep cervical muscles showed negative correlations with pain hypervigilance and headache intensity. These results contribute to a better understanding of the physical and psychosocial factors contributing to the development of TTH, which is useful for implementing appropriate prevention and treatment measures. Headaches are a public health problem and one of the most common symptoms worldwide . AccordiDespite efforts made by the International Headache Society (IHS) to clarify the diagnostic criteria for each type of headache, which is established in the latest edition of the International Classification of Headaches , nonspecClinically, TTH pain is described as bilateral, dull, and oppressive, and can range from mild to moderate intensity . Recent The involvement of musculoskeletal disorders in patients with TTH is sufficiently demonstrated in the scientific literature. Common exploratory findings in these patients are the presence of myofascial trigger points in the cranial and pericranial muscles , presencIn pathologies where pain becomes chronic, psychological affectations seem to be linked. In order to examine this association, one of the most commonly used scales is the Pain Vigilance and Awareness Questionnaire (PVAQ) . A recenIn addition, some authors reported correlations between functional aspects, such as muscle strength, and psychological affectation derived from pain. Thus, a study performed in patients with chronic knee osteoarthritis concluded that a muscle strength program had a positive effect on psychological aspects such as anxiety . These dAs such, the objective of this study was to analyze the relationship between anatomical and functional variables, pain characteristics, and its psychological impact in patients with chronic TTH.An observational study following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Initiative Statement  was condThe study protocol adhered to the principles of the 1964 Declaration of Helsinki and its subsequent clarifications, and was approved by the Research Ethics Committee of the Rey Juan Carlos University of Madrid (reference number: 1802202105721). Additionally, informed consent was obtained from all subjects involved in the study.Recruitment of participants (n = 22) was carried out among students and workers at a university. Participants were included in the study who fulfilled the following criteria: (1) adults aged 18–65 years; (2) having TTH for more than six months . The exclusion criteria were: (1) the presence of pathologies that prevent the performance of physical activity; (2) pregnancy.2) following Shephard’s protocol [Anthropometric variables were age in years, height in centimeters (cm), and weight in kilograms (kg). Height was measured with a measuring rod , and weight with a mechanical scale . Body mass index (BMI) was calculated as weight (kg)/height , the intensity of the tension headache , and the frequency (in days) of the episodes of the subject .Measurements of the thickness of the neck stabilizing muscles flexor longus colli and multifidus at the cervical C5–C6 level  were recIn the counter resistance measurement, the participants were asked to perform a “double chin”, bringing their chin to their sternal notch. For this protocol, the subjects previously performed a familiarization that the physiotherapist demonstrated.The cervical range of motion (ROM) was analyzed with a CROM goniometer Baseline . The ranges evaluated were ROM Left Rotation, ROM Right Rotation, ROM Flexion, ROM Extension, ROM Tilt Left, and ROM Tilt Right, all measured in degrees. The procedure was followed as in the study by Wolan-Nieroda et al., in which the subjects were kept in a seated position to perform the measurements, and data were collected of the mentioned ranges. Measurements made with the CROM goniometer showed inter- and intra-rater agreement on cervical ROM assessments. Therefore, the CROM goniometer is a reliable instrument for use in daily clinical practice . The tesThe protocol and methodology of the Fleckenstein et al. study was followed. A FORCE DIAL FDK/FDN 100 algometer  was taken as the measurement tool. PPT is known to be the most validated mechanical threshold at present .Participants were assessed on a stretcher by a physiotherapist . PPT meaThe PVAQ is an internationally accepted tool to evaluate this characteristic; in 2013 it was validated and translated into Spanish by Esteve et al. . It consThe CCFT was carried out to analyze the functionality of the cervical musculature; for this procedure, we used a Stabilizer Pressure biofeedback tool , following the study of Thongprasert and Kanlayanaphotporn . The parAll the measurements were performed by a research team composed of six physiotherapists, two of them specialized in TTH. Each measurement was supervised by at least two physiotherapists to avoid any bias and poor execution of the techniques.First, the Shapiro–Wilk test was performed to assess the normality of distribution for all the continuous variables  . Second,2.A total of N = 22 participants, mainly women (82%), with chronic TTH were analyzed. The mean age was 39.72 ± 13.91 years, and the mean BMI was 25.01 ± 4.24 kg/mThe mean intensity of the headaches was 7.11 ± 1.33 on a numeric pain rating scale from 0 to 10. These headaches had a mean duration of 18.91 ± 20.23 h per day, and a mean frequency of 13.00 ± 10.78 days per month.Ultrasound imaging measurements of the thickness of left multifidus, right multifidus, right deep flexors, and left deep flexors are described in The ROMs of cervical flexion, extension, left rotation, right rotation, left inclination, and right inclination are described in The PPTs of the right temporalis, left temporalis, right trapezius, left trapezius, right masseter, left masseter, right median nerve, and left median nerve are described in PVAQ and CCFT scores are described in p = 0.01), left multifidus contracted muscle thickness , right multifidus muscle thickness , and right multifidus contracted muscle thickness   .p = 0.01), right cervical rotation ROM , left multifidus contracted muscle thickness , and right multifidus muscle thickness   and the left cervical rotation ROM .In turn, moderate–large positive correlations were found between the CCFT and the following variables: left cervical rotation ROM  . In the p = 0.03). No correlations were found between PPT and the rest of the variables analyzed  and 28 mmHg  pressure values. Similar results were obtained in the study conducted by Jull and Falla [p < 0.01).In the present study, there were large positive correlations between the CCFT performance and the thickness of right and left multifidus in contraction. Other authors have reported similar results. Ishida et al. , analyzend Falla , who anaLikewise, in this study, there was a negative correlation between deep cervical muscles thickness and pain intensity. The role of cervical musculature disorders in patients with TTH seems crucial . PreviouIn addition, another finding was a positive correlation of cervical spine rotational ROM and the CCFT score. Previous studies in people with chronic neck pain, cervico-craniofacial pain, and temporomandibular disorders have reported similar values for neck axial rotation ROM ,43. ThesThe participants of this study had a total axial rotation (right + left) ROM of 127.77°, which is less than other results reported with TTH patients mean = 146.15°) ,45. In l.15° ,45.The lack of association between sagittal (flexion + extension) plane ROM and other variables can be explained due to absence of physical impairment compared with normal values in asymptomatic participants ,45. No aFurthermore, the lack of association in our study between cervical ROM, headache features, or deep cervical muscle thickness with pressure sensitivity of cranial and pericranial points supports the possibility that cervical impairments can sometimes be unrelated to headache and, in some patients, be incidental features or co-existing cervical disorders . One sysConcerning the characteristics of the sample, most participants in the present study were women (82%). Female sex is associated with an increased risk of reporting headache, according to recent health surveys .Finally, this is the first study to investigate the relationship between hypervigilance and the thickness of the deep neck muscles. Previous studies have linked hypervigilance to people with fibromyalgia and knee osteoarthritis ,54,55. HHowever, no correlations between anatomical and functional variables (thickness or ROM) with pressure sensitivity of cranial and pericranial points were found, unlike other previous investigations .Several limitations associated with this study should be acknowledged. First, an observational study was used to explore the associations, but the relationships cannot be inferred from the results. Second, a limitation of the study is the lack of a control group to compare the results with those of TTH patients. Third, only the C5 cervical segment was measured to determine the cervical multifidus thickness. Finally, it would be interesting for future studies to investigate the associations between another psychosocial element and health-related quality of life in TTH patients.In patients with TTH, the CCFT performance showed large positive correlations with the thickness of deep cervical muscles, which in turn had large negative correlations with pain vigilance and headache intensity. In addition, there was also a direct correlation between the CCFT performance and the cervical rotation ROM, but with the lateroflexion and flexion-extension ROM. These results contribute to an understanding of the physical and psychosocial factors contributing to the development of TTH, which is useful for implementing appropriate prevention or treatment measures.


Mental fatigue largely influences technical performance in soccer, including offensive and defensive skills. However, these effects on technical performance among the soccer players have not yet been aggregated to be assessed systematically.The purpose of the review was to evaluate the impact of mental fatigue on soccer players' overall technical skills.Drawing on Web of Science, PubMed, Scopus, and EBSCOhost (CENTRAL and SPORTDicus), an in-depth search was conducted. PICOS established the eligibility criteria to select the studies as follows: (i) population—healthy soccer players; (ii) intervention—involving any mental-fatigue-prompted protocol; (iii) comparison—control conditions ; (iv) outcomes—technical performance (offensive and defensive skill); and (v) study design—randomized controlled trials.p < 0.001), number of tackles , and the percentage of successful tackles , while there were no significant effects on the number of passes , the percentage of accurate passing , and the number of successful passes .A total of eight studies were qualified for inclusion in the systematic literature review. Overall, the results indicate that mental fatigue had significant effects on technical skills, including offensive and defensive skills. Specifically, there were significant effects on errors  of soccer players was detected, while no significant effects on passing skills were detected. Future studies may consider investigating technical performance together with other important results .https://inplasy.com/inplasy-2022-2-0008/, Inplasy protocol 202220008. Technical performance in sports refers to the capacity to effectively engage at a high standard . This isGenerally recognized as a complex psychophysiological phenomenon, mental fatigue is a condition of fatigue caused by an increase in the demand for cognitive activities . BecauseSpecifically, a variety of performances have been investigated and showed impairment among the soccer players, such as intermittent endurance , 13 and Most recent studies have discussed the impact of mental fatigue on soccer players , 20, 21.As a result, this review presents a meta-analysis investigating the effect of mental fatigue on the overall technical performance of soccer players, which can assist in determining the optimal manner to manage this effect, in turn increasing overall performance during competitions or training. The study hypothesizes that mental fatigue greatly impacts soccer players' technical performance.This review used the PRISMA protocol's list of preferred reporting items . A systeIn addition, the planned analyses considered in this study were performed on INPLASY (ref. 202220008). Even though INPLASY comprises protocols that investigate the effect of mental fatigue, they do not consider the overall technical performance of soccer players. Therefore, the proposed protocol is considered novel.The PICOS approach was used to select the relevant studies . The cho*” OR “skill*” OR “technique” OR “performance”) AND . Moreover, the search was also thoroughly carried out on Google Scholar and references. The PICOS approach was employed to check if the studies were eligible to be included.Keywords and Boolean operators were considered separately and in aggregation during the searching process involving the 5 above-mentioned databases . SpecifiThe title and abstract of each study were checked. Next, the full-text version of the articles was checked. Two independent reviewers performed this procedure. Any disagreement was further discussed. A third reviewer assisted until a consensus was reached if needed. The data that were taken from the literature included (i) authors and year of publication; (ii) characteristics of study participants ; (iii) a description of the control and cognitive tasks; (iv) type of technical performance; (v) assessment of technical performance; and (vi) mean and standard deviation of the results for control and intervention groups. All of the information was then put into an Excel sheet.Methodological quality was examined with the quantitative assessment instrument referred to as “QualSyst” , which cFollowing the Cochrane Collaboration guidelines, the risk of bias was assessed with RoB 2.0 . The sigOverall, two independent reviewers applied the QualSyst and RoB 2 tools, respectively. Either consensus was reached or a third reviewer settled disagreements.I2 statistic was employed to assess the heterogeneity. I2 values were considered having low (or <50%), moderate (or 50–75%), or high heterogeneity (or >75%) .The mean and standard deviation (SD) values for the outcomes were considered to compute the effect sizes  for every result under two conditions . In the absence of mean and SD, 95% confidence interval (CI) and standard error of the mean were used. The discussion of effect sizes relied on the following thresholds: trivial (or <0.20), small (or 0.20–0.6), moderate (or >0.6–1.2), large (or >1.2–2.0), very large (or >2.0–4.0), and extremely large (or >0.4) . A minusor >75%) . Egger'sor >75%) . The thrThis study found 369 unique publications. A total of nine studies were eligible after screening. Google Scholar and reference yielded one additional study. Two reviewers agreed on the outcome. The steps involved in selecting the studies are depicted in Regarding the risk of bias, the Rob 2 tool revealed that six studies , 27, 28 Also, five other studies , 27, 28 Notably, even though two of the studies could be considered for the meta-analysis discussion , small sThe effect of mental fatigue on passes was mainly investigated by analyzing the number of passes, the percentage of accurate passes, and the number of successful passes . These tn = 80). No significant impact of mental fatigue on the number of passes  was detected. Moreover, there was no significant heterogeneity for the overall effect . The weight value of every study was in the range of 26.210 to 46.220%.Three studies  providedn = 80). Mental fatigue had no significant effects on the percentage of accurate passing . Moreover, there was a moderate heterogeneity for the overall effect . The weight value of every study ranged from 30.720 to 37.900% in the analysis.Three studies  providedn = 196). Mental fatigue had no significant effects on the successful passes . Moreover, there was a moderate heterogeneity for the overall effect . The weight value of every study in the analysis ranged from 15.850 to 21.910%.Three studies  providedn = 364). Mental fatigue had a significant effect on errors . Moreover, there was a high heterogeneity for the overall effect . The weight value of every study ranged from 9.200 to 10.830% in the analysis.Six studies  providedn = 204). Mental fatigue had a significant effect on the total number of tackles . Moreover, there was a moderate heterogeneity for the overall effect . The weight value of every study ranged from 16.470 to 21.780% in the analysis.Three studies  providedn = 188). Mental fatigue had a significant effect on the percentage of successful tackles . Moreover, there was a moderate heterogeneity for the overall effect . The weight value of every study ranged from 15.170 to 18.050% in the analysis.Four studies  providedThis review analyzes the effect of mental fatigue on the overall technique of soccer players, including offensive and defensive performance. The main results reveal that mental fatigue negatively influences defensive  and offensive techniques   in the frontal part, possibly leading to a rise in adenosine and reducing the concentration , 40. TheSince the performance of soccer players is impacted not only by offensive approaches but also by defensive ones, comprehending the effect of mental fatigue on defensive tackling could be valuable to soccer coaches. It could optimize a team's overall performance or game strategy, especially near the end of a game .via investigations with a direct comparison between these two technical skills.Previous studies have shown that cognitive resources are used for offensive skills more than for their defensive counterparts . TherefoNotably, all the measures of defensive techniques were recorded during SSGs, which offer an effective and efficient training approach, as opposed to the conventional aerobic approach , 45. HowThis review has noteworthy limitations. First, we only focused on overall performance, which is defined as defensive or offensive skills, and excluded players' physical performance and decision-making skills. Since these outcomes contribute to the overall performance of sports players, it is suggested to examine them together to obtain a more comprehensive view in future studies. Second, only choosing studies in English may have limited the results.The consideration of possible covariance was largely absent in the included studies, such as the trait of self-control, which has been recognized as an ability to manage finite cognitive resources , 50. TheMoreover, mental-fatigue-promoting protocols can be compared against mental boosting strategies (such as music or exposure to nature). The difference between the two selections can provide valuable information for coaches to create effective training strategies. Nature exposure, for example, has been shown to mitigate performance declines caused by mental fatigue . As a reMusic listening was reported to be largely accepted by about 82% of players during the period before a match . MoreoveThis review shows that mental fatigue has a great impact on the offensive and defensive skills of soccer players. However, it is vital to discuss the results carefully, since other important results  have been extensively investigated. The effect of mental fatigue considering factors such as various ages, SSG formats, and pitch dimensions may have a moderating impact; thus, it should be considered in future studies.The datasets generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request.All authors participated in the documentation, development, and writing of the manuscript. This study was reviewed by all authors and all of them were responsible for its contents and the final version.This research was funded by the National Social Science Fund of China (Grant No. 21ATY009).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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Many individuals with cerebral palsy (CP) suffer from pain and must develop pain-coping strategies, although the factors determining them are unknown. This observational study aims at exploring the association between different pain-coping strategies and factors such as age, sex, pain, health status, sleep or motor and cognitive function in individuals with cerebral palsy (CP) and typically developing peers (TD). Main caregivers of 94 individuals with CP ) and the closest relative of 145 individuals with TD ) completed questionnaires on the previous topics . Pain presence, duration, intensity, location and ratings of current and worst pain in the last week in an 11-point numerical rating scale were assessed in an interview. Global health was the best predictor the of use of any type of pain-coping strategy, including cognitive self-instruction, problem-solving, distraction, seeking social support and catastrophizing, in both individuals with CP and individuals with TD. However, different health attributes predicted their use in each population. Emotional health was the best predictor in individuals with CP, whereas cognition and pain were the best predictors in individuals with TD. Speech ability was a predictor in both groups. In conclusion, the assessment of health attributes such as emotional health and speech may help design specific interventions for enhancing self-efficacy and adaptive pain coping skills. More than half of individuals with cerebral palsy (CP) have pain from moderate to severe intensity, on a daily–weekly basis, in multiple body locations ,2. Pain Adults with CP describe pain as a personal experience rarely discussed with their social or health environment and, consequently, implying little use for analgesia . FurtherCognitive–behavioral models postulate that pain coping style plays a crucial role in pain consequences. These models seem equally suitable for individuals with CP, who show consistent links between pain-coping strategies and adjustment to chronic pain . Thus, cSeveral factors, such as cognitive level, pain intensity, function, subjective health, sleep deprivation and age, are determinants in the use of different pain-coping strategies in populations with chronic pain conditions ,11,12,13One hundred fifty individuals with CP and 150 TD individuals from Majorca (Spain) were initially contacted through a letter explaining the details of the study. Physiotherapists from specialized centers  identified participants with CP; simultaneously age-matched TD participants were recruited by asking for volunteers in educational centers: primary schools, secondary schools and universities. Inclusion criteria were the diagnosis of cerebral palsy and ages older than 6 years; the presence of chronic pain was not considered an inclusion criterion. Ninety-four individuals with CP , 34 females) and 145 individuals with typical development , 89 females) agreed to participate in the study. Adults provided written informed consent. For participants under the age of 18, with low cognitive levels or who were legally incapable, parents or legal tutors signed informed consent and participants expressed verbal willingness to participate. This study was approved by the Research Ethics Committee of the University of the Balearic Islands, Spain (ref. 127CER19).Parents or the closest relative in participants with CP, and the closest relative in TD participants, underwent a semi-structured interview consisting of questions on demographic data and pain characteristics. Moreover, they completed several questionnaires on coping strategies, global health and sleep disturbance. To avoid a bias between proxy-reports and self-reports, this procedure was performed for all participants, even if they could self-report. In addition, for participants with CP, the type of cerebral palsy, cognitive level  and level of motor impairment determined by the Gross Motor Function Classification System were obtained from their health history. Pain was measured by using the following information from the interview: (1) whether they were experiencing chronic pain or not  and duration of pain; 2) ratings of current and worst pain in the last week by using an 11-point numerical rating scale ; and (3) the location of painful body regions by using a drawing of the human figure and pain intensity ratings at each location by using a four-point numerical scale  . Pain i ratings Pain-coping strategies were assessed with the Parent Report of the Pediatric Pain Coping Inventory   The PPCIHealth status was assessed with the Spanish version of the Health Utility Index (HUI-3) ,18. The Sleep disturbance was assessed with the Spanish versions of two different questionnaires: the Epworth Sleepiness Scale ,21 and tp < 0.05.Analysis of variance (ANOVA) was performed, including the between-subject factors GROUP  and PAIN (chronic pain vs. non-chronic pain) for the dependent variables pain duration, pain intensity, number of pain locations, coping strategies, health attributes, sleepiness and somnolence. ANOVA results were adjusted by using Bonferroni corrections for post hoc comparisons. Pearson and Spearman correlations, chi-squares and linear standard multiple regression analyses were performed to establish the predictors of coping strategies. Linear multiple regressions were performed separately for individuals with CP and individuals with TD, with the different factors that showed significant correlations with pain coping as predictor variables and the different pain-coping strategies as dependent variables. Durbin–Watson tests were used to check the absence of systematic errors in the multiple regression . Significant levels were set at p = 0.01). The main effect of GROUP  = 4.72, p = 0.031) showed longer pain duration in individuals with CP compared with TD controls. The main effects of PAIN were observed in current pain  = 30.75, p < 0.001), worst pain this week  = 34.27, p < 0.001) and average pain intensity  = 114.43, p < 0.001), with higher pain intensity in individuals suffering from chronic pain than in individuals with non-pain. An interaction effect of GROUP x PAIN was found on the number of painful locations  = 7.74, p = 0.006), indicating that, in both groups, people with pain had more painful locations than individuals without chronic pain (both p < 0.001) and that individuals with CP and chronic pain reported a greater number of painful body locations than TD controls with chronic pain (p < 0.001), whereas no differences were revealed in individuals without pain (p = 0.382).The presence of chronic pain was higher in individuals with CP than in TD controls , revealing that individuals with CP used them more frequently compared to TD controls. No significant effects due to PAIN or to the interaction of GROUP x PAIN were found.p = 0.049), indicating that there were no significant differences between individuals with CP or TD if they had pain (p = 0.734), but in the absence of chronic pain, individuals with CP had lower scores than in TD controls without chronic pain (p = 0.025); moreover, no significant differences in the pain attribute between individuals with or without chronic pain were found for any of the groups (both p > 0.072). The rest of the HUI attributes and the HUI total score revealed the main effects of GROUP , with lower scores  in individuals with CP than in TD controls. No significant effects were found on the HUI emotion attribute.An interaction effect was observed on the HUI-3 score of the pain attribute  = 3.93, p = 0.019) with lower sleepiness in individuals with CP than in TD controls.There were no sleep disturbances in any of the groups or conditions. A main effect of GROUP was found on sleepiness  = 5.6, p < 0.01). Distraction was correlated with somnolence (p < 0.05). Distraction and seeking social support were also significantly correlated with age . No significant correlations were found among coping strategies and any of the pain variables, type of cerebral palsy, gross motor function or cognitive level. Chi-square comparisons did not show significant associations among coping variables and sex . Those variables involved in significant correlations were used as predictors. In addition, the presence of chronic pain was included in the regression analyses to evaluate the effects of chronic pain on pain-coping strategies.Multiple regression analyses were performed separately for each group of participants using each of the coping strategies as the dependent variables. Predictor variables were selected from the variables of pain, age and sleep disturbance, and the health status whose correlations with coping strategies were statistically significant . The samp < 0.516). Additionally, seeking social support was predicted by age. In individuals with CP, all pain-coping strategies were predicted by the HUI total score, and catastrophizing/helplessness was also predicted by age .p < 0.686) and individuals with CP . In TD controls, cognitive self-instruction was predicted by speech; problem-solving was predicted by pain and cognition; seeking social support was predicted by cognition; catastrophizing/helplessness was predicted by pain and speech. In individuals with CP, all coping strategies were predicted by speech and emotion; problem-solving was also predicted by vision.To further examine the role of the HUI attributes for each of the coping strategies in both groups, further regression analyses were conducted using the HUI attributes as predictors . The regThe aim of the present study was to explore the association between different pain-coping strategies and several pain-related factors, such as age, sex, pain characteristics, health status, sleep disturbance or motor or cognitive function, in individuals with CP and TD controls. Our results showed that health status was the best predictor for the use of pain-coping strategies in both groups, although different health factors were relevant in each group of individuals. Thus, the use of coping strategies was associated with emotional health in participants with CP; whereas coping was more related to cognitive factors in individuals with TD. Interestingly, the speech ability was relevant for the use of coping strategies in both groups.Individuals with CP reported a greater presence of chronic pain at more different body locations and with longer duration than controls with TD. Accordingly, individuals with CP also reported more frequent use of all types of pain-coping strategies than participants with typical development. Moreover, the factors affecting pain coping equally modulated the use of active and passive strategies both in individuals with CP and with TD. Thus, our findings seem to better characterize the amount of the use of pain-coping strategies than the quality of them. This greater use of all types of pain-coping strategies has also been reported in other pathologies suffering from chronic pain . HoweverHealth status was an important predictor for the use of pain-coping strategies in both populations, indicating that worse health was associated with more frequent use of coping strategies. Illness symptoms have consistently correlated with coping strategies and poor subjective health or unexplained symptoms have been predictors of maladaptive coping strategies in individuals with low back pain . It has Poor speech predicted higher use of pain-coping strategies both in individuals with CP and TD controls. Poor verbal ability has been previously linked to an increment of behavioral coping strategies . Self-efAlthough cognitive factors and pain intensity may play a relevant role in predicting the use of adaptive and maladaptive coping strategies in TD controls, they are not good predictors for the use of coping skills in CP, as it happens in patients with chronic pain . FurtherAge showed significant correlations with several pain-coping strategies, such as distraction, social support and catastrophizing, revealing higher use of pain-coping strategies in lower ages. In addition, age was a predictor of seeking social support in individuals with TD, indicating higher use of this strategy in younger individuals. In individuals with CP, age was a predictor of catastrophizing, with higher use of this strategy at lower ages. This is in accordance with other studies pointing to the use of different coping strategies at different ages in TD individuals with chronic pain ,37 and sStudy limitations: Proxy-reports, although allowing the inclusion in the study of individuals with low cognitive levels, might be different from self-reports, especially when caregivers report in participants with severe cognitive and verbal impairments, where proxy reports of pain could be inaccurate; moreover, self-reports would have given a more accurate portrayal of the variables. Questionnaires were not intended or validated across all the age ranges. The cognitive level of TD individuals was not assessed, although the data collection procedure was identical to that used in individuals with CP. Gender differences between the groups, as well as the wide age range or the diverse cognitive level, could have biased the results, although these factors did not predict coping strategies in any of the groups. Verbal abilities or the use of augmentative or alternative communicative devices were not assessed, preventing a deeper explanation of the influence of speech on coping strategies. The low number of participants in each gross motor function level did not allow for analyzing potential differences in coping strategies in mild and severe disabilities; moreover, the high percentage of individuals with CP with severe impairment makes the generalization of the findings difficult. The percentage of chronic pain in the control group was rather high; it is likely that individuals with chronic pain were more motivated to participate as volunteers for a control group in a research studying pain.In conclusion, the present study seems to point to emotional health status as a relevant factor in predicting the use of coping strategies in individuals with CP, whereas cognitive factors influencing health appear to be more predictive of coping strategies in TD controls. These findings suggest that deficiencies in emotion regulation, together with difficulties in the verbal expression of pain, could affect the use of pain-coping strategies in individuals with CP. Although the design of the study aimed to include individuals with severe impairment, scantily represented in pain studies, this approach had a risk of bias that makes implications unclear and does not allow generalizing the results. However, our findings open a new path to be explored with future research integrating emotion and pain processes in individuals with CP.


The occurrence group was divided into a study group (n = 30) receiving MBI and a control group (n = 30) without any intervention. Independent risk factors influencing the occurrence of PPD were identified using univariate and multivariate logistic regression analyses. The effect of the intervention was also analyzed in the study group. Education level, marital status, household monthly income per person, sex of the newborn, milk volume, sleep quality, and relationship with in-laws were risk factors for the development of PPD. After the intervention, Five Facet Mindfulness Questionnaire scores were increased in the study group and were higher than in the control group (P < 0.05). The study group also exhibited higher 10-item Connor-Davidson Resilience Scale scores, lower Hamilton Depression Rating Scale and Schizophrenia Quality of Life Scale scores than the control group (P < 0.05). A variety of independent risk factors affected the occurrence of PPD in elderly primiparas, and MBI should be targeted clinically to reduce their negative emotions, increase psychological resilience, and improve their quality of life.This study aimed to investigate the independent risk factors for the occurrence of postpartum depression (PPD) in elderly primiparas and the effect of mindfulness-based intervention (MBI) on improving the PPD. Two hundred cases of elderly primiparas who underwent delivery in our hospital from January 2016 to December 2019 were enrolled as study participants and divided into an occurrence group ( The trend toward older parenthood looks set to continue since women have higher pursuits in their career. Influenced by China's late marriage and delayed childbearing policy, many women embraced motherhood at 30 or 40, and are being referred to as elderly primigravida. Childbirth has a significant impact on mothers with a shift in roles for family members . HoweverDue to the high incidence of PPD, effective screening and diagnosis at an early stage and targeted interventions can reduce the risk of the disease . HoweverThe aim of this study was to identify independent risk factors affecting the occurrence of PPD in elderly primigravida by comprehensively analyzing risk factors for PPD identified in existing studies, designing a questionnaire for the elderly primigravida admitted to our hospital, and performing univariate as well as logistic regression analysis on the collected data. The feasibility of this intervention method was analyzed through a MBI for women with PPD by evaluating their level of mindfulness, psychological resilience, and quality of life.n = 60) and a nonoccurrence group (n = 140) according to whether they developed PPD.By cluster sampling, 200 cases of elderly primigravida who underwent delivery in our hospital from January 2016 to December 2019 were included as participants and divided into an occurrence group (n = 30) and a control group (n = 30). The differences in baseline data between the two groups were not significant (P > 0.05) in terms of education level, marital status, household monthly income per person, and sleep quality.The 60 cases of elderly primiparas suffering from PPD were divided into a study group  First stage. The theoretical knowledge of MBI was introduced to make them understand the process of training. Introductory-level courses, such as mindful breathing and mindfulness meditation, looking up at the sky and feeling the breeze blowing, habit breaking intervention, etc. During the training process, the body and mind were kept relaxed and focused, and emotions stabilized. Mothers can gradually develop the ability to focus on mindfulness.(2) Second Stage. Body scan meditation, mindful walking, sitting meditation, etc. are conducted. These trainings enable mothers to master meditation skills so that they can better handle negative emotions such as anxiety and depression in their daily lives and improve their self-control abilities. After the training, experiences were shared and discussed in group settings, and the changes in emotions and thoughts were observed.(3) Third stage. The content of MBI was reviewed. Mothers were encouraged to integrate mindfulness into their daily lives and summarize the gains and feelings during the training.The Edinburgh Postnatal Depression Scale (EPDS) and the Hamilton Depression Rating Scale (HAMD) were used to determine whether participants developed PPD.The EPDS contains 10 items of anxiety, fear, sadness, crying, insomnia, self-blame, self-harm, hobbies, mental status, and responsiveness, ranging from 0–30. Participants who scored ≥13 demonstrated the presence of depressive disorders, with higher scores associated with more severe depression , 10.The HAMD contains 24 items, and participants scored ≥7 to demonstrate depressive tendencies and >17 to demonstrate depressive disorders .P < 0.05 was associated with PPD.Based on the participants' answers, a univariate analysis was performed and the factor with The factors of interest from the univariate analysis were set as independent variables, assigned values, and then subjected to logistic regression analysis to determine the risk factors affecting PPD.The Five Facet Mindfulness Questionnaire (FFMQ) was used to score the level of mindfulness in two groups before and after the intervention. The FFMQ scale contains 39 items analyzed on five dimensions: observation, description, aware actions, nonjudgment, and nonreactivity, with higher maternal scores indicating higher levels of mindfulness , 13.The level of psychological resilience was assessed using the 10-item Connor-Davidson Resilience Scale (CD-RISC-10) before and after the intervention in two groups. The CD-RISC contains 10 items, and a higher score indicates a higher degree of psychological resilience , 15.The degree of depression in both groups was assessed before and after the intervention based on the HAMD. The HAMD contains 24 items. The higher score indicates the more severe depression.The Schizophrenia Quality of Life Scale (SQLS), which is designed to assess the quality of life of patients with schizophrenia, was used to assess the quality of life in both groups. The SQLS contains 30 items distributed between three factors: psychosocial (15 items), motivation and vitality (7 items), and symptoms and side effects (8 items), with higher scores indicating poorer quality of life , 17.χ2 test were used for univariate analysis, and P < 0.05 indicated a significant difference. Factors with significant differences by univariate analysis were included in a multifactorial logistic regression analysis to determine the independent risk factors for PPD.The collected data were approved and imported into Statistical Package for the Social Sciences (SPSS) 20.0 for statistical analysis . Descriptive statistical analysis and Sixty-five of these participants scored ≥13. Of those 65 participants, 60 of them scored >17 on the HAMD. The prevalence of PPD was 30%, as evidenced by the presence of depressive disorders in 60 of the 200 case in the study.n = 140) and occurrence group (n = 60). According to the statistical results, there was no significant correlation between age, occupation, whether pregnancy was planned and mode of delivery with PPD in elderly primiparas (P > 0.05). Educational level, marital status, per capita household income status, sex of the newborn, milk volume, feeding pattern, maternal personality, quality of sleep, relationship with in-laws, and relationship with husband were correlated (P < 0.05) with the occurrence of PPD and were factors associated with the occurrence of depression  and were comparable between the study and control groups (Baseline data were not significantly different (l groups .P > 0.05). After intervention, the FFMQ scores in the study group were higher compared to the preintervention ones, and the scores of each dimension were increased in the study group. However, nonreactivity scores were decreased in the control group (P < 0.05). The FFMQ scores differed significantly between the two groups  and in the study group (114.48 ± 13.40) did not differ significantly (o groups .P > 0.05) between the two groups before the intervention, and they were higher in the study group and lower in the control group following the intervention, exhibiting significant differences in CD-RISC-10 scores (P < 0.05) (CD-RISC-10 scores did not differ significantly ( < 0.05) .P > 0.05) before the intervention. After the intervention, HAMD scores decreased in the study group and increased in the control group compared to the preintervention (P < 0.05). HAMD scores differed significantly between the two groups after intervention (The difference in HAMD scores between the two groups was not significant (rvention .P > 0.05) and were lower in the study group and higher in the control group than those before the intervention, showing a significant difference between the two groups (P < 0.05)  .The prevalence of PPD within 6 weeks after delivery is as high as 66.5%, decreasing to less than 22% between 6 weeks and 1 year after childbirth . Most adWith regard to the complex mechanisms of PPD, scholars have conducted many studies, and the results have shown that several factors such as social support, couple relationship, maternal personality, life stress, and stress of caring for the baby are risk factors for PPD , 23. ForIn this study, 200 cases of elderly primiparas who underwent delivery in our hospital from January 2016 to December 2019 were enrolled as participants, and the risk factors affecting PPD were identified by multicategorical logistic stepwise regression analysis. Sixty women who developed PPD were grouped. The study group was given MBI, and the patients' mindfulness level and psychological resilience improved, and their quality of life also improved. Evidence has also shown that the degree of psychological resilience in depressed patients showed a positive correlation with quality of life, i.e., patients with higher psychological resilience had a better quality of life , which iIn conclusion, literacy, marital status, monthly household income per person, sex of the newborn, milk volume, sleep quality, and relationship with in-laws were risk factors affecting the development of PPD.The novelty of this study is that, for the first time, PPD in elderly primiparas was analyzed. The shortcomings are as follows: (1) due to the complex factors of postpartum depression and the small number of study samples, the identified factors affecting the development of PPD were limited. (2) Long-term follow-up results need to be verified.


The impact of screen time on mental health, including depression, has attracted increasing attention from not only children and adolescents but also the elderly. Thus, we conducted a meta-analysis of cohort studies to evaluate the association between screen time and depression risk.I2 statistic. Potential publication bias was evaluated using a funnel plot and Begg’s and Egger’s tests.The PubMed, Embase, Web of Science, and China National Knowledge Infrastructure databases were searched for cohort studies up to May 2022, and the reference lists of the included studies were also retrieved. A random-effect model was used to estimate the combined effect size. Heterogeneity was assessed with the I2 = 82.7%, P < 0.001). The results of subgroup analyses showed that the pooled RRs varied according to geographic locations, gender, age group, screen time in the control group, depression at the baseline, and whether the study was conducted during the COVID-19 pandemic. No obvious evidence of publication bias was found.The final analysis included 18 cohort studies with a combined total of 241,398 participants. The pooled risk ratio (RR) was 1.10 , with significant heterogeneity (This study indicates that screen time is a predictor of depressive symptoms. The effects of screen time on depression risk may vary based on the participant’s age, gender, location, and screen time duration. The findings could have important implications for the prevention of depression. Depression is a common and disabling psychiatric condition worldwide . AccordiWith the popularization of modern information and communication technology, time spent using screens on devices, such as mobile phones, laptops, tablets, computers, and televisions, is becoming a core component of daily life , online The relationship between screen time and depression remains controversial, and the biological mechanisms underlying this possible association are unclear. Some studies have reported an independent and interactive relationship between screen time and physical activity , 23–26. This meta-analysis was conducted following the checklist of the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines  and the Studies were included if they fulfilled the following criteria: (1) the exposure of interest was screen time, (2) the outcome of interest was depression, (3) the study design was longitudinal, and (4) provided risk estimates such as hazard ratios (HR), relative risks (RR), or odds ratios (OR) with corresponding 95% confidence intervals (CIs) or sufficient data to calculate them. Studies were excluded if they were as follows: (1) publications that were not full reports, (2) duplicate studies, (3) studies on screen time addiction, (4) studies with inadequate information to calculate risk estimates, or (5) studies reporting time spent on other behaviors as well, causing difficulty in separating only screen time. Two reviewers (QZ and DY) independently reviewed all identified studies by title and abstract or full text. Disagreements were resolved through consultation with a third reviewer (CW).The following information was extracted for each included study: first author’s name, publication year, study source, country, follow-up years, participants’ age range or mean age at the baseline, participants’ gender, sample size, screen equipment, depression measurement, depression definition, depression at baseline, study period, source of participates, screen time measurement, screen time in exposure group, screen time in the control group, depression at the baseline or adjusted, adjusted covariates, and effect estimates with their corresponding 95% CIs. Data extraction was conducted independently by two authors (JZG and QZ). Interobserver agreement was assessed using Cohen’s kappa (κ), and any disagreements were resolved by discussion with a third author (ZL).The methodological quality of the included studies was independently assessed by two reviewers (LL and GZ) using the Newcastle–Ottawa Scale (NOS) , which aP0 indicates the incidence of the outcome of interest in the non-exposed group .I2 = 76.2%); however, this association was not statistically significant in male participants . Screen time was significantly associated with an increased risk of depression in participants who watched television  and used mobile phones . A significant association between screen time and increased depression risk was observed among participants from Asia . The pooled results of studies that excluded baseline depression in their analyses suggested a significantly positive association between screen time and depression risk .Subgroup analyses were conducted by study location, age, gender, sample size, study quality, depression at baseline, depression definition, follow-up time, screen equipment, whether during the COVID-19 pandemic, screen time in the control group, and physical activity controlled for or absent in the models . When stSensitivity analysis was adopted to identify the potential sources of heterogeneity in the association between screen time and depression risk. This helped us to examine the influence of various exclusions on the combined RRs and test the stability of the quantitative synthesis results. The pooled RRs ranged from 1.09 (95% CI: 1.05–1.14) to 1.11 (95% CI: 1.06–1.16) when one study was omitted. The leave-one-out analysis indicated that none of the individual studies significantly influenced the overall results.t = 1.10, P = 0.272; Begg’s test z = 1.08, P = 0.296).Visual inspection of the funnel plot did not reveal any significant asymmetry . Egger’sI2 = 82.7%).We conducted a meta-analysis of 18 longitudinal studies to investigate the association between screen time and depression risk. The pooled results showed that screen time was associated with an increased risk of depression with an RR value of 1.10 , although heterogeneity was high. Our findings support limiting screen time for adolescents. The results regarding the effect of screen time on depression in the elderly were not statistically significant, and our findings did not confirm if the relationship was positive or negative. Insufficient information in the original studies and the wide age range of participants made it difficult to perform a more detailed age group study. Future studies should focus on the effect of age and analyze the effect of screen time on depression risk separately for different age groups. Notably, the results stratified by subgroup, whether the study was conducted during the COVID-19 pandemic, suggested that screen time may alleviate depressive symptoms during lockdowns. Thus, the government should encourage people to use electronic devices to distract themselves and relieve their negative emotions during lockdown situations.The underlying mechanisms of the relationship between screen time and depression risk remain unclear. With the increasing prevalence of depression, depression prevention has become a widespread public health concern. Therefore, identifying modifiable risk factors to aid in depression prevention is an important task. Several hypotheses may explain the impact of screen time on depression. First, increased screen time led to curtailed physical activity, which has been beneficial for reducing depression risk , 64. HowThis meta-analysis highlights the synthesized effects of screen time on depression risk. First, our research was based on cohort studies, which provided much stronger and more sufficient evidence. Second, it included a total of 237,146 participants from seven countries across Europe, Asia, and North America. The large sample size and wide range of locations significantly increased the statistical power and generalizability of the findings on the association between screen time and depression risk. Third, no obvious publication bias was detected in our study, which indicates that the combined results are reliable and convincing overall. Finally, our study excluded mixed sedentary behavior and screen time that could not be separated.Some of this study’s potential limitations should also be discussed. First, recall bias and measurement errors are unavoidable when using self-report questionnaires to assess screen time. Electronic devices, such as mobile phones, computers, and smart televisions, can record time spent using the device in detail, thereby allowing for screen time to be measured objectively and conveniently. Researchers should obtain as much detailed information as possible and use objective measurements in future studies. Second, although included studies had adjusted for confounding factors, some of the included studies did not adjust for potential confounders, such as age, gender, and physical activity level, which might influence the association between screen time and depression risk. Future studies should pay more attention to these important covariates and measure and adjust for key variables. Third, the information in the included original studies was limited; therefore, we were unable to conduct dose-response analyses. Objective measurements of screen time are recommended, so we can easily collect more definite and detailed information about exposure to screen time and further analyze the dose-response effects.This meta-analysis demonstrates that screen time is likely to increase the risk of depression. The high heterogeneity may be the result of a less rigorous original study design across the included studies. The effects of screen time on depression risk may vary widely, and the determinants or the benefits of screen time were shown to differ based on duration and individual characteristics . Among young and female populations, screen time was found to significantly increase depression risk. Compared with less screen time, screen time exceeding 1 h/day was associated with a higher risk of depression. Our findings support the recommendations to limit the prolonged use of electronic devices. Objective measures are recommended to use in future studies to explore complex relationships and specific time constraints of screen time. Considering the increasing prevalence of depression in modern society and the increasing number of people exposed to screens for long periods, our findings have important implications for depression prevention.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.CW and LL conceived the study. GZ, HH, JZ, XK, SY, DY, and ZC were responsible for the collection and cleaning of the data and assisted in the writing of the manuscript. LL and QZ wrote the manuscript. LZ, YG, and ZL contributed to the review and revision of the study. CW was the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. All authors contributed to the article and approved the submitted version.


The sample size effect on the deformation behavior of metallic glasses (MGs) has recently become research of intense interest. An inverse sample size effect is observed in previous experimental studies; where the yield strength decreases with decreasing sample size, rather than increasing. We propose a theoretical analysis based on the shear banding process to rationalize the inherent size dependence of yield strength, showing an excellent agreement with experimental results. Our model reveals that the anomalous inverse size effect is, in fact, caused by a transition in failure mode; from a rapid shear banding process with a shear band (SB) traversing the entire sample in bulk MGs, to an immature shear banding process with propagated SBs only at the surface in micron-sized MGs. Our results fill the gap in the current understanding of size effects in the strength and failure mechanism of MGs at different length scales. The size effects on mechanical properties have been widely investigated in different kinds of materials ,2,3. ForThe size effects on the strength and failure mechanism of MGs at different length scales are important to identify and understand. Aside from the brittle-to-ductile transition in failure mode through sample size changes from a micron-to-nano size regime, many experimental studies on MGs at the micrometer regime have been carried out; moreover, the correlation between sample size and mechanical properties, such as maximum plastic strain, yield strength, and deformation mode, are reported ,27,28,29Arguably, the above-mentioned conflict in size effect may be caused by intrinsic effects; these arise from microstructural heterogeneities, such as sample processing conditions, cooling rates, composition fluctuations, and especially, flaw populations ,31,32. Id > ~10 μm, the inevitable presence of weak flaws introduced during the fabrication process and the inherent structural defects , may easily induce SB initiation [d < 10 μm), due to the lower probability of having weak flaws in small samples and the reduced structural defects in size and population [d < ~100 nm, STZs have little chance for percolation into SBs due to the insufficient space in the nanosized sample [Three different size regimes with different governing deformation mechanisms in MGs are illustrated in itiation . In thispulation ,25,28, wd sample ,19,20. JE is the Young’s modulus; The initial elastic deformation is followed by a jerky deformation with the presence of displacement bursts ,34. In tained by (1)ΔU=σ0It is known that the shear banding process in MGs occurs in stages, consisting of SB formation and SB propagation . Therefoained as (3)UF=2πAssuming that the stress e length . Since tCombining Equations (1)–(4), the yield strength of submillimeter-sized MGs E, 2 [Taking PdSi MGs for an example, ectively . The val 10 J/m2 . The scau et al. . Figure u et al. .Volkert et al. have reported that the yield strength decreases monotonically when the pillar diameter decreases from 8  0.14 μm , which i 0.14 μm ,23,24. U 0.14 μm . Herein,posed as (7)β=d−dectively . CombiniE, In order to verify our theoretical prediction, the yield strengths extracted from the experimental results of Volkert et al.  and Dubaectively . The theIn order to justify our model assumptions, it is instructive to discuss several extrinsic factors; these include the tapering angle, geometry of pillars, and surface strain on the mechanical behaviors of micron-sized MGs. First of all, the appearance of a tapering angle is unavoidable for the focus ion beam (FIB) milling procedure; which has been proven to have a significant influence on the failure and deformation behavior of MG pillars under compression testing ,28. The Furthermore, a core-shell model illustrated in posed as (10)pc=dterature . σcore iPdSi MGs  and ZrTiPdSi MGs , respectIt is intriguing to discuss the difference between the energetic model and the core-shell model for predicting the size effect on micron-sized MGs. The energetic model is based on the assumption that the released strain energy during shear banding is totally utilized for the propagation of a dominant SB. It is necessary to clarify that the initiation of STZs and the formation of tiny SBs during deformation also require some energy; however, they are not considered for convenience. In comparison, the core-shell model is more reasonable. In the core-shell model, the MG micropillar is considered to consist of a soft shell and hard core; this is consistent with the experimental observation that the sample surface is always damaged during the preparation process ,40. MoreG is the shear modulus. T and gT are the room temperature and glass transition temperature, respectively. At the nanoscale, the surface stress 2 from the work of Zhou et al. [In this size regime, the uniform activations of STZs act as the dominant deformation mechanism. According to the cooperative shearing model , the yienificant . GeneralPdSi MGs ; τy is cu et al. . The yieCuZr MGs . As discCuZr MGs  and Lin CuZr MGs , the yieFrom the above discussions, there are three different trends of size-dependent yield strength and the governing deformation mechanisms in MGs. In particular, for the submillimeter-sized MGs, the yield strength is insensitive to sample size and the dominant failure mode is the SB traversing the entire sample. For the micron-sized MGs, the yield strength decreases with sample size, as observed in the work of Volkert et al.  and DubaIn summary, there have been considerable efforts to study the size effect in MGs over the past few years due to both scientific interest and technological significance. However, previous experimental studies in micron-sized MGs have reported conflicting results of increased, insensitive, or decreased yield strength with decreasing sample size. A consensus on the correlation between sample size and mechanical properties has not yet been established. Among previous studies, Volkert et al. and Dubach et al. have reported an anomalous size effect in micron-sized MGs; where the yield strength decreases with sample size. Our present study attempts to propose an energetic model and a core-shell configuration model to rationalize this inverse size effect; these are well-matched with experimental results. This anomalous size effect is suggested to be attributed to the change in the deformation mechanism, where the SB only forms at the micropillar surface. Moreover, we summarize the size effects on the yield strength of MGs in three different size regimes; i.e., the size independence regime in submillimeter-sized MGs, the decreasing regime in micron-sized MGs, and the compression/tension asymmetry regime in nanoscale MGs. The associated failure mechanism in these three size regimes is the full SB in submillimeter-sized MGs, the partial SB in micron-sized MGs, and the homogeneous deformation in nanoscale MGs, respectively. The present study contributes to the current understanding of size effects in MGs at different length scales, which is also helpful to interpret the previous experimental observations.


This study aimed to investigate the association between dry eye disease (DED) and DED-related anxiety and depression tendencies, as well as the risk factors for anxiety and depression in patients with DED of different age groups. This was a cross-sectional study involving 160 patients with DED and 80 healthy individuals aged 20–65 years. All participants completed the investigation of the demographic characteristics, the Hospital Anxiety Depression Scale (HADS), the Ocular Surface Disease Index (OSDI) questionnaire, the Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire, and underwent objective clinical eye examinations. In patients aged 20–40 years, anxiety and depression scores were correlated with OSDI, sleep disorders, and Best Corrected Visual Acuity (BCVA). In patients with DED aged 41−65 years, anxiety scores were correlated with sleep disorders, the level of DED impact on life and work, and the severity of DED. Depression scores were correlated with sleep disorders and the severity of DED. The results indicated that the tendency for anxiety and depression was closely associated with DED and sleep disorders. Moreover, the factors affecting anxiety and depression in patients varied with age. Dry eye disease (DED) is “a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play an etiological role, as defined by the second report of the Tear Film and Ocular Surface Society, TFOS DEWS II –3. DED iThe worldwide prevalence of DED is approximately 5.5−33.7% –6. With To the best of our knowledge, studies on the association between DED and anxiety and depression, such as Sjogren’s syndrome patients or Sjogren’s syndrome patients, and study participants with non-Sjogren’s syndrome, are scarce. Sjogren’s syndrome is a systemic immune disease that tends to cause anxiety and depression among patients. It accounts for a small percentage of daily patients with DED, and patients with non-Sjogren’s syndrome account for the majority of patients with DED. The pathophysiologic changes of DED may occur and may differ between young and elderly patients. Studies have shown that patients with DED aged 20–41 years express more dry eye discomfort symptoms than elderly patients . FurtherEligible participants completed several questionnaires between October 2021 and February 2022 to assess their psychological status and dry eye symptoms. These included the Hospital Anxiety Depression Scale (HADS), the Ocular Surface Disease Index (OSDI), and the Standard Patient Evaluation of Eye Dryness (SPEED). Several clinical eye examinations were also conducted. The study design was approved by the Medical Ethics Committee of the Tianjin Medical University Eye Hospital. The procedures used in this study adhered to the tenets of the Declaration of Helsinki, and informed consent was obtained from all participants included in the study. Dry eye tests were performed on both eyes, and data from the left eye were used for statistical analysis. The questionnaires were self-administered.The criteria for the DED group included non-Sjogren’s syndrome patients with DED seen at the Tianjin Medical University Eye Hospital (160 cases), aged 20−65 years old. Patients with DED were diagnosed according to the definitions of the TFOS DEWS II. DED diagnostic criteria included patients who complained of subjective symptoms, such as eye dryness, foreign body sensations, burning sensations, fatigue, discomfort, redness, and fluctuating visual acuity. Those with the Chinese Dry Eye Questionnaire scores ≥7 or OSDI scores ≥13, and patients with fluorescein tear break-up time (FBUT) ≤5 s, non-invasive keratograph tear break-up time (NIBUT) <10 s, Schirmer I test (SIT) ≤ 5 mm/5 min were diagnosed with DED. Patients with DED-related symptoms and a score of ≥7 on the China Dry Eye Questionnaire or ≥13 on the OSDI, whereas patients with FBUT >5 s and ≤10 s or NIBUT of 10–12 s and SIT > 5 mm/5 min and ≤10 mm/5 min were examined by fluorescein sodium staining of the cornea (FL), and positive staining (≥5 points) to obtain the diagnosis of DED.The criteria for the control group included: patients with non-DED (80 cases), aged 20−65 years, attending the Tianjin Medical University Eye Hospital. Patients without DED were diagnosed according to the definitions in TFOS DEWS II. All participants had to be fluent in Chinese, willing and able to complete a series of questionnaires without much assistance, and willing to perform clinical eye examinations as part of the study.The exclusion criteria for participation in the study included: patients who have used eye medication, such as artificial tears, on the day of the examination; corneal contact lens use within 3 months or eye surgery within 6 months; ocular anatomy or innervation abnormalities ; patients with ocular inflammation and other eye diseases not caused by DED; suffering from systemic immune diseases, such as hyperthyroidism, hypertension, diabetes mellitus, rheumatism, and Sjogren’s Syndrome; use of anti-anxiety drugs, such as benzodiazepines diazepam, lorazepam, alprazolam, and oxazepam; use of antidepressants, such as selective serotonin reuptake inhibitors: fluoxetine, paroxetine, sertraline, fluvoxamine, and tricyclic antidepressants: doxepin, amitriptyline, promethazine, and clomipramine, allergic to fluorescein sodium; and pregnant and lactating women, hormone replacement therapy patients, and menopausal women.The participants completed a standardized assessment of anxiety and depression using the HADS questionnaire. The HADS is a 14-item, four-point Likert scale that contains two subscales . Seven iThe OSDI and SPEED questionnaires were used to complete a standardized assessment of ocular discomfort , 20. TheParticipants’ sociodemographic data were collected, such as name, gender, age, educational background, and sleep status , frequency of sleeping later than 24:00, length of daily visual terminal use , level of discomfort affecting life and work , DED discomfort duration, level of concern about discomfort , and smoking or drinking status.Eye clinical examinations included: best corrected visual acuity (BCVA) , intraocular pressure (IOP), non-invasive keratograph tear meniscus height (NIKTMH), NIBUT, FBUT, FL (12-Point Method), lipid layer thickness (LLT), partial blink rate (PBR), and the SIT. Each examination was performed by the same ophthalmologist. IOP was measured by the Topcon CT-800 computerized tonometer . A non-invasive ocular surface analyzer  was used to measure the NIKTMH and NIBUT. The measurements were performed in a dark room. The time and location of the first tear film break-up were recorded by an infrared camera system. A fluorescein impregnated strip  wetted with non-preservative saline solution was placed in the lower conjunctival sac and the patient was asked to blink several times. Using the cobalt blue filter and slit-lamp microscopy, the time required to observe the first area of tear film break-up after a complete blink was recorded as the TBUT. Each examination was repeated three times and the average of the measurements was calculated. FL was observed through a slit-lamp with a cobalt blue filter and divide the cornea into four quadrants. Each quadrant was graded as 0 (no staining), 1 (1–30 punctate staining), 2 (more than 30 unfused punctate staining), and 3 . An ocular surface interferometer  was used to measure the LLT and PBR. The measurements were performed in a dark room. The patient was asked to look at the indicator light and blink at a habitual frequency. The SIT without topical anesthesia was performed by inserting a sterile Schirmer test strip  into the inferior fornix at the junction of the middle and lateral third of the lower eyelid margin with the eye closed for 5 min.t-test and Mann–Whitney U-test for continuous variables, and the Fisher exact test and chi-square test for categorical variables. A Bonferroni corrected post hoc test was conducted to adjust the observed significant level for multiple comparisons. The association between variables was examined by applying the Spearman rank correlation test and was expressed as the Spearman correlation coefficient. We used multinomial linear regression analysis to investigate the risk factors for the development of anxiety and depression. The statistical significance was defined as a two-tailed p-value < 0.05.Statistical analysis was performed using SPSS for Windows  and reported as means ± standard deviation (SD) or medians. The Gaussian distribution of the parameters was tested using the Shapiro–Wilk test. To assess statistical differences, we used the Student p = 0.300), and the length of use of visual terminals showed no statistically significant difference in the patients with DED aged 41−65 years and the control group (p = 0.765). In addition, sex showed no significant difference between the two age groups (p > 0.05). In the age 20−40 year group, 42 patients (52.5%) felt that the discomfort had a moderate to severe impact on their life or work, whereas in the age 41−65 year group, this value was 37 cases (46.25%). There were 34 patients (42.5%) who were always concerned about discomfort in the age 20−40 year group, compared with 33 patients in the 41−65 year age group (41.25%) (The demographic data are presented in (41.25%) .p = 0.005, 0.8 vs. 0.5; p = 0.038). The LLT of DED participants was also significantly thinner than that of the control group . With regard to comparisons between the projects of the DED group and the control group, the results show a statistically significant difference, except for IOP (p > 0.05).As presented in p = 0.000).To accurately evaluate patients’ discomfort symptoms, we used two DED symptom scales as shown in r = –0.224; p = 0.046), sleep disorders , frequency of sleep late , discomfort duration , level of impact on life and work , and depression scores were found to be correlated with sleep disorders  and discomfort duration  in patients with DED aged 20−40 years. In patients aged 41−65 years, anxiety scores were found to be correlated with sleep disorders , the level of impact on life and work , and the level of concern about discomfort , and depression scores were found to be correlated with sleep disorders , the level of impact on life and work , and the level of concern about discomfort .As presented in r = 0.579; p = 0.000), SPEED scores , BCVA , FL , whereas depression scores were correlated with OSDI scores , SPEED scores , and BCVA . In patients aged 41−65, anxiety scores were correlated with OSDI scores , SPEED scores , NIKTMH , FL , and depression scores were found to be correlated with OSDI scores , SPEED scores , NIKTMH , and FL .As shown in p = 0.014). As presented in p = 0.003; p = 0.019).As presented in Adjusted for independent variables correlated with anxiety and depression scores, multivariate analyses using multiple linear regression revealed that the OSDI, BCVA, and sleep disorders were risk factors for anxiety and depression. OSDI scores and sleep disorders positively affected anxiety and depression scores, and BCVA negatively affected anxiety and depression scores in patients with DED aged 20–40 years , 9. In pIn this study, our results provided insight into the association between DED and anxiety and depression. We demonstrated that patients with DED reported higher anxiety and depression scores than those without DED in both age groups. Anxiety and depression scores were correlated with the OSDI and our study evaluating the association between anxiety and depression with DED parameters reported that anxiety and depression were associated with BCVA in patients aged 20−40 years, and anxiety and depression were associated with FL in those patients aged 41−65 years.n-3 polyunsaturated fatty acids (PUFAs) has been shown to be helpful in alleviating DED symptoms -1, IL-6, and tumor necrosis factor (TNF)-α. These cytokines provoke ocular surface inflammation, resulting in positive fluorescein staining and reduced tear production in patients aged 41−65 years. Therefore, anxiety and depression scores correlated with NIKTMH. Moreover, these cytokines produce and enhance negative mood by affecting neurotransmission and signal transduction  , 59–61. Our study found that anxiety and depression were associated with DED discomfort, sleep disorders, and partial objective DED parameters in patients of various ages. Attention should be paid to patients of different ages. This study has certain clinical significance and may provide guidance for clinicians to treat patients with DED. Health education and psychological counseling should be provided to patients with DED to prevent excessive psychological stress to better alleviate their DED condition and prevent them from developing psychological issues.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 the Medical Ethics Committee of Tianjin Medical University Eye Hospital (No. 2021KY (L)-09). The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.ZL, SS, XS, and YW: material preparation, data collection, and analysis. ZL: write the first first draft of the manuscript and all authors commented on the previous versions of the manuscript. All authors contributed to the conception and design of the study, and read and 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.


Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) has the adverse influence on quality of life and creates significant healthcare costs. However, there were sparse studies investigating the correlation between AECOPD hospital admissions and temperature change. Therefore, it is noteworthy to investigate the impact of various temperature differences and recognize the susceptible population. The purpose of this study was to investigate the impact of temperature differences on AECOPD hospital admissions, and to give potentially helpful material for disease preventative efforts.The distributed lag non-linear model was adopted to characterize the exposure-response relationship and to assess the impact of temperature difference. The stratified analysis and sensitivity analysis were also conducted to determine the susceptible populations and examine the robustness of the results.U-shaped” association between DTDmean and 21 days cumulative relative risk of AECOPD.There were 143,318 AECOPD hospital admissions overall during the study period. The AECOPD hospital admissions had significant association with the daily mean temperature difference (DTDmean) such as the extreme-cold temperature difference (1st DTDmean), the ultra-cold temperature difference (5th DTDmean), the ultra-hot temperature difference (95th DTDmean) and the extreme-hot temperature difference (99th DTDmean). Besides, there was the “The AECOPD hospital admissions was correlated with the DTDmean temperature differences, especially the extreme-cold and extreme-hot temperature difference. Moreover, people older than 65 years were more susceptible to the extreme-hot and extreme-cold temperature difference. Chronic obstructive pulmonary disease (COPD) is a general disease characterized by ongoing airflow restriction and respiratory symptoms . GloballPreviously reported works have demonstrated that ambient temperature have significant association with COPD hospitalization, emergency visits and so forth. For example, a Spanish study found that hospital admissions and mortality for COPD exacerbation were more frequent in autumn and winter . A case-The hospital admissions data of the AECOPD were obtained from the Beijing Municipal Health Commission Information Center and this study was set as the period from January 1, 2013 to December 31, 2016. The data included the anonymous personal information , hospital admission data , and address information (birthplace and present address). International Classification of Diseases 10th revision was used to define AECOPD (ICD-10: J41-J44). To rule out the effect of the floating population on the study's findings, the Beijing resident population were filtrated according to the address information of patients. The daily hospital admissions of different gender subgroups , different age subgroups  and total population were calculated by using the IBM SPSS 26 and R (version 4.1.1). The Peking Union Medical College Hospital (PUMCH) Institutional Review Board approved the study's conduct.The China Meteorological Administration provided the daily meteorological data. It contained both the temperature data , and other meteorological factors . As for meteorological data, four kinds of temperature differences were calculated respectively to represent the temperature change. It contained overall temperature range , daily mean temperature difference , daily maximum temperature difference , and daily minimum temperature difference . The level of air pollution was regarded as one of the confounding factors and adjusted in our study because prior research indicated that air pollution had an adverse influence on multiple respiratory disorders –19. Our https://ivdc.chinacdc.cn/cnic/zyzx/lgzb).The influenza viruses can trigger exacerbations of respiratory diseases –22, the Since temperature typically has a lag effect and prior research disclosed that correlation between COPD and temperature was non-linear , 25. TheE(Yt) represent the number of AECOPD hospital admissions on day t. α and β were the model intercept and regression coefficient, respectively. cb meant the cross-basis function and ns indicates the natural cubic spline function. Tmp refer to the temperature difference. Time refers to the time to control the season and long-term trends. WS, AP, RH, and AQI represent the daily mean wind speed, air pressure, relative humidity, and air quality index on day t, respectively. DOW, IF, and PH are the indicator for day of the week, influenza epidemic status and public holiday. df represent the degree of freedom. All statistical analyses were performed using R (version 4.1.1) software, and the two-sided p-value of 0.05 was conducted to assess statistical significance.Time and 4 for RH, WS, AP, and AQI, or 8 per year for Time and 5 for RH, WS, AP, and AQI in the statistical model to recalculate the CRR of temperature differences. R (version 4.1.1) was used for all statistical analysis along with the packages of “dlnm” and “mgcv.”The single day lag effect was examined using a 3D map that included lag days (Lag), relative risk (RR), and temperature differences. The maximum lag of 37 days was chosen to fully detect the influence of temperature differences and the probable harvesting effects. The figure of association between the specific percentile temperature difference  and relative risk in various lag days were also charted. The extreme-cold, ultra-cold, ultra-hot and extreme-hot temperature difference means first, fifth, ninety-fifth and ninety-ninth percentile temperature difference. The cumulative relative risk of AECOPD hospital admission (CRR) was set to 21 days to fully detect the influence of temperature differences and avoid excessive accumulation. In addition, the stratified analysis was also conducted to determine the susceptible populations and examine the robustness of the results. In various subgroups, the most moderate temperature difference (MMTD) in the total population was taken as the standard. To assess the reliability of findings and the robustness of statistical model, we also conducted sensitivity analyses. We changed the degrees of freedom to 6 per year for U-shaped curve association between the DTDmean and the 21 days CRR (95% C.I.) of AECOPD hospital admissions. From Additionally, we tried to look for the correlation between other temperature changes and AECOPD hospital admissions. However, most of them had no significance. Check out the To examine how robust our results were, the degrees of freedom were modified. As shown in Utilizing a distributed lag non-linear model, our study discovered that there were significant correlations between the hospital admissions of AECOPD and the temperature difference. Overall, a large change in temperature could lead to a rise in AECOPD hospital admissions both when temperature raised and declined extremely.Although different studies have different indicators of temperature change, most of the results were similar from different geological areas. For example, wintertime temperature variability was linked to a higher occurrence of incident respiratory disorders, according to a Chinese cohort of 66,820 older individuals in Hong Kong (≥65 years) with 10–13 years of follow-up. The HR per 1°C change in temperature variability (TV) was 1.20 1.08–1.32) for all incident respiratory disorders and 1.41 (1.15–1.71) for COPD in wintertime . A Taiwa for all Several hypotheses can be made with care, even if the precise physiological processes of the temperature change effect on AECOPD are yet not completely understood. People's capacity to adjust to local climates was hampered by temperature variations, which could raise the chance of unfavorable health consequences like respiratory disorders , 35. TemIn addition, our findings showed people older than 65 years were more sensitive to the extreme-cold or extreme-hot temperature difference. It was agreed with the results in previous studies. A nationwide study suggested that people over 75 and those with respiratory conditions were shown to be particularly vulnerable to temperature changes between days . Aging dThe study contains some solid points. First, the study collected information of over 143,000 AECOPD hospital admissions between January 1, 2013, and December 31, 2016. And the data covered all secondary and tertiary hospitals in Beijing. Longer study periods and larger sample sizes may yield more trustworthy and precise research findings. Furthermore, this is the first research on the association between temperature differences and hospital admissions for AECOPD in Beijing as far as we are aware. At the same time, we analyzed the various temperature differences to find the better indicators of temperature change. Lastly, a number of confounding variables were taken into account in the research, including the impact of the influenza, AQI, and statutory holiday. There are still some limitations to this study. Our research was limited to Beijing, thus results may not generalize to other locales. Besides, as the lack of individualized exposure data, many potential risk factors that could affect the AECOPD hospital admissions such as complication and medication situation were not included.The AECOPD hospital admissions was correlated with the DTDmean temperature differences, especially the extreme-cold and extreme-hot temperature difference. Moreover, people older than 65 years were more susceptible to the extreme-hot and extreme-cold temperature difference.fanzhongjie@pumch.cn.The datasets presented in this article are not readily available because this dataset is now confidential. Requests to access these datasets should be directed to The studies involving human participants were reviewed and approved by Peking Union Medical College Hospital (PUMCH) Institutional Review Board. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.The conception and design in the study were contributed by JF, CH, and ZF. The database was organized by YC, JF, and YL. The methodology was provided by ZF. The statistical analysis was done by ZC and YZ. The software was operated by K-FX and CH. The first draft of the manuscript was written by JF. The submitted version of the work was reviewed, revised, and approved by all authors.