A study was designed to assess whether the individual and combined effects of product-intrinsic and product-extrinsic factors influence the perception of, and liking for, carbonated beverages. Four hundred and one participants tasted samples of one of three flavours  of carbonated aromatised non-alcoholic beer. The beverages were served in receptacles that differed in terms of their colour (red or black) and weight . Each participant received the same beverage in each of the four different receptacles, and rated how much they liked the drink. They also evaluated the intensity of each beverage’s sweetness, bitterness, sourness, and carbonation. The results revealed a significant influence of the colour of the receptacle on perceived carbonation, with the beverages tasted from the red receptacles being rated as tasting more carbonated than when served in black receptacles. In terms of flavour, the participants liked the raspberry beverage significantly more than the others, while also rating it as tasting sweeter and less bitter than either of the other flavours. Furthermore, there was a more complex interaction effect involving the weight of the receptacle: Specifically, the perceived bitterness of the beverage moderated the relationship between the receptacle weight and the perceived carbonation. At high levels of bitterness, the drinks were perceived to be more carbonated when served from the heavier receptacle as compared to the lighter one. These findings highlight the complex interplay of product extrinsic and intrinsic factors on the flavour/mouthfeel perception and preference for beverages, and stress the importance of taking both internal product development and external packaging into account in the design of health-oriented beverages. Human perception and preference for food and beverage products are undoubtedly major determinants of their success in the marketplace e.g., ,2). The . The 2])In terms of product-intrinsic factors, the aroma , colour, and oral-somatosensory texture of food and beverage items have, among others, been found to affect sweetness perception Aromas can be used to modify taste perception , with specific basic tastes , which is in charge of food-intrinsic properties, typically sits far away from, and actually has little interaction with, the marketing department, who may be responsible for product packaging.The current study was designed to assess whether and how the individual and combined effects of intrinsic (flavour) and extrinsic (colour and weight of serving receptacle) factors influenced consumer perception and preference for three differently flavoured carbonated beverages . First, the effects of intrinsic and extrinsic factors were evaluated across all flavoured beverages. Next, potential interactions between intrinsic and extrinsic factors were identified and further analysed using moderation analysis. The underlying hypothesis was that all factors studied—both intrinsic and extrinsic—could influence how consumers perceive and affectively respond to the carbonated beverages. More specifically, given the evidence reviewed above, we would expect perceived sweetness to be influenced by the product flavour (with the berry flavour being perceived as sweeter than the two citrus flavours) and receptacle colour (with red being associated with greater sweetness). Additionally, we would also expect perceived carbonation to be influenced by both receptacle colour and weight (with red colour and heavier weight both being associated with increased carbonation). Furthermore, it is possible that the effect of extrinsic factors could be moderated by the intrinsic properties of the beverages. The study was performed using commercially available products rather than model systems, in order to increase the ecological validity of the study.The effect of receptacle colour  and weight  on consumers’ perception and beverage preferences was tested for three differently-flavoured carbonated beverages in a mixed-model design . Flavour²(2) = 3.74, p = 0.15; for age, F = 1.16, p = 0.31). All of the participants were recruited at the actual test site. The participants were informed that their participation was completely voluntarily and that they could choose to withdraw at any time. Additionally, they were informed that all data would be treated anonymously. After giving their written consent, the participants took a seat at a table within the stand. Since all data were collected anonymously and no potentially harmful procedures were used, ethical approval was not sought for the execution of this study. A total of 401 adult participants  were recruited at Aarhus University’s stand at a large food festival over a two-day period in Aarhus, Denmark. The participants were randomly divided into three groups, where each group tasted one specific flavour variant of the test beverage. The three groups were not significantly different in terms of their gender distribution and age , a non-alcoholic beer which is available on the French market but unfamiliar to Danish consumers, were used in the experiment. As with a regular lager beer, Tourtel® Twist, when poured, has a pale head and is carbonated. The product comes in different flavours as a result of added fruit concentrates and natural aromas, and is described by the distributor to be “without any noticeable bitterness”. The colours of the beverages were all pale and cloudy (due to the presence of yeast particles), ranging from light yellow (Tourtel® Twist Lemon), to light orange (Tourtel® Twist Grapefruit) and finally dusty pink (Tourtel® Twist Raspberry). There were minor differences in the total carbohydrate, sugar, protein, and fat content between the three flavour variants  of Tourtelvariants . Howevervariants , and werFor all three sub-studies, four different types of receptacles were used with two levels of colour (red or black) and two levels of weight (no weight added or extra weight added). Regular 200 mL red and black plastic cups  were used. The colour red was chosen for its positive association with sweetness . While pEach participant was randomly assigned to one of the three beverage flavours. The experimenter provided the participants with four samples of the specific flavoured beverage served in four different types of receptacles see , water, To provide an overview of the dataset as a whole, Pearson’s correlation coefficients for all flavours in combination with all response variables were calculated . To assess the overall effect of receptacle colour and weight on consumer perception and liking for carbonated flavoured beverages, repeated measures of analyses of variance (rm-ANOVAs) were conducted with flavour as a between-participants factor; receptacle colour and weight as the within-participants factors; and rated liking, sweetness, sourness, bitterness, and carbonation as measures. Effect sizes were examined using partial eta squared values. All post-hoc pairwise comparisons were Bonferroni-corrected.To further understand the nuances of interaction effects, we explored the perceived food tastes as possible moderating factors on the influence of receptacle colour and weight using the PROCESS macro in SPSS .To gain an overview on how the response variables were interrelated, Pearson’s correlation coefficients were generated for all response variables for all flavour variants combined. It showed, as expected, that preference was positively correlated with perceived sweetness, and it was negatively correlated with perceived bitterness and sourness see . FurtherblackM = 4.51, Standard Error (SE) = 0.08, redM = 4.66, SE = 0.07, p = 0.02). In addition, there was a significant effect of flavour on preference, sweetness, and bitterness; raspberry was more highly preferred, and it was rated as sweeter and less bitter than grapefruit and lemon. Notably, the effect sizes of the product flavour , which are medium-sized according to [ηp2 = 0.014), which is a small effect.Rm-ANOVAs were conducted with flavour as the between-participants factor, receptacle colour and weight as the within-participant factors, and rated liking, sweetness, sourness, bitterness, and carbonation as measures see . Averagerding to , were laF = 2.76, p = 0.064, ηp2 = 0.014). Further univariate ANOVAs revealed that, for the grapefruit-flavoured beverage, receptacle weight had a significant effect on carbonation, where the beverages in the heavier receptacle were perceived as being more greatly carbonated than the beverages served in the lighter receptacle (heavier(SD)M = 4.69 (0.12), lighter(SD)M = 4.46 (0.13), F = 6.05, p = 0.015, p2η = 0.044). We did not observe similar influences for weight on carbonation, for the lemon (p = 0.79) or raspberry (p = 0.53) flavour variants  = 3.88, p = 0.049; b = 0.078, t(1589) = 1.97, p = 0.049. Furthermore, the interaction plot revealed that for high bitterness levels (defined as one standard deviation above the mean bitterness level), beverages from the heavier receptacles were perceived as being more carbonated than those from light receptacles  and werBesides a study on different coloured yoghurts sampled with spoons of different colours , a studyThe moderating effect of product bitterness on how receptacle weight influences perceived carbonation is a good example of why product-intrinsic factors should be taken into account when designing crossmodal studies (and products). We found that participants who drank from heavier receptacles perceived more carbonation (in agreement with findings from ), but onAlong with calculating the significant differences between the intrinsic (flavour) and extrinsic (colour and weight of receptacle) factors, effect sizes were also calculated. This made it possible to compare which of the factors were most influential in terms of the participants’ ratings of the stimuli. According to the results of the combined flavour model, the effect size of the product flavour was medium, compared to the relatively small effect size of receptacle colour. For this particular study, this means that the intrinsic factor of product flavour was more influential (in terms of explaining a greater amount of variance in participants’ responses) as compared to the extrinsic factor of receptacle colour. It should also be clarified here that the medium effect size of product flavor was found for ratings of overall beverage preference, sweetness, and bitterness, where receptacle colour did not have a significant influence. On the other hand, for the ratings of carbonation intensity, the effect size of the receptacle colour was greater than that of product flavor (where we did not find a significant effect). Therefore, while flavour was more influential than receptacle colour as a whole, these two factors influenced disparate ratings in the present study. Intriguingly, there is a stronger association between carbonation and receptacle colour than between carbonation and product flavour, possibly because red colour and carbonation are both perceived to be higher in terms of arousal/excitement ,47 whereThe present study found that for three commercially available, differently-flavoured carbonated beverages, the flavour as well as the receptacle colour generally affected consumer perceptions and preferences. The raspberry-flavoured drink was the most highly liked, and was rated as tasting the sweetest and least bitter, even though all three beverage flavours contained almost equal amounts of sugar . In ter


Positive feelings are an important health dimension for family caregivers of cancer patients. The aim of this study was to investigate whether Langerian mindfulness is a valid proactive method to increase the positive feelings of family caregivers for cancer patients. Participants were randomly assigned to either a mindfulness group or a mindlessness group and completed the Caregiver Reaction Assessment (CRA) as a measure of caregivers’ feelings before the intervention. Subsequently, both groups were given four sessions of mindfulness training using “innovation classification”. Finally, participants completed the Langer Mindfulness Scale (LMS) and the Positive Aspects of Caregiving (PAC) scale as post-intervention measures. The results revealed that participants in the mindfulness and mindlessness groups differed significantly in LMS and PAC scores, with the mindfulness group having higher levels of positive feelings than those in the mindlessness group. The results also indicated that mindfulness level significantly predicted positive feelings of caregivers. Thus mindful interventions may play a meaningful role in promoting family caregivers’ spirituality and faith, improving the willingness of sharing their thoughts, beliefs, and grief, which could be useful for increasing the positive feelings of caregivers. Incidences of cancer in the world have been rising, with the World Health Organization listing cancer as a chronic disease of high intensity and sustained care needs. Family caregivers are critically important to provide care and enhance the well-being of patients with cancer . Most prThe majority of research on cancer caregiving has long focused on stress, anxiety, and depression . ResearcInterventions regarding caregivers’ negative emotions are more common than those targeting positive emotions, for example, the solutions and connections intervention, based on theories of stress coping , and espInterventions targeting positive feelings have increasingly attracted researchers’ attention , and somLangerian mindfulness has been used in studies examining the relationship between mindfulness and health-related outcomes in caregivers of patients with amyotrophic lateral sclerosis , as wellOverall, based on previous research, the current study aimed to test the effectiveness of a Langerian mindfulness intervention in promoting positive feelings in family caregivers for cancer patients. It was hypothesized that the mindfulness intervention would increase the level of positive feelings in family caregivers. n = 31) or the mindlessness group (n = 29). Participants were recruited from the Department of Oncology in Gulou Hospital, affiliated to Nanjing University in China, and all of them had cared for a patient for longer than one month. Participants were provided with four sessions of mindfulness training (30 min each session). All subjects gave their informed consent for inclusion before they participated in the study. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of Nanjing University. A total of 60 caregivers of patients with cancer participated in the study. Participants were randomly assigned to either the mindfulness group  increased sensitivity to the human environment; (b) increased openness to accept new information; (c) creation of new categories for constructing perceptions; and (d) enhanced awareness of multiple perspectives in problem-solving [-solving . The int-solving . The expLanger Mindfulness Scale. Langer designed the Langer Mindfulness Scale (LMS) to measure individuals’ level of mindfulness [dfulness . The LMSdfulness . In the Caregiver Reaction Assessment. Given et al. [n et al.  originaln et al. . The curn et al. . Positive Aspects of Caregiving Scale. The Positive Aspects of Caregiving (PAC) scale was developed by Tarlow (2004) [w 2004) . Previou004 . Prew (2004) . In addiw (2004) , and it w (2004) . ConsequAll participants voluntarily participated in the experiment and were tested individually in a private room. Participants provided written consent to participate in the study. They were informed that they were to complete a free-association task; a final inquiry showed that no one had surmised the actual purpose of the study. Participants were randomly assigned to two conditions: Mindlessness and mindfulness. Firstly, all participants were assessed using the self-report CRA scale to obtain baseline measurements; next, participants in each group completed either mindfulness or mindlessness intervention tasks; subsequently, they completed the LMS and PAC scales; finally, participants were thanked and debriefed. We used the following steps in the analyses: (i) the data were screened according to the principle of three standard deviations above or below the mean scores, and one outlier was excluded. Consequently, there were 30 participants in the mindfulness group and 29 participants in the mindlessness group. (ii) SPSS 20.0  was used to examine the differences between the mindfulness and mindlessness groups before the intervention. (iii) The mindlessness and mindfulness groups were identified in LMS scores after the intervention. (iv) PAC scores were analyzed between the mindfulness and mindlessness groups which showed a statistically significant difference; and (v) the Pearson product-moment correlation coefficient was used to analyze the relationship between the LMS and PAC scores, using the “enter” method of regression analysis to validate the relationship between caregivers’ mindfulness level and the level of positive feelings. To validate the findings, all study team members participated in discussions about the empirical analysis and writing of the manuscript. r = 0.47, p < 0.01). Moreover, there was no significant difference between the two groups in CRA scores . As predicted, the mindlessness and mindfulness groups differed significantly in LMS scores after the intervention (t(60) = 2.61, p < 0.05, Cohen’s d = 0.68; Mmindless = 97.62, SD = 11.04 versus Mmindful = 105.97, SD = 13.41). Therefore, the mindfulness intervention was shown to be effective. Regarding PAC scores, there was a statistically significant difference between the mindlessness and mindfulness groups (t(60) = 2.56, p < 0.05, Cohen’s d = 0.67; Mmindless= 35.59, SD = 7.89 versus Mmindful = 40.30, SD = 6.20).Descriptive analyses and independent-samples t-tests were performed using SPSS 20.0 to examine the differences between the mindfulness and mindlessness groups. The results showed that the scores of the CRA and PAC were significantly positively correlated . Furthermore, according to the results of the correlation analysis, taking the level of mindfulness as the independent variable, the level of positive feelings as the dependent variable, and using the “enter” method of regression analysis, it was found that caregivers’ mindfulness level can significantly predict their level of positive feelings (t(60) = 2.96, p < 0.01).The Pearson correlation coefficient was used to analyze the relationship between the LMS and PAC scores. The results showed that there was a significant positive correlation between the caregivers’ levels of mindfulness and positive feelings  universally applicable but irrelevant to the subject; (2) specifically relevant to the subject . In prevA growing number of applications and theories have shown that mindfulness training has a positive impact on participants, including positive thinking, emotions, and behaviors. Some examples are the positive effects on perceived stress , studentThis is one of the few studies focusing on the influence of mindfulness on caregivers’ positive feelings. However, this research would not be rigorous enough if limitations were not acknowledged. The study lacked a long-term follow-up; thus, it was not possible to track the persistence of the effects of the intervention and its effectiveness could not be ensured. Moreover, this research did not examine the effect of the mindfulness intervention on the actual care provided to patients. Future studies should track and evaluate the effect of interventions and include the behaviors of participants to better understand the intervention effects. Furthermore, it would be useful to extend mindfulness interventions to other groups, such as patients with cancer, health professionals, and even the general population. In addition, LMS is usually used as a measure of trait mindfulness, thus an alternative manipulation check beside the LMS would be helpful for future studies. Additionally, given the concerns about the reliance on subjective assessment tools for mindfulness, it is recommended that a direct creativity-based tool such as Triangle Task be adopted in the future . OverallThis study has demonstrated that a mindfulness intervention can be an important tool to promote positive feelings in caregivers of patients with cancer, and illustrates the function of mindfulness interventions in the field of health care. Future studies could examine the influence of mindfulness interventions at the behavior level and their practical application. Moreover, future research could broaden the effects of mindfulness interventions using other perspectives or multiple backgrounds.


There was a higher number of subjects previously vaccinated for TB , and of vaccinated subjects found positive for TST and QTF  in the postgraduate group. Conclusion: Latent TB is relatively low among medical school students in our geographic area. Nevertheless, this infectious disease must be regarded as a re-emerging biohazard for which preventive strategies are required to limit the risk of infection, especially among exposed workers.Background: Tuberculosis screening is part of the standard protocol for evaluating the risk of infection in healthcare workers. The aim of this study was to evaluate the prevalence of latent tuberculosis infection (LTBI) among students attending various healthcare profession degree courses and postgraduate medical courses at the School of Medicine of the University of Palermo, Italy, and assess the possible professional origin of infection. Methods: In total, 2946 students (2082 undergraduates and 864 postgraduates) took part in a screening program for LTBI between January 2014 to April 2019 using the tuberculin skin test (TST). Students with a positive TST result underwent a Quantiferon-TB test (QFT). Results: Among the 2082 undergraduates, 23 (1.1%) had a positive TST; the result was confirmed with QFT for 13 (0.62%) of them. Among the 864 postgraduate students, 24 (2.78%) had a positive TST and only 18 (2.08%) showed a positive QTF. Latent tuberculosis infections were significantly more frequent among postgraduates than undergraduates (2.08% > 0.62%,  Italy is one of the European countries with a low incidence of tuberculosis. ‘Tuberculosis surveillance and monitoring in Europe 2019′ showed a notification rate of 6.5 per 100,000 population in Italy in 2017, with a mean annual change in the notification rate of −0.6%. The report showed a TB mortality rate of 0.6 per 100,000 population in Italy in 2017 [Analysis by Italian age group showed that the rate was 15 per 100,000 for 15- to 24-year-olds and 9.4 per 100,000 for 25- to 44-year-olds. Italy was the birthplace of 33.8% of TB cases, and the remaining cases were among the foreign population [Mycobacterium tuberculosis is high [Due to geographical location, some EU areas like Sicily are today facing epochal inflows of new economic migrants and asylum seekers. Tuberculosis is a frequent cause of hospitalization among migrants coming from areas where circulation of  is high .Tuberculosis is a preventable disease. Identifying latent TB infection (LTBI) is vital to achieving the goal of controlling and eliminating TB with specific therapeutic measures.Although there is no diagnostic gold standard for LTBI, two tests are available to identify it: The tuberculin skin test (TST) and the gamma interferon (IFN-γ) release assay (IGRA) . DiagnosCompared to the general population, healthcare workers (HCWs) are known to be at an increased risk of acquiring tuberculosis (TB). Surveillance of other professional categories, such as the Italian State Police (ISP) and undergraduate and postgraduate students attending medical school, has been described and outbreaks of TB disease reported ,5,6,7,8.According to Italian law, students receiving practical training in the territory’s hospitals are regarded as workers exposed to biohazards, as are physicians and nurses regularly employed and working in the various departments. Therefore, they undergo regular health surveillance . To evaluate the epidemiology of LTBI in undergraduate and postgraduate Sicilian students attending medical school, we conducted a surveillance study on the usefulness of identifying LTBI-positive subjects and risk factors among healthcare students in Palermo, southern Italy, using TST, and subsequently Quantiferon testing (QFT-IT) for those with a positive TST result. -Identifying infected subjects to prevent evolution from infection to disease;-Reviewing the adequacy of the protocols; and-Reclassifying risk levels.The main health surveillance system for workers exposed to contagious TB involves monitoring latent tuberculosis infection by:According to the guidelines of the Italian Ministry of Health, published in 2009, the recommended procedure is based on the tuberculin test (TST) . The proThis was a cross-sectional study, including all students attending healthcare profession and postgraduate medical courses at the School of Medicine of the University of Palermo, Italy. LTBI infection was defined by a positive tuberculin skin test (TST) result followed by a confirmatory positive Quantiferon TB test result in an asymptomatic subject .The inclusion criteria for this study were: Asymptomatic undergraduate and postgraduate students, who gave informed consent. Exclusion criteria included: Knowledge of a previous positive reaction to the Mantoux test or to QTF-IT; lost to follow-up due to missed scheduled appointments to collect data, such as TST testing, quantiferon analysis, and clinical record; inaccurate data provided; and refusal to sign informed consent. None of the medical school students were disqualified for exclusion criteria, and all those who presented for the medical examination were enrolled. The study was performed at the University of Palermo’s Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine, and Medical Specialties “G. D’Alessandro”, and involved a sample of 2946 students enrolled between January 2014 and April 2019.2082 undergraduate medical school students attending various degree courses (UMSs), 39.35% male and 60.65% female, aged 18 to 64 years old, with a mean age of 23.80 years old, and standard deviation of 5.01 years old;864 postgraduate medical students (PMSs), 42.36% male and 57.64% female, aged 25 to 57 years old, with a mean age of 30.12 years old, and standard deviation of 3.15 years old.The study population was made up of:We compiled a clinical record for each student, which included information on any conditions or diseases affecting family members, and personal remote and proximate pathologies (anamnesis). We then conducted a physical examination and Mantoux test. HIV and HCV status were analyzed, with none of the participants testing positive. All the enrolled subjects were vaccinated against HBV. All the participants were asked to sign an informed consent letter prior to the processing of data. The study was approved by the local Ethics Committee—Palermo 1.Participant anonymity was guaranteed. No economic incentives were offered or provided for participation in this study. Using anamnesis data, we collected information on the following variables: Age, sex, nationality, incidence of the disease in the country of origin (low/medium/high), parental history of TB, travel or work in countries with a high incidence of TB (not performed by any of them), degree or specialization and year, specifying if the student had already carried out in-hospital training courses  or not , and any previous vaccination against TB (BCG vaccination). ®; Sanofi Pasteur, Lyon, France) was injected into each participant [The tuberculin skin test (TST) was performed by trained personnel following standard procedures: 0.1 mL of purified protein derivative  to confirm LTBI diagnosis, due to the latter’s greater specificity compared to conventional TST. Mycobacteria or BCG vaccination [Several studies have shown how IGRA is more specific than TST. A false positive TST result can be seen, for example, in people who have previously received the BCG vaccine, or in patients with autoimmune diseases ,13,14. Vcination ,16.QFT-IT was performed using TB antigen-, mitogen, and unstimulated tube (nil) at the Central Laboratory of Advanced Diagnosis and Biomedical Research (CLADIBIOR), University Hospital “P. Giaccone”, Department of Biopathology and Medical Biotechnology, University of Palermo, Italy, as previous reported .The cutoff value of the Quantiferon TB test is 0.35 IU/mL greater than the null control for the plasma sample stimulated with the TB antigen: An IFN-γ ≥ 0.35 IU/mL (TB antigens minus negative control) was considered a positive test. Subjects with an antibody TB response above the cutoff rate are probably infected.The IFN-γ concentration level is not necessarily correlated with the stage or degree of infection, or the probability of disease progression, but can be influenced by the subjects’ immune status. Cases of patients with cavitary tuberculosis, cancer, or HIV infection showing low IFN-γ concentration levels have been described in the literature ,19,20. AStudents with a diagnosis of latent tuberculosis were examined by an infectious diseases specialist and underwent a chest X-ray to exclude active TB disease. In the absence of clinical and radiographic signs of active TB, they were considered to have LTBI and underwent a clinical follow up at 6, 12, and 24 months after diagnosis. An infectious diseases consultant evaluated all LTBI cases and the decision to prescribe prophylaxis was made on a case-by-case basis. 2 test and χ2 test with Yates’s continuity correction were performed to evaluate significant differences in proportions or percentages between the two groups. Particularly, the χ2 test with Yates’s continuity correction was used where the χ2 test was not appropriate. In addition, the Binomial test was performed to compare two mutually exclusive proportions or percentages. A significant difference between two means was evaluated by the Student’s t-test. The multivariate analysis was performed with the multiple comparison chi-square test, to define significant differences among percentages (more than two). In this case, if the multiple chi-square test was significant , the post hoc test (Z-test) was performed to identify the significant highest and lowest percentages. Finally, all tests with p-value (p) < 0.05 were considered significant. Statistical analysis was performed using the Matrix Laboratory (MATLAB) analytical toolbox version 2008 . Data are presented as the number and percentage for categorical variables, and continuous data expressed as the mean ± standard deviation (SD) unless otherwise specified. The χp < 0.0001), and there was a significant gender difference as regards students who were LTBI positive for QFT-IT . In this case, the significant number of females who were LTBI positive for QFT-IT might be conditioned by the significant presence of females in the UMS group.Similar to p < 0.0001), but there was no significant gender difference as far as subjects who tested positive for QFT-IT was concerned . In this case, we observed a significant presence of males in the PMS group compared to the UMS group , and consequently, the greater male presence in the PMS group implies there was no significant difference between females and males who tested positive for QFT-IT.Regarding nationality, although the sample consisted almost exclusively of Italians, with only eight foreigners, we found in the UMS group one positive student from a high incidence country (Ukraine), which he had visited before his hospital training, while none of the foreigners in the PMS group were positive.The foreign students in the sample came from Greece (one postgraduate student), Morocco (two undergraduate students), Ukraine (two undergraduate students and one postgraduate), Madagascar (one undergraduate student), and Sri Lanka (one undergraduate student); in all these countries, apart from Greece, the prevalence of TB infection is high.In p = 0.0008), i.e., subjects with LTBI were older than students without LTBI.In the first section of p = 0.756; PMS: 100% = 100%, p < 0.0001) and preclinical subgroups . As far as university training is concerned, no significant differences were observed in the UMS or the PMS group, or between students without LTBI and students with LTBI in both the clinical . BCG vaccination analysis showed a higher percentage in both the UMS and the PMS group of BCG-vaccinated students with LTBI compared to students without latent tuberculosis , and a significant presence of students without BCG vaccination vs. students with BCG vaccination .In the second section of p = 0.053), but a significant presence of students with clinical university training . In the third section of p = 0.0042). Post hoc analysis (Z-test) showed that the medical schools with a significantly higher number of students with a positive Mantoux test, confirmed at QFT-IT, were: Digestive system surgery , emergency surgery , urology , and otolaryngology . Finally, we observed a significant connection between all the postgraduate schools and LTBI (p = 0.0003), students with clinical university training , vaccinated students , and students with positive Mantoux and QFT-IT results , while in the UMS group, there was a significant presence only of students with preclinical university training .In the fourth section of p = 0.0060; UMS clinical: 53.85% < PMS clinical: 100%, p = 0.0060) and TB vaccination . Finally, in the fifth section, we compare the UMS and PMS groups, considering students with LTBI only. Significant differences were found only for university training , as described in We found a statistically significant result regarding the higher number of students with LTBI in the PMS group compared to the UMS group , and for 31 of them, diagnosis was confirmed with QFT-IT (13 UMS and 18 PMS). A large part of the students enrolled in our study were Italian, and Italy is considered to be one of the European countries with a low incidence of tuberculosis . Only in the UMS group was there a significantly higher presence of females with LTBI. These results are in accordance with recent data, which showed that 59% (in OECD countries) and 66%  of PhD graduates in the healthcare field are women . In thisMost of the enrolled subjects were undergraduate students who had had preclinical and clinical university training; on the other hand, all the postgraduate medical students had clinical experience in a hospital setting. There was a significantly higher number of students with LTBI in the PMS group, particularly among older subjects. This may be due to their longer clinical training in terms of exposure to patients, and greater risk of exposure to occupational infections.TB vaccination analysis showed a significant difference between the two groups of students: 17% of postgraduate medical students had received BCG vaccination versus 0.24% of undergraduate students. Mycobacteria. Thus, this undergraduate group was excluded from tuberculosis (TB) vaccination [As previously mentioned, compulsory BCG vaccination for all students attending medical faculty degree courses in Italy was abolished in 2001, and the vaccine is now only reserved for students exposed to multi-drug-resistant cination . On the Mycobacterium tuberculosis: (US: 7.69 < PMS: 66.67%). This confirms that BCG vaccination is not always effective in preventing Mycobacterium tuberculosis infection. The benefits of BCG have been vehemently debated for many years and a consensus has been hard to reach, especially as far as the adult population is concerned. Quantiferon analysis for Mantoux-positive students reduced the number of them with latent tuberculosis, since the test can be influenced by various factors, including skin hyperreactivity or BCG vaccination. In this regard, it is interesting to observe how some vaccinated subjects in our sample are infected with Regarding the specialization schools attended by our participants, no significant statistical differences between the various areas have emerged, although the number of subjects with LTBI is very small. We observed that digestive system surgery, emergency surgery, urology, and otolaryngology were the specialization schools with a significantly higher presence of students with LTBI, although the number of students in these schools was low.As regards the fact that some of our subjects with LTBI attended specialization schools that are not historically linked to TB, such as digestive system surgery, emergency surgery, urology, and otolaryngology, we believe that students in these contexts have still not developed the critical thinking required to foresee the importance of taking universal precautions. Thus, they tend to consider the use of gloves to be adequate self-protection and fail to take any prevention measures against tuberculosis. This attitude is reported by Bergamini et al. . SimilarDue to the current very frequent migration from countries with a high incidence of tuberculosis to Italy, it is likely that the incidence of LTBI and TB disease will increase in the general population.In this regard, faculty of medicine students and, even more so, specialists and doctors in service in hospitals will be at a greater risk of contracting infection and illness at work.As also highlighted in this study, the risk is not confined to traditional specialist contexts, such as the infectious disease units, emergency departments, radiology, or pneumology. It also exists in very different specialist contexts, where patients, sometimes without a diagnosis of tubercular disease, present with other coexisting diseases. Greater attention is needed when working in contexts where the risk exists. Moreover, healthcare workers in Italian companies are required by law to participate in training and information programs.The incidence of LTBI among the medical students in our study turned out to be very low, similar to what has been observed in analogous contexts in other Italian universities, but lower than in recent German studies, and is work-related ,28,29,30Although this study detected just a few cases of LTBI, its prevalence in our population may be relevant to improving our knowledge of latent tuberculosis among Italian young adults, especially those exposed in the workplace, as data relating to LTBI in the general Italian population are not known. Our results confirm that the incidence of LTBI is low in Italy but also that effective prevention strategies need to be implemented in the university hospital under study. However, the authors stress that, as in the case of healthcare workers (HCWs), there is an occupational risk of students undergoing clinical training contracting tuberculosis, due to close and prolonged contact with patients.In a country like Italy, where the presence of TB is low, screening programs for healthcare students may be useful in this era of international exchange for early identification and treatment of LTBI ,32,33.This study had a good sample size but it was conducted in a single geographical area. Therefore, a multicenter study that examines different geographical areas is needed in order to determine the prevalence and incidence of latent tuberculosis infection and associated risk factors among HCWs student, and their adherence to LTBI screening.Ethics approval and consent to participate: Informed consent was signed by all participants in the study. Anonymity was guaranteed for all participants. The study was approved by the Local Ethics Committee Palermo-1 on 23 May 2016 (document n. 21).


This study uses an explanatory model of the dimensions of leadership and emotional intelligence according to the methods used in particular teaching environments . The effect of different kinds of leadership on emotional intelligence dimensions is also established using an explanatory model. A total of 954 teachers participated in this cross-sectional study, teaching in 137 different schools/universities. The instruments used for the data collection were the Multifactor Leadership Questionnaire (MLQ-5) and the Trait Meta Mood Scale (TMMS-24). Data analysis was performed with the software IBM AMOS 23.0.  using multi-group analysis and structural equations. Results showed that the structural equation model had a good fit. Transformational leadership depends mainly on intellectual stimulation in university teachers, whereas intrinsic motivation is more relevant at the lower educational levels. In relation to transactional leadership, contingency reward has a greater regression weight in non-university education, whereas passive leadership is governed more by passive exception in university teachers. There was a positive and direct relationship between levels of emotional intelligence and transformational leadership in non-university teachers, which reveals the need for effective understanding and management of both one’s own and students’ emotions in order to act effectively as a leader. Transactional leadership was negatively related to some emotional intelligence dimensions, given the relevance of obtaining power in this dimension. Teachers’ personal traits as well as their professional skills are significant in relation to bringing about behavioral changes in students . Among tIn light of the scientific literature on this topic, above all focusing on emotional understanding and control skills, these factors are considered predictors of a better management of everyday life and are related to higher levels of well-being and psychological adjustment ,5,6,7. ONotwithstanding the various viewpoints from which emotional intelligence and positive psychology have been studied, it can be seen that almost no studies address leadership as indicated by Sánchez et al. , despiteA positive relationship was found between emotional intelligence and the different styles of educational leadership . In factRecently, the term leadership has come to represent one of the most important and recurrent lines of research in studies on organizations in general and on educational institutions in particular ,16,17,18The idea of implementing emotional intelligence as a tool to improve teachers’ leadership and well-being has been considered in almost all educational institutions worldwide. Specifically, Asrar-ul-Haq et al.  have carIn this way, several researches determine the existence of different types of leadership ,21,22,23Bearing all this in mind, this study is based on the following theoretical assumption and hypothetical model  with theThe model that has been developed aims to ascertain the connection between the emotional intelligence dimensions  of teachers and their different leadership styles, since various studies show a close relationship between them ,25,26. AIt is also convenient to eliminate connections between dimensions in the TMSS-24, since each of the parameters  is an independent entity. In the same regard, and according to Marsh , it is cIn the proposed model, passive leadership, transformational leadership, and transactional leadership act as exogenous variables, whereas behavioral idealized influence, attributed idealized influence, inspired motivation, intellectual stimulation, individualized consideration, contingent reward, management-by-exception passive, laissez-faire, emotional intelligence perception, emotional intelligence understanding, and emotional intelligence regulation act as endogenous variables. Two-way arrows (covariances) connect exogenous variables, whereas one-way arrows reveal the effects (direct and indirect) between endogenous variables. Associations are established between prediction errors in the endogenous variables, which receive the effects of others and need errors in variables. Estimation of the parameters was carried out using the maximum likelihood estimation method (ML), which is coherent, non-biased and unaffected by the type of scale. Thus, this study has as its main objectives: (a) to analyze and determine the relationship between leadership and emotional intelligence in Spanish teachers; (b) to define and contrast an explanatory model of the dimensions in emotional intelligence according to leadership styles and type of teaching (in universities or otherwise), and (c) to analyze the effect of leadership styles on emotional intelligence dimensions using a multigroup explanatory model according to different educational levels.This descriptive and cross-sectional research project was carried out on a sample of 954 teachers in Spain, both men and women , from 137 schools, with different typologies and levels . The sample was chosen by random sampling among teachers from all educational levels in Spain , being 117,716 university teachers and 573,519 teachers at other levels. The sampling error was acceptable, specifically 0.03 for the overall sample (0.06 for university teachers and 0.04 for the rest). It should be noted that 65 questionnaires were invalidated because they were not properly completed.Three different types of instrument were used in this project. The first was a self-completion questionnaire where the teachers indicated their gender, their age, and their seniority or the educational level at which they taught .The second instrument used was the MLQ-5X by Bass & Avolio , named iThe third instrument is the TMMS-24, which is based on the Trait Meta Mood Scale (TMMS-24) proposed by Salovey, Mayer, Goldman, Turvey, & Palfai . The oriFirstly, all the teachers in Spain were counted. Then, the Faculty of Education of the University of Granada (Spain) composed an explanatory letter inviting people to collaborate. This document explained the nature and objectives of the study and requested the consent of those willing to participate. Once an affirmative reply had been received, the questionnaire was sent by email so that participants could answer frankly; in some cases, on request, the questionnaire was mailed in paper form. A total number of 1019 teachers took part in this project, 65 questionnaires being invalidated because they were not correctly completed. The instruments were applied from January to March 2018. Anonymity and confidentiality of data was ensured. Data were collected and its quality was confirmed, whilst ensuring throughout that the process conformed to the ethical principles for research defined in the Declaration of Helsinki in 1975 and later updated in Brazil in 2013. For data analysis, the statistical software IBM SPSS 24.0.  was used in order to establish the values of the basic descriptors (means and frequencies). For the analysis of relations and effects existing between the constructs of the structural model, program IBM AMOS 23.0.  was used, carrying out a multigroup analysis. A model of route analysis was created with the following observable variables: transformational leadership (LTRANSF); transactional leadership (LTRANSA); passive Leadership (LPASIVO); Behavioral Idealized Influence (IIC); attributed idealized influence (IIA); inspired motivation (MI); intellectual stimulation (EI); individualized consideration (CI); contingent reward (RC); management-by-exception: passive (DEP); laissez-faire (LF); emotional intelligence perception (PERIE); emotional intelligence understanding (COMIE); emotional intelligence regulation (REGIE).Model fit was checked in order to verify compatibility and the empirical information obtained. Fit reliability was assessed using Marsh’s goodness-of-fit indices, which indicate that in Chi-square, non-significant values associated with p denote a good model fit. The comparative fit index (CFI) will be acceptable if higher than 0.90, and excellent if higher than 0.95. The normed fit index (NFI) must be higher than 0.90; the Incremental Fit Index (IFI) will be acceptable if higher than 0.90 and excellent if higher than 0.95. Finally, the root mean square error of approximation (RMSEA) will be excellent if lower than 0.05 and acceptable if lower than 0.08.The descriptive study of data relating to the 954 participants established that values were similar by gender. The greater proportion of non-university teachers is also significant, most such participants having worked as a teacher for less than 20 years. As regards the distribution of teachers according to education type, there were more men (35.6%) than women in higher education, the proportions being reversed in all other types of education. Regarding the length of service, there is a greater presence of senior teachers in higher education, as can be seen in the following table .2 = 273.540; gl = 70; p < 0.001). Nevertheless, this index cannot be interpreted in a standardized way, added to which a problem is posed by its sensitivity to sample size [The proposed structural equation model obtained a good fit in all assessment indices. The Chi-square had a significant value of p  and Intellectual Stimulation (r = 0.784). Likewise, the same tendency is found in Passive Leadership (p < 0.005), with a stronger correlation in Laissez-faire (r = 0.780) and Transactional Leadership (p < 0.005), Contingent Reward being the variable with the highest positive correlation in relation to its dimension (r = 0.842).p < 0.005. In contrast, Passive Leadership is inversely related to Transformational Leadership (r = −0.375) and to Transactional Leadership (r = −0.298), both being significant at a level of p < 0.01.Next, relations between the different leadership dimensions were analyzed. A positive and direct relationship between Transformational and Transactional Leadership is found (r = 0.863), the level being significant at p < 0.01 between Transactional Leadership and Emotional Intelligence Regulation (r = −0.673), and between Transactional Leadership and Emotional Intelligence Understanding (r = −0.447), both negative and inverse. Finally, no association was found between Passive Leadership and the three dimensions of Emotional Intelligence .Checking associations between Leadership and Emotional Intelligence, statistically significant differences are revealed between Transformational Leadership and Emotional Intelligence Regulation (r = 0.986), and between Transformational Leadership and Emotional Intelligence Understanding (r = 0.785), both positive and direct. The same tendency is displayed in the relation between Transformational Leadership and Emotional Intelligence Perception (r = 0.311). Likewise, statistically significant differences are found in level p < 0.005 level for all the associations between Transformational Leadership and the indicators in this dimension, all of them being positive and direct, the factors having the strongest correlation being Inspired Motivation (r = 0.787) and Intellectual Stimulation (r = 0.829). Likewise, the same tendency is displayed for Passive Leadership (p < 0.005) with a stronger correlation in Management-by-exception Passive (r = 0.589), and in Transactional Leadership (p < 0.005), with Contingent Reward being the variable with the highest positive correlation with its dimension (r = 0.738).p < 0.005. In contrast, Passive Leadership is inversely related to Transformational Leadership (r = −0.441) and Transactional Leadership (r = −0.443), both being significant at level p < 0.01.Next, the relations between the different leadership dimensions are analyzed. In the first place, a positive and direct relation is revealed between Transformational Leadership and Transactional Leadership (r = 0.997), being significant at level p < 0.05).Analyzing the associations between leadership and Emotional Intelligence, the only statistically significant difference found was between Passive Leadership and Emotional Intelligence Understanding, being positive and direct .From the findings obtained herein, it can be deduced that the most influential indicator of transformational leadership in non-university teachers is intrinsic motivation, attributed idealized influence exerting the least influence. This could be related to the vocational component inherent in education at basic levels (Infant and Primary), in line with the studies by Evers et al.  and AndeIn the case of university teachers, the most relevant indicator of transformational leadership is intellectual stimulation. This may be due to teaching strategies that aim to generate problems and get students to solve them in the context of higher education . This tyWith regard to passive leadership, it should be noted that the Laissez-faire dimension was the most relevant for non-university teachers, since at basic levels it is common to use methodologies based on the discovery and self-management of resources and tasks, with the aim of acquiring certain skills . In addiIn relation to transactional leadership, contingent reward is the most influential factor in both types of teacher, although the correlation is stronger for teachers at the lower educational stages. This is common, given that contingent reward is based on the positive reinforcement of appropriate behavior, which is a widely used strategy for controlling contingency in infant and primary education . By contAnalysis of the links among leadership dimensions showed a positive and direct relationship between transactional and transformational dimensions, which was stronger in university teachers. Transformational leadership is characterized by a leader’s desire to bring about change, and in order to do so, he or she needs to be granted authority by the group. Similarly, transactional leadership is characterized by increasing empowerment of the leader as positive benefits for the group are achieved, evidencing the relationship between the two types of leadership . Some unIn the case of university teachers, there is little connection between emotional intelligence and leadership, the only positive relationship being that between passive leadership and emotional understanding, which implies that these teachers have less need to understand emotions in order to act as leaders. In the case of non-university teachers, this relationship is not statistically significant, contrary to the findings of Majeed et al. , which pIt is notable that in non-university teachers there are various connections between leadership and emotional intelligence that are not found in university teachers. As suggested by Halitsan et al. , as partFinally, transformational leadership was positively related to emotional understanding and emotional regulation, having a strong positive and direct association that was not found in university teachers, thus confirming the conclusions of Majeed et al. . LikewisThe data obtained from this study show the importance of conducting studies in this sphere, since, from the point of view of positive psychology and leadership, it is interesting to discover the influence of emotional intelligence on teachers’ ability to act as leaders, not only in higher education, but at all educational levels. One of the limitations of the study is that the multigroup analysis could only be performed on two groups, so a breakdown of the associations between variables for each of the different educational levels would give the study greater richness. Another limitation is the representativeness of the various groups, there having been substantial participation by infant, primary, secondary and university teachers, which was not the case in other categories .Transformational leadership depends mainly on intellectual stimulation in university teachers, whereas intrinsic motivation is more relevant at the lower educational levels. In relation to transactional leadership, contingency reward has a greater regression weight in non-university education, whereas passive leadership is governed more by passive exception in university teachers.There is a positive and direct relationship between transactional leadership and transformational leadership, which is stronger in university teachers. Additionally, both are inversely related to passive leadership at all levels.There is a positive and direct relationship between levels of emotional intelligence and transformational leadership in non-university teachers, which reveals the need for effective understanding and management of both one’s own and students’ emotions in order to act effectively as a leader. Transactional leadership was negatively related to some emotional intelligence dimensions, given the relevance of obtaining power in this dimension.The main conclusions of this study are:


Long-term venous access has become the standard practice for the administration of chemotherapy, fluid therapy, antibiotics, and parenteral nutrition. The most commonly used methods are percutaneous puncture of the subclavian and internal jugular veins using the Seldinger technique or surgical cutdown of the cephalic vein.  This study is based on a quality registry including all long-term central venous catheter insertion procedures performed in patients >18 years at our department during a five-year period. The following data were registered: demographic data, main diagnosis and indications for the procedure, preoperative blood samples, type of catheter, the venous access used, and the procedure time. In addition, procedural and early postoperative complications were registered: unsuccessful procedures, malpositioned catheters, pneumothorax, hematoma complications, infections, nerve injuries, and wound ruptures. The Seldinger technique using anatomical landmarks at the left subclavian vein was the preferred access. Fluoroscopy was not used.  One thousand one hundred and one procedures were performed. In eight (0.7%) cases, the insertion of a catheter was not possible, 23 (2.1%) catheters were incorrectly positioned, twelve (1.1%) patients developed pneumothorax, nine (0.8%) developed hematoma, and three (0.27%) developed infection postoperatively. One (0.1%) patient suffered nerve injury, which totally recovered. No wound ruptures were observed.  We have a high success rate of first-attempt insertions compared with other published data, as well as an acceptable and low rate of pneumothorax, hematoma, and infections. However, the number of malpositioned catheters was relatively high. This could probably have been avoided with routine use of fluoroscopy during the procedure. The use of tunneled long-term venous catheters has become the standard practice for the administration of chemotherapy, fluid therapy, antibiotics, and parenteral nutrition. Long-term venous access was first described by Broviac et al.  and HickThere are several approaches to implantation; percutaneous puncture using the Seldinger technique  or surgiThe most common complications related to the insertion of venous ports/central venous catheters (CVC) are malposition, pneumothorax, accidental arterial puncture, hematoma, infection, nerve injury, wound rupture, malignant arrhythmias, and thrombosis , 9.Our study is based on a quality registry of percutaneous tunneled long-term central venous catheterizations performed at our department during a five-year period. The aim of the study was to investigate procedural and early postoperative complications.This study is based on a quality registry containing data on all tunneled long-term central venous catheterization procedures performed at the Department of Anaesthesiology, Oslo University Hospital, Ullevaal in the period lasting from 01.01.2012 to 31.12.2016. The data for the first three years are retrospective, and for the two remaining years, the data were prospectively collected. Both the creation of the quality registry and the publishing of the registry data have been approved by the hospital's data protection officer, and the registry data are stored and processed on a local data server approved by the data protection officer.In the quality registry, the patient data were registered and analyzed for procedural and early postoperative complications. The following demographic data were registered: sex, age (yr.), weight, height, and body mass index (BMI). Only patients >18 years were included.In addition, the patients' main diagnosis and indications for the procedure were registered. For one single patient, several indications could be registered.The following blood tests were routinely performed and registered in most of the patients: hemoglobin, activated partial thromboplastin time (APTT), international normalized ratio (INR), and platelets.The identity of the operator (an anaesthesiologist) and the assistant (a nurse anaesthetist) was also registered, as well as the type of catheter and the venous access. Three types of catheters were used: Braun Celcite® Implantable Venous Port (single or double lumen), Bard Hickman® Catheter , and Bard Hemostar® Long-Term Hemodialysis Catheter.The preferred site of access was the left subclavian vein, except for in patients with previous surgery for left-sided breast cancer and in patients with a preference for the right side. In cases where access via the subclavian vein was not possible, the procedure was performed using an access via the jugular vein at the same side. When access via the jugular vein was also unsuccessful, the procedure was defined as unsuccessful. Fluoroscopy was not used during the procedures, and when the procedures failed, a new procedure in cooperation with a radiologist using ultrasound and fluoroscopy was usually performed the following day.Occasionally, the preferred site of access had to be changed in some patients due to prior central vein thrombosis.μg/ml was administered as local anaesthesia, and for sedation, a combination of midazolam and fentanyl was given. In some patients, propofol was additionally administered. In patients experiencing pain during the last part of the procedure, alfentanil was administered. Prophylactic antibiotics were not used. Patients with platelet levels less than 20–30 × 10/L received platelet infusion immediately before or during the procedure. The catheters were locked with heparin 100 IE/ml at the end of the procedure. The procedure time and total operating room time were registered. In all cases, a chest X-ray was performed two hours or more after the catheter insertion.The procedures were mainly performed by four experienced anaesthesiologists (>10 years as consultants) using the Seldinger technique . HoweverThe following main complications were registered for the whole five-year period: unsuccessful procedure, malpositioned catheters, pneumothorax, with or without the need of chest tube drainage, hematoma, infection , nerve injury, wound rupture, and malignant arrhythmias during the procedure. We assumed that an infection which occurred the first week indicated a procedure-related infection. Infections occurring later than one week after insertion were not registered. Accidental arterial punctures were registered only for the two last prospective years and is therefore not included in the results.t-test for continuous variables with nearly normal distribution and nonparametric test for not normal distributed variables. The chi-squared test was used for categorical data. All comparison tests were two-tailed. The Statistical Package for the Social Sciences (SPSS) version 23  was used for analyzing the data. The significance level was set to 0.05.Two different groups of anaesthesiologists performing the insertions were also compared: the experienced group (the four anaesthesiologists who inserted most of the catheters) and the less experienced group (the other 13). Our hypothesis was that the experienced group had fewer complications and used less time performing the procedures. We also investigated if there were any significant differences regarding complication rates between the operators at an individual level. The data were analyzed using the independent samples During the five-year period, a total of 1101 procedures were performed, and 1099 tunneled long-term catheters were inserted. Two of the patients received a short-term central venous catheter. One patient had five catheters inserted, one patient had four, 13 patients had three, and 56 patients had two catheters inserted during the five-year period.The demographic data are presented in The five most common indications for the procedure were chemotherapy (77.7%), difficult vein access (37.0%), parenteral nutrition (15.3%), administration of other medications (8.6%), and fluid treatment (4.9%). More than one indication could be registered for one single patient.n = 837) of the tunneled catheter insertion procedures. In total, 17 anaesthesiologists, both consultants and residents, performed the procedures. Four consultants performed 76% (The mean procedure time was 41 min (range 15–210 min). The mean operating room time was 71 min (range 35–265 min). For sedation, four different drugs were used: fentanyl , midazolam , alfentanil , and propofol .p < 0.001; operating room time: mean 67 min vs. 83 min—p < 0.001). There were no significant differences in the number of unsuccessful procedures, malpositioned catheters, and in the rate of pneumothorax, hematoma, infection, nerve injury, and wound rupture between the two groups. In addition, we did not find any significant differences regarding the complication rates between the individual operators (data not shown).In the comparison of the experienced group (the four consultants performing 76% of the procedures) to the other 13 anaesthesiologists, we found that there were statistically significant differences in the procedure time and the operating room time in favor of the experienced group  placements with the Seldinger technique (both the jugular and the subclavian vein) compared with the venous cutdown technique via the cephalic vein . This reA systematic review and meta-analysis by Orci et al. demonstrated a higher primary success rate with percutaneous subclavian vein puncture vs. surgical venous cutdown. In this review, no significant differences in terms of risk of pneumothorax, hematoma, or infectious events were found; however, pneumothorax only occurred after the percutaneous approach .Of the 1,101 procedures in our material, 1,093 (99.3%) of the long-term catheters were successfully implanted at the first attempt. Compared with other published data, this is a high success rate , 14. In We defined the success rate after also performing via the jugular vein at the same side when access via the subclavian vein failed.The usual reasons for an unsuccessful surgical cutdown procedure via the cephalic vein are that the vein is impossible to locate, too small, or occluded . When miA recent Cochrane systematic review summarizes the current evidence for ultrasound (US) guidance vs. anatomical landmark techniques for central venous catheter (CVC) placement in the subclavian vein with regard to complications . The metAlthough the use of ultrasound offers small gains in safety and quality, the authors concluded that the meta-analysis does not generally support the use of ultrasound for CVC placement in the subclavian vein.Ultrasound guidance can improve patient safety and procedural quality during CVC placement in the subclavian vein. Some medical societies recommend the use of ultrasound for CVC placement also in the subclavian vein, even though the evidence is debatable . Data frThe data in our registry demonstrated that the anatomical landmark technique for subclavian vein access has a complication rate comparable to that of the ultrasound technique , 15.Interestingly, a study by Ertel et al. indicates that the outcome depends more on the operator than on the technique per se . In theiIn our study, there were 23 (2.1%) malpositioned catheters, 22 were repositioned in a fluoroscopy lab the next day , and oneWe did not use fluoroscopy during the primary procedures. In many published studies, fluoroscopy is the standard , 20, 21.p=0.01) in the rest of the patients. This is in line with earlier findings [Twelve (1.1%) of the patients developed pneumothorax (PT) , and foufindings .A multicenter trial comparing three different anatomical sites  for nontunneled central venous catheterization in patients in the adult intensive care unit  demonstrCompared to published studies on insertion of a Port-A-Cath, our pneumothorax rate is acceptable. The lowest rate that we have found in the literature has been documented by Tsai et al. . In theiNine (0.8%) of the patients in our study developed local hematoma postoperatively. However, none of the catheters were removed, and all could be used. This result is acceptable compared to other studies where bleeding associated with CVC insertion has a reported incidence of 0.5–1.6% . Of thes9/L). Two patients had fever 2-3 days after insertion and positive blood cultures (one Staphylococcus aureus and one Staphylococcus lugdunesis). One patient had no fever, but local rubor and pain, and microbiological tests of the wound secretions detected Staphylococcus epidermidis. All three catheters were removed, and the patients were treated with antibiotics. All recovered. Mudan et al. [In three procedures in our study described as uncomplicated, postoperative wound infections were detected. All three were women suffering from cancer. One of the patients had diabetes, and two had a low leucocyte level (1.8 and 2.8 × 10n et al.  did not n et al. , 28 but n et al. –31.In our material, there was only one report of nerve injury, with symptoms that recovered totally. However, as three years of our data are retrospective, we may have missed some injuries; symptoms of a minor degree compared to the patients' serious disease may not have been reported.There were no wound ruptures. Even though three years of the data are retrospective, wound ruptures would have been reported as a primary complication after the procedure.This study is based on a single institution registry of tunneled long-term central venous catheterizations covering a five-year period. Compared with other studies, we have an acceptable and low rate of pneumothorax, hematoma, and infections. We have a high success rate of first-attempt insertions compared with other published data. Even though our group used the anatomical landmarks technique at the subclavian vein, the complication rate is comparable to the use of ultrasound technique. To achieve these results, the procedure should be performed by a limited number of operators, and the total number of catheters inserted needs to be large enough to ensure that each operator inserts catheters on a regular basis. The high occurrence of malpositioned catheters is a cause of concern, and we will therefore consider using fluoroscopy in our future procedures.


The double burden of malnutrition (DBM) and anaemia is a growing concern in developing countries. Using the cross-sectional Bangladesh Demographic Health Survey, 2011, 5763 mother–child pairs were examined. In households where the mother was overweight, 24.5% of children were stunted, 19.8% underweight, 9.3% wasted, and 51.7% anaemic. Significant regional differences were found in DBM and anaemia as well as drinking water source, while DBM alone was more common in more well-off households  and where the father was employed in skilled or service occupations. More policy and awareness programmes are needed to address the coexistence of child undernutrition and maternal overweight/obesity and anaemia in the same household. The number of undernourished people in the world increased from 777 million to an estimated 815 million in 2016. At the same time, adult obesity continues to rise in all regions. Multiple forms of malnutrition therefore co-exist, with countries experiencing simultaneously high rates of child undernutrition and adult obesity . The socIn Bangladesh , the preThe present study uses a nationally representative sample from Bangladesh to examine the coexistence of overweight mothers with undernourished  and anaemic children living in the same household. The study also examines the differences in DBM and anaemia in relation to a number of socio-economic variables. This study provides important information on the reality of the health of the mother and the child in a developing country such as Bangladesh.The data source for this research was the Bangladesh Demographic and Health Survey (BDHS), 2011. The DHS programmes are nationally representative, cross-sectional household surveys. They provide a wide range of information mainly related to population, health, and nutrition. The sample design used in DHS surveys is mainly based on a two-stage cluster format. In the first stage, enumeration areas (EAs) are generally drawn up from census information. Secondly, a sample household is drawn from each selected EA. Demographic and Health Survey data are representative at the national level, residence level, and regional level .BDHS 2011 obtained informed consent from the participants before the survey. The contents of the household and individual questionnaires were based on the Monitoring and Evaluation to Assess and Use Results (MEASURE) DHS model questionnaires. Ethical permission was obtained by the Macro International Inc. Institutional Review Board on 22 February 2011 when the DHS were carried out, with ICF Macro Project Number: 631561.0.000.00.091.01. All data in the present study were anonymous and no additional ethical permission was required. BDHS used five types of questionnaires: a Household Questionnaire, a Woman’s Questionnaire, a Man’s Questionnaire, a Community Questionnaire, and two Verbal Autopsy Questionnaires to collect data on causes of death among children under age 5. These model questionnaires were adapted for the use in Bangladesh during a series of meetings with a Technical Working Group (TWG) that consisted of representatives from National Institute of Population Research and Training (NIPORT); Mitra and Associates; International Centre for Diarrheal Diseases and Control, Bangladesh ; United States Agency for International Development (USAID)/Bangladesh; and MEASURE DHS. Draft questionnaires were then circulated to other interested groups and were reviewed by the 2011 BDHS Technical Review Committee [A total of 18,222 ever-married women aged 12–49 were identified in these households, and 17,842 were interviewed, yielding a response rate of 98 percent. In one-third of the households, ever-married men over age 15 were eligible for interview. Because there were only 90 ever-married women aged 12–14 (less than one percent), these women were excluded. Children aged from 0 to 59 months were selected. Only the first child of each family was selected. Only children and their mothers having anthropometric information (height and weight) and all the socio-economic variables were included. Finally, 5783 mother–child pairs were selected based on the abovementioned criteria. The principal reason for nonresponse among women and men was their absence from home despite repeated visits to the household. The response rates do not vary notably by urban–rural residence.Following WHO recommendations, any children with height-for-age Z-score (HAZ) and weight-for-age Z-score (WAZ) either above +6 or below −6 and Weight for Height Z-score WHZ above +5 or below −5 were excluded. For women, anthropometric measurements above and below 4 standard deviation (SD) were considered outliers and were excluded from the data . ChildreThe nutritional status was assessed using anthropometry (body mass index (BMI) in mothers and stunting, underweight, and wasting in children) and anaemia status of mother–child pairs. Height and weight were measured using standard procedures by trained staff. Children younger than 2 years were measured lying down (recumbent length) on an anthropometric board, while standing height was measured for older children and mothers. For weighing of children and mothers, a weighing scale was used which allows for weighing of very young children through an automated mother–child adjustment that eliminated the mother’s weight while she was standing on the scale with her baby. Haemoglobin concentration was determined using a Hemocue , a portable photometer which uses the absorption of light from a single drop of blood to measure haemoglobin concentration. Maternal BMI was categorised into three categories of underweight (BMI < 18.5), normal (18.5 to 24.9), and overweight (≥25.0) and stunting, underweight, and wasting by z-scores of <−2.00 of height-for-age, weight-for-age, and weight-for-height, respectively, following the WHO guidelines . All mot2 testing and sequential multinomial regression analysis was performed to examine the association between maternal and child nutritional status and the socio-economic variables. Initially the analyses removed the linear and quadratic effects of age and sex before testing for the significance of a socio-economic variable. Later, after removing the linear and quadratic effects of age and sex, all the socio-economic variables were entered into the model except for the variable of interest. In χ2 test, Cramer’s V was used to observe the effect size. In the analyses, one category with a socio-economic variable has to be the reference value, and Region Sylhet was chosen (arbitrarily). IBM SPSS 21  software was used in data analysis, and the cut-off for significance was p < 0.05.χThe occurrence of maternal overnutrition and child undernutrition in the same household was observed in the current study. Of the total sample of overweight mothers, 24.5% had stunted children, 19.8% underweight children, 9.3% wasted children, and 51.7% anaemic children. However, there was significant heterogeneity in the occurrence of the DBM, as can be seen in For overweight and stunting there was marked regional variation  with theHouseholds with three possession scores had the highest prevalence (32.9%) as did “richer” households on the wealth index (35.3%) . Househop < 0.05) Barisal was the region with the highest prevalence after taking into account the other socio-economic variables, while children from richer families on the wealth index had the highest prevalence   .p < 0.05)  . The res < 0.05) Table A1Khulna had almost 20% overweight mothers with anaemic children, which was highest among the seven regions. Rural households had a high number of overweight mothers with anaemic children. Fathers working in services had a high number of overweight mothers with anaemic children. More than 80% of the unemployed mothers were overweight with anaemic children.The number of overweight mothers with anaemic children increased with improvements in father’s education, wealth index, and toilet facilities, and vice versa . The resThe present paper observed the existence of a double burden of malnutrition in the same household. Overweight mothers with undernourished (stunted/underweight/wasted) children were found under the same roof. When the effects of all other variables were removed, the double burden of malnutrition was significantly associated with region, wealth index, and father’s/husband’s occupation. Overweight mothers and undernourished children were more evident in the richest households . The preOddo et al.  observedIn a regional context, Shukla et al.  have conIn the present paper, three major big cities  had the highest percentages of overweight mothers with undernourished children . More thWith increased female employment and related time constraints, urban dwellers also increase their consumption of street foods or processed, ready-to-eat foods. Street foods often contain unhealthy levels of energy, saturated fats, salt, and refined sugars. They are also a good source of microbes responsible for food-borne illnesses due to poor hygiene status ,31,32. AThere is a general perception that women living in urban areas are more likely to engage in income-generating activities outside the home than rural women. Previous analysis of the Demographic and Health Surveys in developing countries showed that the main difference between urban and rural areas was not the rate of women’s employment (which was roughly 50% in both areas) but rather the fact that urban mothers were much less likely to take their child to their place of work than rural women . This isMothers educated up to primary-level education from poor households with unimproved toilet facility were underweight with anaemic children. Lower rates of extra-household employment and reduced economic power within the household ,36, highNutrition transition is caused by globalisation, rapid urbanisation, and economic development. A major shift in food consumption and physical activity patterns is evident in nutrition transition . Urban pIn recent years, adult overnutrition has come to exist simultaneously with child undernutrition in Bangladesh, which is well known as the double burden of malnutrition. The United Nations Development Programme (UNDP) have confirmed the double burden of malnutrition, i.e., the co-existence of under- and overnutrition, in South Asia. For the last few decades, this region has been undergoing demographic and socioeconomic transitions . These tAccording to the foetal origin of disease, early  undernutrition causes an irreversible differentiation of metabolic systems. For example, a foetus of an undernourished mother will respond to a reduced energy supply by switching on genes that optimise energy conservation. This survival strategy causes a permanent differentiation of regulatory systems that result in an excess accumulation of energy  when the adult is exposed to an unrestricted dietary energy supply. Consequently, an undernourished child grows into an obese adult given the proper environment. Based on our current findings and the limited evidence available to date, it is likely that maternal obesity plays an important role in child anaemia. Kelven et al. observed that the larger size of foetuses of obese mothers may negatively influence cord blood iron markers . Even afIncreasing economic status and gross domestic product (GDP) decrease undernutrition but the relationship between GDP and nutrition is complex. Being poor in a middle-income country increases the risk of obesity compared with being rich in the same country . In urbaThe increasing number of overweight mothers is becoming a new health concern for Bangladesh. The results of this recent study clearly show that double burden exists in Bangladesh and in the same household. Apart from that, the co-existence of overweight mother and undernourished children in the same household portrays the complex dynamics of possible causes. Future longitudinal studies are needed to understand the factors linked to DBM risk. The interaction between maternal overweight/obesity and early childhood undernutrition can be identified and addressed by effective large-scale population studies to reduce the long-term risk of obesity in the offspring.The Bangladesh Demographic and Health Survey is based on a cross-sectional study design. Although the data collection and study design were of high quality, the data did not allow us to draw causal relationships between variables in the current study. The data lacked information on maternal energy intake, physical activity level, and micronutrient intake, which are important for a proper assessment of nutritional status. Only one in every three households was selected for haemoglobin concentration assessment, which may not give a clear idea about the anaemia status of the whole population. It was not possible to examine the relationship between child feeding practise and infection and nutritional status due to a large amount of missing information on complementary feeding, immunisation, and infectious disease. Incomplete information and inconsistent information on some selected variables complicated the analysis process considerably.


Describing injury severity in trauma patients is vital. In some recent articles the Revised Trauma Score (RTS) and Kampala Trauma Score (KTS) have been suggested as easily performed and feasible triage tools which can be used in resource-limited settings. The present meta-analysis was performed to evaluate and compare the accuracy of the RTS and KTS in predicting mortality in low-and middle income countries (LMICs).Two investigators searched the Web of Science, Embase, and Medline databases and the articles which their exact number of true-positive, true-negative, false-positive, and false-negative results could be extracted were selected. Sensitivity and subgroup analysis were performed using Stata software version 14 to determine the factor(s) affecting the accuracy of the RTS and KTS in predicting mortality and source(s) of heterogeneity. The heterogeneity was high (I2 > 80%) among 11 relevant studies . While the sensitivity of the KTS (0.88) was slightly higher than RTS (0.82), the specificity, diagnostic odds ratio, negative likelihood ratio, and positive likelihood ratio of the KTS  were lower than those of the RTS . The area under the summary-receiver operator characteristic curve for KTS and RTS was 0.88 and 0.93, respectively.  However, regarding accuracy and performance, RTS was better than KTS for distinguishing between mortality and survival; both of them are beneficial trauma scoring tools which can be used in LMICs. Further studies are required to specify the appropriate choice of the RTS or KTS regarding the type of injury and different conditions of the patient. Traumatic injury as one of the major causes of morbidity and mortality remains a worldwide concern. According to the World Health Organization (WHO) 16% of the global burden of disease refers to injuries , 3. FurtRegarding the great trauma burden in countries with such a resource-limited setting, developing protocols for allocating resources in a strategically good way to minimizes injury-related morbidity and mortality, and maximizes patient survival seems necessary. Multiple injury scoring systems have been used in high-income countries (HICs) since 1970s for triage, injury description and outcome, and mortality prediction, such as injury severity score (ISS), revised trauma score (RTS), and the trauma and injury severity score (TRISS) , 7. RTS However, these scoring systems perform well in developed countries and their calculation and performance require not-available diagnostic tools in resource-limited setting and can be difficult to achieve. In 1996, the Kmapala trauma score (KTS) a simplified scoring system, was developed to specifically address this problem in resource-limited settings. It reflects SBP, RR, patient age, number of serious injuries and neurologic status , 14.Some recent articles have been mentioned the KTS and RTS as easily performed and feasible triage tools suggested to be used instead of other complicated and difficult ones such as TRISS , 16. TheSearch Strategy and Study Selection Here, regardless of publication status, studies of the mortality predictive ability of the RTS and KTS were included. Two investigators (AA and ShM) carried out a systematic search using the electronic databases such as Embase, Web of Science, and Medline from their commencements until July 2018. The search strategy in Medline used the following terms:  AND (((sensitivity[tiab] OR specificity[tiab]) OR “receiver operating characteristic curve”[tiab]) OR ROC[tiab] OR prognosis[tiab] OR “prognostic value” [tiab] OR prediction[tiab] OR “predictive value” [tiab])). The search strategy in Web of Science and Embase used the following terms: Revised Trauma Score, or RTS, or Kampala Trauma Score, or KTS; and sensitivity, or specificity, or receiver operating characteristic curve, or ROC, or prognosis, or prognostic value, or prediction, or predictive value. Furthermore, searching all potentially eligible references cited in related review and original articles were carried out manually in Google Scholar and Google search engines. If the full text was not accessible or the required details were not completely available in the full text, we tried to get the details from the authors by email. Inclusion and Exclusion Criteria In order to include certain studies in the present study, they should have evaluated the performance of the RTS or KTS for patient mortality prediction in LMICs, and also the exact number of true-positive, true-negative, false-positive, and false-negative results could be extracted either directly or indirectly. The studies with the following criteria were excluded: did not evaluate the performance of RTS or KTS in predicting patient mortality; were not conducted in LMICs; were not English-language; and letters to editors or conference abstracts. The two reviewers who carried out the literature search also individually made decisions and selected studies regarding inclusion criteria (AA and ShM). Data Extraction and Quality AssessmentUsing two reviewers (AA and ShM) the following details were extracted from included studies independently: study location, year of publication, the first author’s surname, study design, age, number of cases, proportion of male subjects, area under the receiver operator characteristic (ROC) curve (AUC), cut-off value, sensitivity, and specificity. Two reviewers (AA and ShM) individually used the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool which is widely used to assess the quality of systematic reviews of diagnostic studies . The QUADAS-2 is four-key domain tool: patient selection, index test, reference standard, and flow and timing. “Concerns regarding applicability” and “risk of bias” were assessed for the first three domains and all four domains, respectively . To evaluate the “risk of bias,” a low risk of bias is defined as “yes” answer to all signaling questions in a domain. If any signaling question has been answered as “no”, it indicated a high risk of bias. “Applicability” section was judged as same as the bias section, excluding signaling questions.Statistical analysisThe I2 test was used to evaluate the heterogeneity which was defined as low, moderate, and high in thresholds of 25%, 50%, and 75%, respectively. We used true-positive, false-positive, true-negative, and false-negative parameters to calculate the sensitivity, specificity, diagnostic odds ratio (DOR), AUC, positive likelihood ratio (PLR), and negative likelihood ratio (NLR). Based on differences in inclusion criteria and study population or type of injury, we selected and excluded specific studies, and then performed sensitivity analysis to identify if the results have been affected by these exclusions or not.We performed subgroup analyses based on the number of patients. Regarding the distribution of sample size among studies, we categorized them into two different groups as small and big samples. Thus, studies with a sample size <1000 patients defined as small sample. The publication bias was assessed using a funnel plot.Stata version 14 was used for all statistical analysis and a statistically significant difference was defined as a P-value <0.05.The search strategy initially returned 1341 studies after removing the duplicates . Titles Using a random-effects model, we pooled related statistical parameters owing to the high level of heterogeneity (I > 80%). For the RTS, the pooled estimates were 0.82 (95% CI: 0.66–0.92) for sensitivity, 0.91 (95% CI: 0.81–0.96) for specificity, 8.90 (95% CI: 4.50–17.80) for PLR, 0.20 (95% CI: 0.10–0.39) for NLR, 45 (95% CI: 21–99) for DOR. For the KTS, the pooled estimates were 0.88 (95% CI: 0.70–0.96) for sensitivity, 0.73 (95% CI: 0.57–0.85) for specificity, 3.30 (95% CI: 2.00–5.60) for PLR, 0.16 (95% CI: 0.06–0.44) for NLR, 20 (95% CI: 6–69) for DOR . 2 value for sensitivity did not change, and the sensitivity value was similar to that found without excluding mentioned studies.In order to determine the source of heterogeneity, sensitivity analysis was conducted . The stuSubgroup meta-analysis was performed by classifying studies according to their number of samples. The changes in sensitivity and specificity values are shown in In order to explore publication bias , a funnel plot asymmetry analysis was used .Although the KTS was developed to simplify the mortality prediction in LMICs, the present meta-analysis showed high accuracy of the KTS and RTS in predicting mortality with a slightly better performance for RTS. The specificity, DOR, NLR, and PLR of the KTS were slightly lower than those of the RTS, while the sensitivity of the KTS was slightly higher than RTS.In emergency settings, physicians are always challenging with the issue of classifying the trauma patients according to the severity of their trauma . In thisHowever, the RTS necessitates the use of a formula to admit the GCS, respiratory rate and systolic blood pressure and it remains the most commonly used pre-hospital trauma scoring system. Moreover, the RTS is considered as one of the most easily calculated triage tools available shortly after trauma admission , 32, 33.Stability of sensitivity and specificity can be integrated to make a comprehensive test performance named likelihood ratios, which is superior to their components. The PLR of the RTS (8.90) was higher than that of the KTS (3.30), with a positive RTS or KTS outcome indicating an approximately nine and three-fold higher risk of mortality, respectively. However, it should be considered that PLR should be more than 10 so as to be useful. The slightly higher NLR for the RTS (0.20) suggests that it had a slightly lower accuracy comparing to the KTS (0.16) for predicting survival.The DOR combines the sensitivity and specificity values into a single number indicating the test accuracy (between zero and infinity). Higher DOR values indicate higher accuracy of a test (better discriminatory performance), and a DOR value of 1.0 indicates that the RTS or KTS does not distinguish between mortality and survival. In the present study, the higher DOR of the RTS (DOR = 45) indicates that it is more capable than the KTS (DOR = 20) in distinguishing between mortality and survival.In addition to summarizing the sensitivity and specificity, the SROC curve is a more effective index than the other indices (since the threshold effect has no influence on it). Based on the SROC curve in our study, the AUC of the RTS (0.93) was slightly higher than that of the KTS (0.88).All of these indices indicate that the overall accuracy of the RTS and KTS in predicting mortality was as high as expected, and both of them had high sensitivity and specificity. In the three studies evaluating the RTS and KTS, two studies , 21 concThe accuracy of RTS in predicting mortality has been affected by some factors and was different in each subgroup. The sensitivity value of RTS was higher with sample size ≥1000, indicating better result of mortality prediction in studies with a higher sample size. Moreover, the sensitivity was not changed by removing the study of Valderrama-Molina et al. (which was the only study conducted in a level one trauma center) indicating no difference of the RTS performance in a hospital or a level one trauma center. The sensitivity value of RTS increased after removing the study by Yousefzade-Chabok et al., which shows worse performance of RTS in elder populations.After removing the specific studies, the heterogeneity did not change. The subgroup meta-analysis showed that the differences in the number of patients between studies contributed to the heterogeneity. Thus, studies with a larger sample size contributed more to the heterogeneity. The differences in the populations and countries can also effect on the heterogeneity.The present study had several limitations. First, we used only English written studies. Second, due to the lack of data, we focused only on the ability of mortality prediction and excluded physiology and age that could influence the trauma outcome. Third, because of the limited data, we could not analyze additional factors such as type of injury, age, ethnic group and treatment which might change the RTS or KTS accuracy. To the best of our knowledge, this is the first study on the ability of the RTS and KTS in mortality prediction as a meta-analysis.Briefly, high accuracy of both the RTS and KTS for predicting mortality in LMICs has been confirmed. However, regarding accuracy and performance, the RTS was better than the KTS for distinguishing between mortality and survival; both of them are beneficial trauma scoring tools which can be used in resource-limited settings. Further studies are required to specify the appropriate choice of the RTS or KTS regarding the type of injury and different conditions of the patient.