The rate of cesarean delivery (C-section) has been increasing worldwide, including Bangladesh, and it has a negative impact on the mother and child's health. Our aim was to examine the association between C-section and childhood diseases and to identify the key factors associated with childhood diseases.We used four nationally representative data sets from multiple indicator cluster survey  and Bangladesh Demographic and Health Survey  and analyzed 25,270 mother-child pairs. We used the frequency of common childhood diseases  as our outcome variable and C-section as exposure variable. We included mother’s age, place of residence, division, mother’s education, wealth index, child age, child sex, and child size at birth as confounding variables. Negative binomial regression model was used to analyze the data.In the BDHS data, the prevalence of C-section increased from 17.95% in 2011 to 23.33% in 2014. Also, in MICS, the prevalence almost doubled over an eight-year period (17.74% in 2012 to 35.41% in 2019). We did not observe any significant effect of C-section on childhood diseases in both surveys. Only in 2014 BDHS, we found that C-section increases the risk of childhood disease by 5% . However, the risk of childhood disease differed significantly in all survey years by division, child's age, and child’s size at birth after adjusting for important confounding variables. For example, children living in Chittagong division had a higher risk [ and ] of having disease compared to Dhaka division. Maternal age, education, and wealth status showed significant differences with the outcome in some survey years.Our study shows that C-section in Bangladesh continued to increase over time, and we did not find significant association between C-section and early childhood diseases. High C-section rate has a greater impact on maternal and child health as well as the burden on the health care system. We recommend raising public awareness of the negative impact of unnecessary C-section in Bangladesh. Cesarean delivery (C-section) is a surgical procedure that is often performed or recommended when the life of the mother or child is at risk . RecentlThe prevalence of the C-section is expeditiously growing in many developed and developing countries , 5. DuriThere are several risks associated with C-section for mothers and children , 12. BabIn Bangladesh, young children, in general, are suffering from several common diseases such as fever, cough, short/ difficulty in breathing, diarrhea etc. . SeveralWe used two different survey data sets of 2011, 2014 Bangladesh Demographic and Health Survey (BDHS) and 2012, 2019 Multiple Indicator Cluster Survey (MICS). The BDHS is a large household survey produced by the Demographic and Health Surveys Program, and the MICS is also a large, multi-dimensional household survey conducted by UNICEF. Both surveys collects maternal and child health indicators. Details of the methodology and sampling procedure of both surveys were published elsewhere , 24. We For creating the outcome variable (childhood disease), we used several variables such as fever, short/ rapid breaths, cough, blood in stools, and diarrhea in the two weeks before or during the survey. We created a count variable that means the frequency of the diseases of the children. Here, the number of diseases for a child varies from 0 to 5. The zero means the child did not suffer any above-mentioned diseases in the two weeks before or during the survey.The exposure variable was the type of delivery , which is a binary variable.We considered important confounding variables and/or covariates are mothers age, place of residence, division, mother’s education, wealth index, religion, mother’s body mass index (BMI), breastfeeding status, child age, child sex, and child’s size at birth.Svyset command in Stata . The Svyset command helps us to use design elements such as the primary sampling unit, strata, cluster, and sample weight.Descriptive statistics of each of the selected covariates and distribution of type of delivery were shown by adjusting the sampling weight of the survey. Similarly, weighted percentages were calculated to compare demographic and socioeconomic characteristics among the type of delivery. Pearson's chi-squared test was used to determine the association between C-section  and other covariates. As our outcome is a count variable, frequency of diseases, we first applied Poisson regression models. However, due to over- dispersion in the data, we then applied negative binomial (NB) regression models. We first fitted univariate models to estimate the effect of C‐section on the outcome variable (disease count). Subsequently, we also fitted univariate models using all potential covariates. We used an arbitrary p—value of ≤ 0.20 as a criterion to include covariates in the multivariable models. We used stepwise procedures to select the best model. Therefore, in our final model, we had included all significant covariates and some key variables related to the outcome. To account for the complex survey design, we used the Our study was exempt from the ethical review approval because we used publicly available de-identified data.Fig 1).The prevalence of C-section increased over time in both surveys. In BDHS, the rate increased from 17.95% in 2011 to 23.33% in 2014. Also, in MICS, the prevalence almost doubled over an eight-year period (17.74% in 2012 to 35.41% in 2019). Other than 2012 MICS, the distribution of common childhood diseases across survey years were fairly similar. More than half (48 to 52%) of the children had no diseases, followed by 15 to 19% had one disease in two weeks prior to the survey. The proportion of the disease counts by delivery type was approximately similar across survey years and between surveys . In both surveys, women from Dhaka division, living in urban areas with higher education and higher wealth status, had a higher proportion of having C-section in recent surveys compared to the previous surveys. Among the child's characteristics, the baby's size at birth was one of the significant factors found to be associated with C-section. For example, one-third of the baby's size larger than average was delivered by cesarean section in 2014 BDHS.Tables 3 and 4 show the results of the multivariable negative binomial regression models for BDHS and MICS surveys estimating the effects of C-section  on childhood diseases after adjusting for maternal and child’s characteristics. No statistically significant effects of C-section on childhood diseases were observed in both sets of surveys. However, having a C-section appears to increase the risk of childhood disease by 5%  only in 2014 BDHS. Overall, the risk of common childhood diseases differed significantly in all survey years by division, child's age, and child’s size at birth. In both surveys, children living in Chittagong division had a higher risk [ and ] of having disease compared to Dhaka division. The risk of having common childhood diseases decreases as children grow. For example, one year old child had a 42%  and 19%  higher risk of having common childhood diseases in 2019 MICS and 2014 BDHS, respectively. There were significant differences in common childhood diseases among children born with smaller and larger than average sizes. Children born with either smaller or larger than average size had a higher likelihood of having common childhood diseases. Mothers' age plays a key role in childhood disease, compared with younger mothers (15–19 years) children born to young adult mothers had a lower risk of having childhood diseases was observed in 2019 MICS, not other surveys. For example, children born to 30–34 years old mothers had 18% less risk of having childhood disease. There was a significant increase in childhood disease among the children who were born to mothers with lower levels of education. Similarly, children born to a lower socio-economic status family had a higher risk of having common childhood diseases.In this study, we investigated the relationship between C-section  and early childhood diseases in Bangladesh using multiple nationally representative survey datasets. We also investigated the factors associated with common childhood diseases. We observed that for BDHS (2011), MICS (2012), BDHS (2014), and MICS (2019), the prevalence of cesarean deliveries was 17.95%, 17.74%, 23.3%, and 35.41%, respectively. The distributions of childhood diseases were approximately similar in both cesarean and normal delivery in all survey datasets across the survey years.In multivariable negative binomial regression models, there was no significant association between C-section and common childhood diseases. Similar results have been observed by Gondwe et al. in a similar population setting in India , 26. HowWe have noticed that the delivery rate for the C-section was higher particularly in the Dhaka division compared with other geographical divisions in Bangladesh. An earlier study found that women in the division of Chittagong, Dhaka, Khulna and Rajshahi were more likely to go C-section . For insOur study findings also confirmed that the highest rate of C-section has occurred among secondary or higher educated females. Since education is directly linked to women's autonomy, they are more economically solvent and mostly living in urban areas, can decide to give birth through the C-section. However, some studies show that women's choice of C-Section has no visible link with their educational level , 30. In The analyses of this study confirmed that childhood disease is associated with maternal age, according to MICS data. An earlier study showed that children born to younger teenage mothers were found to have a relatively high risk of diarrhea, cough, and fever . This isOur study has several strengths: first, to our knowledge, this the first study to examine delivery-section and childhood diseases in Bangladesh; second, we used the latest available four data sets from two nationally representative surveys, third, we used proper data analyses methodology in which we accounted for all complex survey designs. However, there are some limitations of the study: first, we used cross-sectional survey data and the childhood disease changes over time and the reported association may change in the longitudinal studies, although our study exposure variable, C-section, was a time-independent variable; second, an important maternal factor complications during pregnancy that have a significant number of missing values and could not consider them in the analyses; third, data on reasons for C-section were not available to capture an understand of the choice.Our study shows that cesarean delivery in Bangladesh has continued to increase rapidly over time, and we did not find any significant association between cesarean delivery and early childhood diseases. The study also confirmed that childhood disease is significantly related to maternal age, geographical division, maternal education and wealth index, age of the child, and birth size.


Cesarean section (CS) rate has risen dramatically and stayed at a very high level in China over the past two to three decades. Given the short- and long-term adverse effects of CS, effective strategies are needed to reduce unnecessary CS. We aimed to evaluate whether a multifaceted intervention would decrease the CS rate in China.We carried out a cluster-randomized field trial with a multifaceted intervention in Shanghai, China, from 2015 to 2017. A total of 20 hospitals were randomly allocated into an intervention or a control group. The intervention consisted of more targeted health education to pregnant women, improved hospital CS policy, and training of midwives/doulas for 8 months. The study included a baseline survey, the intervention, and an evaluation survey. The primary outcome was the changes of overall CS rate from the pre-intervention to the post-intervention period. A subgroup analysis stratified by the Robson classification was also conducted to examine the CS change among women with various obstetric characteristics.A total of 10,752 deliveries were randomly selected from the pre-intervention period and 10,521 from the post-intervention period. The baseline CS rates were 42.5% and 41.5% in the intervention and control groups, respectively, while the post-intervention CS rates were 43.4% and 42.4%, respectively. Compared with the control group, the intervention did not significantly reduce the CS rate . Similar results were obtained in subgroup analyses stratified by the risk level of pregnancy, maternal age, number of previous CS, or parity. Scarred uterus and maternal request remained the primary reasons for CS after the interventions in both groups. The intervention did not alter the perinatal outcomes .A multifaceted intervention including more targeted prenatal health education, improved hospital CS policy, and training of midwives/doulas, did not significantly reduce the CS rate in Shanghai, China. However, our experience in implementing a multifaceted intervention may provide useful information to other similar areas with high CS use.www.chictr.org.cn) (ChiCTR-IOR-16009041) on 17 August 2016.This trial was registered at the Chinese Clinical Trial Registry ( Cesarean section (CS) rate has increased dramatically in many parts of the world in the last few decades . It was Extensive evidence has shown that CS without medical indications is associated with an increased risk of short-term and long-term adverse outcomes as well as substantial economic burden –10. The Shanghai is one of the largest cities in China. The CS rate increased from 17.5% in the early 1980s to 55% in 2010 , 14. DesThis stratified, cluster-randomized, parallel-group field trial was conducted to examine the effects of a multifaceted intervention on the use of CS in 20 hospitals in Shanghai, China, from 2015 to 2017. Hospitals were invited to participate in this trial and were informed that they could be assigned to either intervention or control group. Seven tertiary hospitals and 13 secondary hospitals agreed to participate. Primary care hospitals were not included in the present study, as they usually do not provide obstetric services, and very few women are delivered outside of the hospital. The participating hospitals delivered approximately half of all births in Shanghai .An ethical approval was obtained from the Ethics Review Board of the Xinhua hospital, Shanghai Jiao Tong University School of Medicine and other participating hospitals .Hospitals were first stratified by their levels (tertiary vs secondary). Within each stratum, hospitals were randomly assigned to the intervention and control groups and designated as the units of randomization to ensure that there would be minimal cross contamination between the intervention and control groups. The randomization was conducted by the data management group. The study included a 6-month pre-intervention (baseline survey) period, an 8-month intervention period, and a 6-month post-intervention  period. No masking was applied in this study.Before the intervention, we conducted a baseline survey. A total of 62,653 births were delivered in the 20 hospitals from January 1 to June 30 in 2016. A random sample of all births was selected. To ensure the precision of the CS rate estimates, we randomly selected 20% of the total births in hospitals with an annual delivery volume under 10,000, and 10% in hospitals with an annual delivery volume over 10,000 . On averA multifaceted intervention was developed based on previous research , 22, 27.Second, after a careful review of the literature, a focus group discussion with obstetricians, midwives, and hospital administers, and consultation with hospital management, an improved hospital CS policy was established and promoted in the intervention hospitals. The policy included three measures: To install a CS second opinion process, i.e., if an obstetrician decides to perform a CS on a woman, he/she needs to request a review by the unit chief or a designated senior physician for a second opinion , 27, 28.Third, several training courses with a specially designed syllabus were offered to midwives and doulas in the intervention hospital to improve their skills.The intervention was implemented from September 1, 2016, to April 30, 2017. The control group did not receive any of the above interventions except for providing the usual care.A total of 54,257 births were delivered in the participating hospitals during the evaluation period from May 1 to October 31 in 2017. A random sample was selected, and data were abstracted in the same way as that of the baseline survey. A total of 10,553 deliveries remained for analyses . The primary outcome was the changes of the overall CS rate from the pre-intervention to the post-intervention period. A subgroup analysis stratified by the Robson classification was also conducted to examine the CS change among women with various obstetric characteristics. The secondary outcomes were gestational weight gain (GWG), obstetrical interventions, and perinatal outcomes. GWG was defined as the difference between documented weight at the first and last prenatal visit just before delivery. Obstetrical interventions included planned and intrapartum CS rate, artificial rupture of the membranes, labor induction, oxytocin use during labor, epidural analgesia, use of doula, assisted vaginal delivery, and episiotomy. Planned and intrapartum CS were defined as CS before and after the onset of labor, respectively. Labor induction was defined as artificially induced uterine contraction. Perinatal outcomes were measured by a composite score, defined by the American College of Obstetricians and Gynecologists (ACOG) Quality Improvement and Patient Safety Committee (QuIPS) . Each of2).Maternal age was treated as a continuous variable. Information on maternal height, weight at delivery, nulliparous (yes/no), assisted reproductive technology , previous cesarean delivery (yes/no), gestational age (GA) at delivery, birthweight of newborn, pathology (yes/no), and hospital level  were collected. Body mass index (BMI) was calculated as maternal weight at delivery in kilograms divided by the square of height in meters , heart disease, deep venous thrombosis, kidney disease, pre-gestational and gestational diabetes mellitus, pre-gestational and gestational thyroid disease , premature rupture of membranes , Rh incompatibility, or congenital malformation.2, and were without previous ART, CS, prior or current stillbirth, and morbidity during pregnancy defined above. In contrast, a pregnancy was considered as high-risk with any of the above conditions.A pregnancy was considered as low-risk if the newborn was born in cephalic presentation, and the mothers were aged 18 or above and younger than 40 years old, gave a term birth (37–41 completed weeks of gestation), had a pre-pregnancy BMI between 17 and 28 kg/mBased on the overall CS rate of 45% in Shanghai, we estimated that the intervention may reduce the CS rate by 7 to 38%. Assuming that the unit size was about 500 subjects per hospital and the intraclass correlation coefficient was 0.011, we calculated that we would need to enroll 20 hospitals for the purpose of the study to have 90% power to detect 7% reduction in CS rate. A two-sided alpha significance level of 0.05 was used.β, and corresponding 95% CIs were computed to compare the changes between the intervention group and the control group from the pre- to the post-intervention period. For the GEE models that did not converge, a logistic regression model was used with p values of less than 0.001 being considered as statistically significant and p values of less than 0.003 being marginally significant [Continuous variables were described as mean (standard deviation), whereas categorical variables were presented as numbers and percentages. An intention-to-treat analysis was applied according to the assignment of randomization at the beginning of the study. Given the clustering of women  within hospitals (randomization units), generalized estimating equations (GEE) were used to assess the effects of the multifaceted intervention on CS rates, GWG, obstetrical interventions, and perinatal outcomes, separately, adjusting for maternal age, BMI at delivery, parity, ART, previous CS history, GA at delivery, birthweight of the newborn, pregnancy complications, and hospital level. Adjusted OR, adjusted nificant , 34.We conducted stratified analyses by the risk level of the mothers (low vs. high), maternal age ≥ 35 vs. < 35), the number of previous CS (0 vs. ≥1), and parity (primipara vs. multipara without a previous CS vs. multipara with a previous CS or not). Additionally, to identify factors that were negatively associated with CS, we evaluated the intervention effect in each group of mothers by the modified Robson Classification System [ vs. < 35www.chictr.org.cn) (ChiCTR-IOR-16009041).All statistical analyses were conducted with SAS 9.4 software . This trial was registered at the Chinese Clinical Trial Registry  . Scarred uterus, CS by maternal request without medical indication, abnormal fetal heart rate pattern, breech or transverse presentation, prolonged labor, and macrosomia ranked the top six primary indications for CS in both groups during the baseline and the evaluation periods. The proportion of CS due to scarred uterus had increased from the baseline to the evaluation period in both groups  (Table The baseline GWG were 13.2 SD 5.3) kg and 12.3 (SD 5.5) kg in the intervention and control groups, respectively, versus 11.2 SD 4.8) kg and 11.2 (SD 5.1) kg in the post-intervention period, respectively. The intervention did not significantly reduce the GWG when comparing with the control group during the same period .This trial showed that a multifaceted intervention did not reduce the high CS rate in Shanghai, China. Scarred uterus and maternal request were still the primary indications for CS even after the intervention. To our best knowledge, our study was so far the first randomized trial to reduce the CS rate by a multifaceted intervention in China.Numerous attempts have been made to reduce the CS rate around the world , 36–38. On the other hand, two Chinese retrospective observational studies suggested that multifaceted interventions involving government policy, finical incentives, local benchmarking, health education for health professionals and pregnant women, doula care, and access to labor analgesia could decrease the CS use effectively , 41. In Yu et al. conducted a retrospective pre-/post-intervention study which focused on CS on maternal request changed by institutional interventions and government policy . InstituDespite that these studies were conducted in quite different settings and cultures, and all of them showed some effects of the multifaceted interventions, they seemed to have some common characteristics. First, studies with interventions initiated by academic organizations reduced CS rate only to a modest degree , 27, 34.It is also understandable that interventions conducted in a single hospital tended to gain more support from medical opinion leaders and, thus, easier to form a concerted action in the hospital. Similarly, the government-led interventions could be directly implemented in healthcare systems. In contrast, interventions initiated by academic researchers did not have such advantages. Kingdon et al. and Chaillet et al. found that the negotiation of health professionals with healthcare system and the practice environment including unit leadership, policy, availability of equipment, and the extent to undertake the guideline recommendation were the major keys to decrease the CS rate successfully , 45.Due to a high CS rate for over a decade, a higher proportion of women in China have a scarred uterus comparing to other countries. Women with a previous CS were more likely to select repeat CS. This explains why our CS rate actually increased from the baseline to the post-invention period because during our trial, the two-child policy was instituted. The proportion of multiparas increased, many of whom had a previous CS, leading to a higher overall CS rate. However, in nulliparas, the CS rates did decline but the difference between the intervention and control groups did not reach statistical significance. It should be noted that the considerable flux of declining primary CS and increasing repeat CS may hamper a substantial decline in the overall CS rate in the near future.Our study has several limitations. First, although we provided women more targeted health education via the online and offline programs free of charge in the intervention hospitals, approximately half of the women in the intervention hospitals participated in our targeted health education program. Thus, the overall impact may have been diluted. Second, due to a high volume of deliveries, it is challenging to provide one-on-one doula support throughout labor in most hospitals. A total of 30–40% had doula support, among whom some women shared a doula . Third, CS issue is extremely complex and deeply rooted. Despite our recognition of their importance, some measures were beyond what our study could do while other measures were difficult to implement. For example, we knew that fear of pain could be effectively addressed by providing epidural analgesia, but some hospitals were constrained by anesthesia resources. Only 8 hospitals in our study provided epidural analgesia, resulting in still low epidural analgesia use (20–30% of women who attempted labor). Doula is effective in reducing CS use and increasing women’s satisfaction. But the overwhelming volume of deliveries in Chinese public hospitals hampers one-to-one doula or midwife support. In our study, only one third of parturients had doula. And a doula is often shared by more than one laboring woman.We also knew that physicians play a critical role in CS decision making, prelabor, and intrapartum. But the “physician factor” is also complicated by multiple forces. The shortage of medical staff to handle the large volume of delivery, financial incentives, and constrained doctor-patient relationship all likely draw the decision leaning towards CS. Physicians’ practice pattern is often unclear. Our trial did not attempt to address the physician factor directly, which may be an important determinant in the success of an intervention trial on reducing the CS rate. For future studies, an assessment of practice pattern among physicians may provide useful insights. For example, asking the surgeon to complete a detailed reporting form that uncovers the indications as well as intentions and actions of the surgeon may help to identify potential targets for intervention. Given its importance, the physician factor could be a focus for future research. But the government health policy that can address some of the above issues may be more effective.Our multifaceted intervention for 8 months was not effective in reducing the CS rate in a large, multicenter cluster-randomized field trial in Shanghai, China. Further strategies that can be tailored to local contexts and drivers of CS are warranted to result in more effective measure to reduce the high CS rate. Government policy may have a greater impact on reducing the CS rate than the interventions initiated by hospitals or academic organizations.Additional file 1:Table S1. The list of health education classes available to pregnant women. Additional file 2.Study protocol. Additional file 3:Table S1. CONSORT 2010 checklist of information to include when reporting a cluster randomised trial. Table S2. Extension of CONSORT for abstracts1,2 to reports of cluster randomised trials. Additional file 4:Chart Abstraction Form for Maternal and Neonatal (or Stillbirth) Information.


Atrial fibrillation (AF) is a public health problem and its prevalence is increasing worldwide. Electronic cohorts, with large electrocardiogram (ECG) databases linked to mortality data, can be useful in determining prognostic value of ECG abnormalities. Our aim is to evaluate the risk of mortality in patients with AF from Brazil.This observational retrospective study of primary care patients was developed with the digital ECG database from the Telehealth Network of Minas Gerais, Brazil. ECGs performed from 2010 to 2017 were interpreted by cardiologists and the University of Glasgow automated analysis software. An electronic cohort was obtained linking data from ECG exams and those from a national mortality information system, using standard probabilistic linkage methods. We considered only the first ECG of each patient. Patients under 16 years were excluded. Hazard ratios (HR) for mortality were adjusted for demographic and self-reported clinical factors and estimated with Cox regression.From a dataset of 1,773,689 patients, 1,558,421 were included, mean age 51.6 years; 40.2% male. There were 3.34% deaths from all causes in 3.68 years of median follow up. The prevalence of AF was 1.33%. AF was an independent risk factor for all-cause mortality  and cardiovascular mortality . Females with AF had a higher risk of overall and cardiovascular mortality compared with males (p < 0.001).AF was a strong predictor of cardiovascular and all-cause mortality in a primary care population, with increased risk in women.To assess risk of mortality in AF patients, an electronic cohort was obtained linking data from ECG exams of Brazilian primary care patients and a national mortality information system. From 1,558,421 patients, AF  carried a higher risk of overall and cardiovascular mortality, with increased risk in women.This is the first study with a large Brazilian electronic cohort to evaluate the risk of mortality linked to AF in primary care patients.AF patients from a Brazilian primary care population had a higher risk of death for all causes  and cardiovascular mortality .Female patients with AF had an increased risk of overall and cardiovascular mortality compared with male patients (p < 0.001). As the world population ages, the prevalence of atrial fibrillation (AF) is increasing, with a consequent increase in medical and economic global burden . It is e2Atrial fibrillation increases the risk of all-cause mortality, cardiovascular mortality and morbidity 6. Stroke8There are few studies on AF mortality and its risk factors in low- and middle-income countries, especially in a primary care population. In Brazil, AF and atrial flutter mortality rate was estimated in 2.8 per 100,000 inhabitants, standardized by age . The useThis is an observational retrospective study, developed using the database of digital ECGs from the Telehealth Network of Minas Gerais (TNMG) , which iMinas Gerais is a state in southeast Brazil with a large number of municipalities (853), most of them small, and more than 20 million inhabitants. It can be considered representative of the country , as age Tecnologia Eletrônica Brasileira model ECGPC  or Micromed Biotecnologia model ErgoPC 13 .All ECGs recorded by the TNMG from patients at least 16 years-old from 2010 to 2017 were assessed. Exams without valid tracings or with technical problems were excluded. In patients who underwent more than one ECG, only the first exam was analyzed. ECGs were performed by the local primary care professional, using digital electrocardiographs by Clinical data  were self-reported and collected using a standardized questionnaire by health professionals at the primary care unit at the same time of the ECG exam. Clinical conditions included self-reported smoking, hypertension, diabetes, dyslipidemia, Chagas disease, previous myocardial infarction and chronic obstructive pulmonary disease (COPD),Specific software was developed in-house, capable of capturing an ECG tracing for immediate upload, along with the patient’s self-declared clinical history, to the TNMG analysis center via the internet. The clinical information, ECGs tracings and reports were stored in a customized database. For the purpose of the present study, the Glasgow University Interpreter program, an automatic 12 lead ECG analysis software,  was used to automatically interpret all ECGs available in the database, exporting the diagnoses, accompanied by the corresponding Minnesota codes . The MinECGs were also interpreted by a team of trained cardiologists using standardized criteria, in order to generate an ECG report, which was done as free text. A hierarchical free-text machine learning tool was used to recognize a diagnosis of AF among these reports. First, the text was preprocessed by removing stop-words and generating n-grams. Then, we used the Lazy Associative Classifier 1718, a m17The electrocardiographic diagnosis of AF was accepted automatically when there was agreement between a cardiologist report and the automatic report from the Glasgow program or the Minnesota Code. In cases where there were discordances between the medical report and one of the automatic programs, some heuristic rules such as Standard Deviation of Normal to Normal RR intervals (SDNN) ≥647 ms (ROC curve area = 0.94) were used to automatically identify AF. If SDNN <647 ms, a manual revision was done in 4343 exams by trained staff. Those for which AF was diagnosed only by one of the automatic systems were not considered as AF Figure . Atrial The electronic cohort was obtained by linking data from the ECG exams  and those from the national mortality information system, using standard probabilistic linkage methods .The primary endpoint was all-cause mortality. The secondary endpoint was cardiovascular mortality, defined by cardiovascular disease through the International Classification of Diseases (ICD) coding: I00-I99, G45-G46.8, A39.52, B33.2-B33.24, D86.85 and A39.51.R program  was used for statistical analysis. Categorical data were reported as counts and percentages while continuous variables were reported as mean and SD or median , as appropriate. The time elapsed between the date of the electrocardiogram (index event) and the event of interest (date of death) was considered a dependent variable. The presence of the AF was an independent variable, along with the clinical characteristics of the population. Patients who did not present the event of interest until the end of the follow-up were censored, but contributed with follow-up time until the end of the study (September 2017).To assess the relation between AF and mortality, we analyzed Cox proportional regression, reporting hazard ratios and 95% confidence intervals, adjusted for age, sex, and clinical conditions . A two-tailed P-value of 0.05 was considered statistically significant. In addition, to examine the association between ECG and all-cause mortality, survival curves were computed using Kaplan-Meier estimates.This study complies with all relevant ethical regulations and was approved by the Research Ethics Committee of the Universidade Federal de Minas Gerais, protocol 49368496317.7.0000.5149. Since this is a study with secondary data, obtained for clinical reasons, a waiver of informed consent was required and granted by the Research Ethics Committee. Researchers signed terms of confidentiality and data utilization.From a dataset of 1,773,689 patients, 1,558,421 primary care patients over 16 years old underwent a valid ECG recording during 2010 to 2017 and, therefore, were included . Hypertension was reported in 31.6% of patients, diabetes in 6.5%, dyslipidemia in 3.9%, Chagas disease in 2.2%, previous myocardial infarction in 0.7%, COPD in 0.7%, and 7.0% reported current smoking.The prevalence of AF overall was 1.33% n = 20,782) with higher prevalence with advancing age, particularly from 70 years, reaching 7.0 % in octogenarians . Female patients also had an increased risk for cardiovascular mortality  compared to men ; p < 0.001  made in the same population , probablA Dutch ECG database of primary care patients with equivalent clinical conditions reported a similar prevalence . On the Male sex had a higher prevalence of AF in our study. The higher prevalence of AF in men has already been reported in several studies in high and low- and middle income countries (LMIC) . Our rat21AF is a well-known risk factor for death from all causes and cardiovascular deaths , in partPrevious studies had reported higher mortality in women with AF than men. In a systematic review and meta-analysis of thirty cohort studies that included more than four million participants, AF was associated with a higher risk of all-cause mortality, stroke, cardiovascular mortality, cardiac events and heart failure in women compared to men . AF in wIt is unclear what factors predispose to a higher risk of mortality in women versus men. Differences in hormones and in electrical and structural characteristics might help explain variation in incidence, prevalence, burden, and complications associated with AF in women and men . PhysiolCardiovascular mortality was also higher in AF patients. The association between AF and higher risk of stroke and heart failure may underlie this finding . The GAROur study reported a higher risk of mortality in AF patients. This finding has major implications in public health policy, particularly in LMIC, as Brazil, in where there are no specific protocols for AF screening and treatment in the primary public health system. Anticoagulation management in primary care also remains a challenge, since primary health care personnel are not trained in the anticoagulation control and direct oral anticoagulants are not available in most LMIC. Hence, stroke is the second leading cause of death worldwide with a significant impact on the economy 31. TreatThe automated reports may very occasionally differ in reporting AF. The Minnesota Code does not state any criteria for AF but simply assigns code 8-3-1 to this arrhythmia. However, if the Glasgow program reports for example ‘Probable atrial fibrillation with complete AV block’ this has been automatically assigned only a code 6-1-0, i.e. Complete (third degree) AV block. Thus, the strategy of using a report of AF in either the diagnostic interpretation or the Minnesota Code was adopted.As AF is often asymptomatic, can be paroxysmal, and because we used the first available ECG in the data set, the prevalence of AF may be underestimated. Comorbidities and medication data were self-reported, and thus might have been underreported and misclassified non-randomly. We did not have data from heart failure in our patients; therefore, it was not included in our statistical model. For the cross-sectional clinical correlates of AF we cannot establish temporality and note that risk factors may have a bidirectional relationship with AF . For both the clinical correlates and the mortality of AF, we acknowledge the observational nature of the data; we cannot rule out residual confounding and we cannot establish causal relations. Lazy Associative Classifier used for ECG report classification has good accuracy, sensitivity, and positive predictive value, but it is not free from errors. The information from the national mortality system is heterogeneous among the regions of Minas Gerais and misclassification in the basic cause of death can occur. The probabilistic linkage also has some issues such as a less than perfect sensitivity and the possibility of false pairing. To minimize this problem, we defined a high cut off point for true pairs and made a manual revision in the doubtful cases.Our study was innovative because it was the first to assess mortality in AF in a large Brazilian primary care population. However, further studies with reliable clinical and hospitalization data are needed to better understand epidemiological features of AF in our population. As the study involves a large electronic cohort with millions of patients, we believe that these small imperfections do not impact on our findings.AF is an independent risk factor for all-cause and cardiovascular mortality in patients of Brazilian primary care centers, with increased risk in women for overall and cardiovascular mortality. Public health policy should improve surveillance in this population with better prevention and treatment strategies, as evidence-based treatment for cardiac conditions , guidelines for management of oral anticoagulation and education of primary health care professionals.


In cattle, the overall seroprevalence was 1.7% (17/1011) . The porous interface recorded a seroprevalence of 2.3% (95% CI: 1.2–4.3), the non-porous interface recorded a prevalence of 1.8% (95% CI: 0.7–4.3) and the non-interface area recorded a seroprevalence of 0.4% (955 CI: 0.02–2.5), but the difference in seroprevalence according to site was not significant (p > 0.05). All impala and kudu samples tested negative. The overall seroprevalence in buffaloes was 11.7% (95% CI: 6.6–19.5), and there was no significant (p = 0.38) difference between the sites . The overall seroprevalence in buffaloes  was significantly (p < 0.0001) higher than in cattle . The results established the presence of RVFV in cattle and selected wildlife and that sylvatic infections may be present in buffalo populations. Further studies are required to investigate if the virus is circulating between cattle and wildlife.A study was conducted to investigate the seroprevalence and associated risk factors of Rift Valley fever (RVF) infection in cattle and some selected wildlife species at selected interface areas at the periphery of the Great Limpopo Transfrontier Conservation Area in Zimbabwe. Three study sites were selected based on the type of livestock–wildlife interface: porous livestock–wildlife interface (unrestricted); non-porous livestock–wildlife interface (restricted by fencing) and livestock–wildlife non-interface . Sera were collected from cattle aged ≥ 2 years representing both female and intact male. Sera were also collected from selected wild ungulates from Mabalauta (porous interface) and Chipinda Pools (non-interface) areas of the Gonarezhou National Park. Sera were tested for antibodies to Rift Valley fever virus (RVFV) using a competitive enzyme-linked immunosorbent assay (ELISA) test. AX2 test was used to assess differences between categories, and  Wildlife has often been perceived as a reservoir for some livestock diseases, and one major feature of human/wildlife interface areas is human encroachment into wildlife habitat. The drivers of this encroachment include climate change, deforestation, changing food patterns, the need for drinking water, the disposal of waste and the human population explosion. All of these together with changes in agricultural activities have profound effects on domestic livestock patterns that, in turn, influence wildlife behaviour and migratory patterns , which is an arthropod-borne viral zoonosis with evidence of widespread occurrence in humans and animals in Africa and the Arabian Peninsula  in the South Eastern Lowveld (SEL) of Zimbabwe. The study further aimed to investigate risk factors, including exposure to wildlife, associated with the occurrence of the infection in cattle.This study was conducted as part of a broader investigation into three zoonotic causes of abortion in cattle, namely, brucellosis, chlamydiosis and RVF. The results of two of the diseases, brucellosis and chlamydiosis, have been published  , located at the southern border of GNP on Sengwe communal lands , located on the periphery of the Malilangwe conservancy, was selected as the non-porous interface. The conservancy is located on the northern boundary of the GNP and is surrounded by a well-maintained game fence, which hinders direct contact between wildlife on one side of the fence and humans and livestock on the other. The conservancy is home to the full range of African wild ungulates occurring in the area, while on the other side of the fence, the Chizvirizvi village hosts livestock, mainly cattle, goats and sheep. The fence creates a physically defined linear interface, separating wildlife and cattle.Chomupani communal lands , located at least 15 km from the north western boundary of GNP, was the selected non-interface site. Wild ungulates are reportedly absent in the Chomupani area, and this site was considered to be a control site with no wildlife/livestock interactions as it was far away from the GNP.z is the value from standard normal distribution corresponding to the desired confidence level , p is the estimated prevalence and e is the desired precision , greater kudu (Tragelaphus strepsiceros) and impala (Aepyceros melampus), were targeted for sampling south of the GNP in Mabalauta close to the porous Malipati interface. The species were selected on the basis of their reported mixing with livestock during grazing and at water points as confirmed by communities in previous studies . All sampled animals were ear-tagged to avoid resampling them on subsequent visits.Each cattle dip tank was visited four times for sampling, as highlighted previously. Farmers enrolled their herd in the sampling protocol on a voluntary basis. Cattle were systematically randomly selected as they passed through the handling facilities of the dip tank. As cattle passed through the handling pen, each fourth mature (>1 year) and intact  individual was targeted for sampling. The targeted individual would then be physically restrained and 15 mL – 20 mL of blood collected using coccygeal venipuncture and a 20 mL disposable plastic syringe and an 18-gauge needle. Upon collection, the blood was immediately transferred to 4 mL plain tubes. To allow clot separation, all blood samples were left to stand for approximately 15 min in the shade at ambient temperature (25 °C – 30 °C). Clotted blood samples were then centrifuged at 3000 Within GNP, two buffalo groups were selected by aerial spotting from a helicopter in an area as close as possible to the porous park border , and in the northern part of the park (Chipinda area) closer to the non-porous border, respectively. The buffaloes were immobilised using a standard protocol similar to Burroughs et al. : one to Specific anti-RVFV antibodies were tested in serum samples using the commercial ID Screen® RVFV competition multi-species enzyme-linked immunosorbent assay (ELISA)  with a level of sensitivity and specificity of 91% – 100% and 100% (95% CI: 99.58% – 100%), respectively, based on livestock samples  , two for sex , four for parity , two for abortion history (history of abortion and no history for abortion) and two for season (wet and dry). For wildlife, species, age and site categories were as follows: three for species , three for age  and two for site . Descriptive statistics on abortion history, parity and season were restricted to female cattle and because of a small sample size, seasonal and interface type descriptive statistics were not assessed for male cattle. The chi-square test was used to measure differences between categories, and values of p < 0.05 were considered as significant.Data recording and editing were performed in Microsoft ExcelAll standard ethical consideration were followed with strict observation to the five degrees of animal welfare freedom adhered to.A total of 1011 cattle were sampled with 46.7% from the porous , 28.2% from the non-porous (Chizvirizvi) and 25.1% from the non-interface (Chomupani) areas.p > 0.05). All positive cattle were females, but again the difference according to sex was not significant (p = 0.27). Similarly, the difference in seroprevalence according to abortion history in cows was non-significant (p = 0.44). In contrast, the wet season recorded a significantly (p = 0.0002) higher seroprevalence compared with the dry season .The distribution of the sampled animals and their RVF seroprevalence according to interface, sex, abortion history and season is shown in p = 0.38) difference between the sites .A total of 161 samples were collected from wild animals: 111 buffaloes, 32 impalas and 18 kudus. p < 0.0001) higher than in cattle .The overall seroprevalence in buffaloes  was significantly . The serological test used, the competitive ELISA, has been shown to have a sensitivity of 91% – 100% and a specificity of 100% (95% CI: 91.24% – 100%) in cattle, horses, sheep, goats, cats, dogs and humans (Comtet et al. Our results show an overall low prevalence of the disease in cattle with no statistical differences between the three interface types. Previous studies in Zimbabwe, although scant, have demonstrated serological evidence of RVFV in cattle and wildlife (Anderson & Rowe In our study, both kudus and impalas were detected as being seronegative for RVFV. There are no previous reports of the disease in kudus in Zimbabwe and only one out of 801 impalas tested positive for RVFV in the study by Anderson and Rowe . Rift VaIn conclusion, our study provided evidence that RVF is present in the SEL of Zimbabwe in both cattle and buffalo populations, with cattle having a low level of infection and buffaloes having a moderate level. Proximity to wildlife is not a risk factor to cattle and vice versa as differences in seropositivity between study sites were not significant. The kudus and impalas were all negative for infection in spite of sharing the same ecosphere as the buffaloes. The level of infection in cattle is too low to warrant any preventative measures such as vaccination. However, surveillance of the disease by the Department of Veterinary Services and the Ministry of Health under the One Health concept should continue as the disease is an important zoonosis. Further studies, including prospective cohort studies, should focus on investigating the possible role of buffaloes in the epidemiology of the disease in cattle.


Divergent thinking (DT) has attracted research interest because of its potential role in early diagnosis and rehabilitation programs for patients affected by neurodegenerative diseases. Recently, DT has received even more attention because of its proven relationship with cognitive reserve (CR) and the possibility of a standardized assessment. However, few studies have investigated this ability in dementia patients, and even less is known about patients affected by Mild Cognitive Impairment (MCI). Thus, this study aims to investigate DT abilities in MCI patients.A total of 25 MCI patients and 25 healthy controls subjects  matched for age, gender, and educational level were enrolled. General cognitive functioning was measured by the Montreal Cognitive Assessment (MoCA), while the Abbreviated Torrance Test for Adults (ATTA) was selected to measure DT.MANOVA analysis did not reveal any significant differences in DT abilities between MCI patients and HC except for the figural indicator score. A logistic hierarchical regression analysis revealed that the figural indicator score added an 8% of accuracy in the prediction of the group variable over the general cognition measure (MoCA).MCI patients seem to perform significantly worse than HC only in the figural DT score and this evidence has significant practical implications. First, that figural DT seemed to decrease even earlier than verbal DT and could therefore be taken into account for early diagnosis of MCI patients. On the contrary, the sparing of all the other DT skills  may suggest that, given its relationship with CR, verbal DT could instead be considered a possible target for prevention or early cognitive stimulation interventions. Indeed, it seemed that early studies agreed on the evidence of a curvilinear decline in DT abilities during the life-span, with a peak around the 1950s and then a decline during late adulthood , whereasDivergent thinking has also recently received renewed attention because of its potential for early diagnosis  and rehaIn spite of this significant evidence, few studies have evaluated DT abilities through standardized tests in patients affected by different types of dementia  and studThe study involved a total of 75 participants: 25 MCI patients (MCI) and 50 Healthy Control subjects (HC). However, due to the lack of proportionality of the two samples, a random selection of 25 subjects from the HC group was performed. Their socio-demographical data are summarized in Mild Cognitive Impairment patients were recruited at the Neuropsychology Service of the ASST Spedali Civili in Brescia , while HC subjects were enrolled from a pool of older adult volunteers. The MCI group was composed by subjects diagnosed as affected by Mild Cognitive Impairment according to Petersen’s criteria , which iThe MoCA  test wasThe ATTA test  was seleThe scores and indices of the sub-scales of fluency, originality, processing have been calculated according to the manual’s norms. Moreover, the evaluation of creativity indicators for verbal  and for figural  tasks were computed . The sum of the creative indexes and creative indicators constitute the total score, the Divergent Thinking Total Score (DTTS).t-tests were performed and no significant differences were found for age and years of education; a Welch’s t-test was used to compare gender, which was found to be non-significant (see t-tests were performed. The homogeneity of variances assumption was checked using Levene’s Test. Considering the high correlations (greater than 0.30) between the different DT indexes, a multivariate analysis of variance (MANOVA) was chosen to test between-group differences in these variables. Finally, a hierarchical logistic regression was run to evaluate the possible predictive role of cognitive and DT measures to discriminate between the two groups.Data analyses were performed using SPSS software (version 24.0.0). Normality was checked for all the variables with the Shapiro-Wilk test and the examination of the skewness and asymmetry indexes were performed. Furthermore, a check for outliers was run. Almost all of the variables met the assumptions of normality; transformations (square root) were performed when necessary, and parametric tests were then used for all the analyses. To ensure that the two groups (HC vs. MCI) did not differ with regards to important demographic data, two independent cant see . To asset(48) = 3.762, p < 0.001 between MCI patients and HC groups, with MCI patients performing worse than HC  = 1.472, p > 0.05. Univariate ANOVA revealed that only the figural indicator score was significantly affected by group, F = 5.655, p < 0.05, with MCI patients performing significantly worse  than HC . A comparison between drawings from one MCI patient and one matched HC subject is presented in F = 3.756, p > 0.05, originality, F = 0.636, p > 0.05, elaboration, F = 0.278, p > 0.05, flexibility, F = 2.025, p > 0.05, and verbal F = 0.578, p > 0.05 indicators were not affected by the independent variable.A MANOVA was performed with fluency, flexibility, originality, and elaboration scores and verbal and figural indicator scores of the ATTA test as dependent variables and “group” treated as the between factor variable. The analysis returned a non-significant effect of group, Wilks’ Lambda = 0.830, Considering this first exploratory result, a hierarchical logistic regression was run in order to check for the possible predictive value of Figural Indicator, over the general cognition variable (MoCA), as a predictor of the group variable. p < 0.05) and accounted for 68% of correctly classified cases. A second block was then added so that Model 2 tested the predictive effects of the Figural Indicator predictor on the dependent variable “group” over the effect of MoCA. The change in the amount of information explained with this second model is significant . The significance values of the Wald statistics of the two predictors indicate that both the MoCA  and Figural Indicator  significantly predict the dependent variable; furthermore the odds ratios of MoCA, (Exp(B) = 0.34, CI0.95 = ) and Figural Indicator (Exp(B) = 0.50, CI0.95 = ) indicate that if the value of MoCA or Figural Indicator goes up by 1 point, the odds of being part of the HC group increase. Together, the predictors accounted for 76% of correctly classified cases.Model 1 tests the effects of MoCA as the only predictor of the dependent variable “group.” The estimated coefficients for Model 1 indicate that MoCA significantly predicted the dependent variable . The between-groups comparison has highlighted that MCI patients performed worse only in the figural indicator score. This result is partially in line with previous studies that have already proved the impairment of visual DT in dementia of Alzheimer’s type  and haveInterestingly, if a worse performance emerged in the figural indicator score in MCI patients, all the other indexes  and the verbal indicator score seemed to be unaffected. These results are partially in line with the complex and sometimes inconsistent studies that have evaluated the impact of the aging processes on DT abilities . Some authors highlighted a major impact of normal aging on visual DT abilities compared to verbal ones  or at leIn conclusion, our preliminary results highlight a slight impairment in DT abilities in patients affected by MCI, but only in the figural indicator score. Thus, figural abilities seemed to be affected earlier than verbal ones in mild pathological aging. This result has two significant practical implications: first, figural DT might be considered for the early diagnosis of MCI patients and, secondly, the sparing of all the other DT abilities  may suggest that, considering its relationship with CR, verbal DT could be considered as a possible and meaningful target for prevention or early cognitive stimulation programs.Some limitations have to be reported: first of all, the sample size for each group was relatively small and could not be fully representative of the population. Secondly, a mixed MCI group was enrolled; further analysis considering the different subtypes of MCI (amnestic vs. non-amnestic, single domain vs. multiple domains; The raw data in the dataset supporting the conclusion of this manuscript and the cognitive and behavioral measure for MCI patients will be made available upon request.The studies involving human participants were reviewed and approved by Ethic Committee of the ASST Spedali Civili of Brescia. The patients/participants provided their written informed consent to participate in this study.MR, LR, and AA were responsible for the study design. GF, EF, and MR wrote the manuscript. MZ was responsible for the patients’ assessment. GF, MC, and LC were responsible for the healthy controls’ assessment. EF and CB contributed to the assessment. AP critically revised the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Hearing in Adults, published in 1995,contains the fullest report of the United Kingdom’s Medical Research CouncilNational Study of Hearing. It was designed to determine the prevalence anddistribution in Great Britain of audiometrically measured hearing loss as afunction of age, gender, occupation, and noise exposure. The study’s size,quality, and breadth made it unique when it was done in the 1980s. Thesequalities remain, and its data are still the primary U.K. source for theprevalence of auditory problems. However, only 550 copies were printed, and thebook is essentially unobtainable today. We describe here a fully searchable,open-access, digital (PDF) “reprinting” of Hearing in Adults,summarizing the study’s design and the book’s contents, together with a briefcommentary in the light of subsequent developments.The 1011-page book,  The Medical Research Council’s (MRC) “National Study of Hearing” (NSH) was a group ofmajor epidemiological studies of the prevalence and distribution of hearing problemsof adults in England, Scotland, and Wales. It was conducted by the former MRCInstitute of Hearing Research (MRC IHR) in the 1980s. The NSH gave the UnitedKingdom its first stratified and precise quantification of degrees of severity ofhearing loss in a designed study and related these to demographic and pathologicaldeterminants. Its scale and type of measurement have never been repeated in theUnited Kingdom; its data and analysis framework are still used to determineprevalences and derive population numbers e.g., . The curHearing in Adults (hereafterHiA). This book . These goals wereimplemented strategically through six key design features. Given the number of mainvariables supported and the requirement for narrow confidence intervals across thewide age range, a large sample size was needed. The six design features were asfollows: A structured two-tier design to reconcile population reach withclinical/laboratory precision of measurement. The first tier was apostal survey; the second tier was auditory and clinical assessment atfour specially equipped hospital-based research clinics with qualifiedotorhinolaryngolical (ORL) and audiological staff.A double basis of accessing the population, via two sampling frames:individuals from the electoral register and then from households, withcross-checking of the two sets of estimates.Repeated postal reminders, then domiciliary visits to ensure remarkablyhigh response rates and hence reduce attendance bias.Calibration of equipment and detailed analyses of calibration results bycenter, tester, and frequency to determine which effects were largeenough to be worth adjusting for.Initial stratification of first tier responses for efficient gearing ofclinical testing, then poststratification for populationprojections.A broad range of clinical and demographic data to be acquired, includinga rigorous structured protocol for eliciting and calculating lifetimenoise immission.The NSH was designed to determine the prevalence and characteristics of both measuredhearing impairment and self-reported hearing disability in adults (18–80 years) as afunction of severity, age, gender, occupational group, and occupational noiseexposure  and to maintainaudiometric calibration and fixed procedures.HiA OnlineAppendix 1) was informed by related earlier work by In the first tier, a postal questionnaire on hearing, tinnitus, and demographics wassent to 48,313 adults selected at random from the electoral registers. The overallresponse rate was 80%. The questionnaire (reported in HiA Online Appendix 4), otologicalexamination and clinical interview. The sample was initially stratified by age,self-reported hearing, and whether they possessed a hearing aid . For efficiency and precise estimation of means and variances, thestratum with self-reported hearing disability was sampled more densely than thosewith no reported hearing problem. For example, all those who reported in Tier 1 thatthey used a hearing aid were contacted to take part in Tier 2, whereas only about 1in 25 people who reported no hearing problem whatsoever were contacted. The finalTier B sample contained 2,578 individuals with complete audiograms at the usualoctave-spaced frequencies up to 8 kHz for each ear but additionally including 3, 6,and 12 kHz. There were 2,208 otoscopic examinations. The data were poststratifiedfor calculating prevalences, according to location, age band, gender, andself-reported hearing.In the second tier, a reduced sample drawn from those who responded to Tier 1 wasinvited to one of the four clinics of MRC IHR for an audiological assessment, adetailed questionnaire (see https://acorn.caci.co.uk/what-is-acorn). This was a widely usedsurrogate residential marker for socioeconomic status. This study also had atwo-tier design, with a postal questionnaire followed by a home visit forabbreviated clinical assessment.A complementary two-stage study was also conducted on 6,650 addresses to check thenational representativeness of the main study sample. The addresses were chosen fromthe U.K. Postal Address File, which was the most complete postcode database in theUnited Kingdom at the time, also being stratified by health region and by the CACIAcorn housing type .Tinnitus was defined as having prolonged sustained tinnitus,lasting more than 5 min: “Nowadays, do you get noises in your head or ears?” “Dothese noises usually last longer than 5 minutes” .Hearing-aid possession was “yes” to “Have you ever had ahearing aid?” Further definitions were as follows: for audiometry,standard across-frequency averages were calculated on audiograms, with a pragmatic boundary for conductive hearingloss was taken as an air-bone gap ≥15 dB when averaged over 0.5, 1, and 2 kHz. Occupational groups were basedon head-of-household information collected at the clinical interview rather than theself-report data. They were coded in accordance with the recommended RegistrarGeneral’s Classification of Occupations at the time . Noise emission was defined interms of the equivalent continuous sound level (Leq) fora 50-year working lifetime; no noise was ≤80 dB(A). The 80-dBcutoff was used to identify individuals with no noise exposure in the screened data.Higher bands were also defined, but these were only used in associated papers. This led to another major product ofthe study: a parsimonious four-term demographic model for predicting the probabilityof a hearing loss in October 2017. The British Library’s (BL) digitization department undertook thetask of scanning HiA. Photographic reproduction was brieflyconsidered, but pilot work showed that scanning was preferred as generallydelivering more consistently high quality. The digital version was thus created byscanning each page of a copy of HiA and then converting to PDF. Dueto an oversight on our part, the opening material  was not scanned by the BL. This was therefore done by one of us(Akeroyd) at the University of Nottingham and then added to the PDFs. The BL scan isfully text searchable so that any table, section, or page can be accessed rapidly.It is easy to find key words in the text chapters, which enables a high degree ofaccess to the data in a relatively raw form.Online Chapters 1 and 2 give an overview and describe the methods; Online Chapters 3,4, and 5 report, respectively, the prevalence, distribution, and type of hearingimpairment; Online Chapters 6, 7, and 8 report, respectively, hearing impairment byage, social classification, and regional districts current in the mid-1980s; andOnline Chapters 9 and 10 cover self-reported hearing impairment.For the overall prevalence of hearing loss (four-frequency average) inthe better ear across age, gender, and occupational group, see TableB5124-1 (online p. 46).For the prevalence of hearing loss up to 95 dB for those aged 80+, seeTable 8.1 (online p. 822).For medico-legal purposes, see the tables in Online Chapter 4 for decadebands giving audiometric averages and distributions for each of theeight test frequencies, stratified by gender, and manual/nonmanualoccupational group. Online Chapter 6 is also useful, giving data insingle-year bands of three- and four- frequency averages by gender alongwith their distribution in percentiles.A first-time reader may be somewhat daunted by the amount of data and the number oftables. As an orientation, it is therefore useful to give examples of some tablesthat are most useful for answering particular questions: In more detail, Online Chapter 3 reports the cumulative prevalence of differentdegrees of hearing impairment (0 to 95 dB in 5- or 10-dB steps) for each ear andfrequency (plus frequency average) as a function of age-group (decades), gender, andoccupational group . There is a table for every combination ofage , gender , occupational group , audiogram , and ears (better or worse). Online Chapter 4reports the distribution of hearing threshold levels  for the same combinations ofclassifications, along with new classifications of everyone or “normal” ears  only, and better, worse, left, and rightears. The plots on pp. 357–358 illustrate the mean hearing losses by gender anddecade for the better and worse ears, also left, right, and overall.Online Chapter 5 reports prevalences classified by conductive loss, sensorineuralloss, or normal hearing with factorial tables by age, gender, and occupationalgroup. Online Chapter 6 provides numerical estimates of the percentiles of thedistribution of hearing impairment year-by-year then models the percentiles of thehearing threshold distribution using a smoothing window within the regression, as afunction of age, gender, and type of population. Note that this is the only chapterthat reports modelled data; all other chapters use estimates from the data that arenot smoothed or modeled in any way. The tables are structured by age, gender,otologically typical or otologically screened , conductive or sensorineural hearing loss, and ear.Appendices reproducing the questionnaires andprotocols, together with a Foreword by Mark Haggard and a Preface by AdrianDavis.Online Chapter 7 presents the distribution of hearing impairment as a function of afull social class coding according to head of household. The tables reportcombinations of age, gender, and particular ear. Online Chapter 8 projects the datato estimate the number of people at different levels of severity, for localauthority and health regions and districts in Great Britain, as at 1992. The numberswere derived using census figures for the population and its age structure; theyhave been recalculated since e.g., . FinallyHiA makes the data andconclusions as widely available as modern technology allows. In doing so, ithighlights the clearest weakness in the NSH as a project, namely, its dissemination.Just 550 copies of HiA were printed, and so there was a generalfailure to secure the justified broad distribution and promotion of the study.The accompanying digital reprinting of Timeliness is high on the list of desirable properties for science, so it may beasked why we are now republishing research prioritized and conceived in the 1970sand executed in the 1980s. We argue that the NSH’s continued relevance is rooted inthe scale of the study and the quality and breadth of its data. The quality is dueto the profound multidisciplinary professional care taken in its design, protocols,execution, and analysis. This level of care required substantial resources; thus,the field of hearing arguably owes a permanent debt of gratitude to the U.K. MedicalResearch Council, and the English, Welsh, and Scottish Health Departments. In thelate 1970s and early 1980s, their funding of MRC IHR (see Appendix) enabled it tobuild up a team of applied scientists with the necessary multidisciplinaryknowledge, ensured it had the breathing space for a profound consideration ofmethodological and logistical issues, and allowed piloting to work out exactly whatneeded to be done and how, all with the purpose of giving the requisitegeneralizability and precision. This marriage of research resources and hospitalresources was crucial, and is usually hard to achieve. It is perhaps unlikely thatsuch a harmonious conjunction of resource, expertise, purpose, and team structurewould occur again in the foreseeable future. The NSH may remain unequaled in itsexperimental care.use, the simple answeris yes, as evidenced by the fact that it was one of seven data sets used todetermine the current ISO standard for the statistical distribution of hearingthresholds related to age and gender (ISO 7029:2017). Almost 90% of theHiA median thresholds for the combinations of Frequency × AgeBand × Gender  are within ±5 dB of the corresponding ISO values,though the differences reach up to 10 dB for some of the 8-kHz data or for the 71 to80 age band. In terms of purpose, the answer is more complicatedbecause a study like HiA is unlikely ever to be replicated at thesame scale and quality as the NSH and because the population, with its health andlife, has moved on. Certainly most of the empirical methods are still used;someone’s hearing is still established subjectively by self-report questionnaire andobjectively by pure-tone audiometry. Stratification questions similar to “Do youfind it very difficult to follow a conversation if there is a background noise, egTV, radio, children playing?” are still used routinely in survey or cohort work, but forthe population in total, having many more older people will have made the populationaverage hearing level worse. The life expectancy at age 65 years has increased from13 and 17 years  to 19 and 21 years . ThemagThird, the growth of obesity and diabetes is a major change in population healtharound the world. There is now consistent evidence from large cohort studies of anassociation of diabetes with hearing loss e.g., , althougHiA waspublished and about 40 years since the project was started, much scientific andpublic comment on the prevalence of hearing loss  is,ultimately, traceable to its data.Against this reservation about the possible incompleteness of the projection modelinto the indefinite future and to all populations must be placed the severalfavorable considerations discussed earlier, of which the main two are (a) thecontinuity of standards in the audiological test measures plus relevantquestionnaire items and (b) the uniquely comprehensive design and sampling,otological screening, and attention to measurements. These give the NSH a continuingimportance and relevance. It remains a primary source of formal control data anddetailed distributions of audiological level by age, gender, occupation, and noiseexposure. Thus, despite it being nearly 25 years since https://www.nottingham.ac.uk/mrcihr/index.aspx for a finaloverview.The MRC Institute of Hearing Research was founded in 1977 following the advocacy oftwo members of the Wilson Government of the United Kingdom: Jack Ashley(Parliamentary Private Secretary) and Barbara Castle . It was an intramural unit of the Medical Research Council,which was set up to conduct and coordinate multidisciplinary research in hearing.The NSH was one of its primary projects; the need for multicenter studies set therequirement for the multicenter structure of IHR that continued throughout itshistory. The Institute closed in 2018. See Click here for additional data file.Supplemental material, TIA887614 Supplemental Material for Hearing in Adults: ADigital Reprint of the Main Report From the MRC National Study of Hearing byMichael A. Akeroyd, George G. Browning, Adrian C. Davis and Mark P. Haggard inTrends in Hearing


Career aspirations are considered to be one of the most important motivation variables in the study of psychology and career development, as well as being connected to an individual’s career-related goals, intentions or options. The aims of this study were: (a) to develop and validate a model for predicting career aspirations, and (b) to investigate direct and indirect links between paternal education, self-esteem, resilience, future orientation, and career aspirations of university students. The participants were 445 students from two universities in Thailand. Confirmatory factor analysis confirmed that the factor structure of four measurement models presented in the study was suitable and compatible. To achieve the intended research objectives, the empirical data were analyzed using structural equation modeling with decomposition analysis of total effects in direct and indirect effects. Results showed that paternal education, resilience, and future orientation have significant direct effects on students’ career aspirations, while self-esteem has an indirect effect. This suggests that self-esteem can help students develop their resilience, as well as promoting their development of a positive future orientation, which also helps foster a higher level of career aspiration. These results can be fundamental to supporting the continued use of the structural equation model in future research on career development. In the current competitive labor market, it is increasingly challenging for higher education institutions to produce graduates that are well prepared for employment . One of Career aspirations are often linked to the political agendas of some developed and developing countries, with social mobility and the enhancement of work skills forming a basis for economic growth , 8. In gA study on high school students revealed that parental educational level contributed to students’ educational and occupational aspirations and parents with prestigious professions tended to encourage their children to aspire to their professions . It appeIn the past decades, a number of research studies have been conducted on the relationship between self-esteem and career aspirations –29, the In the context of the Thai higher education, factors related to resilience in undergraduate nursing students were studied using descriptive statistics . The resIn Thailand, as in other developing countries in general nowadays, most students from lower-income families are encouraged to attain higher levels of education than did their parents . BecauseStudents’ attitude toward career achievements should clearly be addressed within the context of their specific culture , but carThe term “aspiration” is widely used in reflecting the future lifestyle, dreams, desires and ambitions of individuals . StudiesIn addition, lecturers and policymakers can help improve the learning environment and increase students’ aspirations through fostering “the-love-of-learning” . Castro Interestingly, the results of several studies indicated that rural students possessed lower educational and career aspirations than their urban peers , 52, 53.Although several interesting influences on career aspirations have been identified, to better understand students’ career development, further studies regarding their quality of life and future employment are still necessary.Hypothesis 1: Paternal education would have a positive significant related to self-esteem, resilience, and future orientation.Hypothesis 2: Self-esteem, future orientation, and resilience would have significant positive direct and indirect effects on career aspirations.Hypothesis 3: Paternal education level would have significant positive results, both direct and indirect, in predicting career aspirations.The participants in this study were 445 undergraduate students (response rate = 91.75%) in two universities (of technology), one of which was a prestigious public autonomous research university (one of the top nine well-funded research universities in Thailand) with strong science and engineering programs, and the other was a vocational university. The former is located in a populated city in the lower north-eastern region, and the latter is in the eastern industrial seaboard area of Thailand. Participants were recruited using a convenience sampling method during September 2017–March 2018. They were undergraduate students aged between 17 and 26 years. The inclusion criteria were the students, who were willing to participate in the survey. The exclusion criteria were students who were not convenient or comfortable to participate in the study and incomplete returned questionnaires with missing responses more than 10% for a particular variable. Because the participants were either freshmen or senior, the study sample of 445 can be representative of large population  at the 95% confidence level , 58, espDemographic characteristics of participants are included in A self-report instrument was developed to measure the variables for this research. The details of all the instruments used in the study are as follows:In measuring the outcome variable, the study focused on career ambitions, based on the concept proposed by O'Brien . The resTo assess how the students felt about themselves, the Rosenberg’s self-esteem scale  was usedDi Maggio, Ginevra  developeIn this research, because demographic data analysis in In statistical analysis concerning with the measurement of level of education, it is necessary to translate the level of education into the number of years of educations . EspeciaThe participants were asked to report their gender, type of study program, and experience in the workplace through co-operative education.r) matrix was used to examine the relationship between the variables in the model. Cronbach's Alpha coefficient (α) was assessed to measure the measurement scale reliability. Confirmatory factor analysis (CFA) was carried out to confirm the factor structure of the measurement model. Structural equation modeling (SEM) was conducted to explore causal relationships of the career aspirations structural model.Statistical analyses were conducted using SPSS 18.0 and Mplus 8.3 software . Descrip2 to the degrees of freedom , the comparative fit index , Tucker-Lewis index , the root mean square error of approximation , and the standardized root mean squared residual  [Assessing the goodness of fit of the model was conducted by using the ratio of χ ≤ 0.08) , 68.This study was a cross-sectional study conducted in accordance with ethical principles and guidelines for research in human subjects. The ethical approval was granted by Suranaree University of Technology, Thailand EC-61-93). The Thai versions of all four instruments  were developed using back-translation from English into Thai by the researcher and an expert in the English language. The questionnaires in English , 61, 69 -93. The M), standard deviations (SD), skewness (SK), and kurtosis (KU) of the constructs and each item are displayed in M = 24.13, SD = 4.42) than educational , and leadership aspirations . The mean of future orientation  and resilience  was in good levels. The same applied to self-esteem, which was in a good range  on a 4-point scale. Besides, the average number of years for the highest education of fathers was 11.62 years (SD = 4.02), which meant that the average level was high school level. SK values ranged from -0.16 to -1.43 (SK < |3|), and KU values ranged from -1.02 to 1.87 (KU < |10|) [p < 0.01) to each predictor variable.The dataset for investigating the relationship between paternal education, self-esteem, resilience, future orientation, and career aspirations were included as . Mean (M < |10|) , indicatχ2(10) = 28.154; p = 0.002, χ2/df = 2.815, CFI = 0.994, TLI = 0.997, RMSEA = 0.073 , SRMR = 0.014. All of the standardized path coefficients were statistically significant and had a positive direct effect on career aspirations. The slightly high upper range for the 90% confidence interval of RMSEA (> .08) could be attributed to the sampling uncertainty that might be affected by sample size and the model complexity [Based on the conceptual framework, SEM was performed to explore the effects of paternal education level, self-esteem, future orientation, and resilience on career aspirations. The resulting career aspiration SEM is presented in mplexity , 73.R2 = 0.761) of the variance in career aspirations. Hypothesis 1 was confirmed only for future orientation and resilience, whereas self-esteem was not confirmed. Results indicated that paternal education level had a significant positive relationship with future orientation  and resilience , while there was no relationship between paternal education and self-esteem. Hypothesis 2 was also partially confirmed, as the path coefficients between future orientation  showed a significant positive direct effect on career aspirations, whereas resilience had both a strong positive direct  and indirect  impact on career aspirations, mediated by future orientation. The total effect of resilience was 0.404 (p < 0.001). Hypothesis 3 also confirmed that paternal education showed a strong predictive relationship with the other constructs in this model; in predicting the level of career aspirations, paternal education level was significant with regard to positive effects, both direct and indirect. The standardized direct effect of paternal education level on career aspirations was 0.475 (p < 0.001), while the total indirect effect was 0.249 (p < 0.001). The total effect from paternal education level to career aspirations was 0.724 (p < 0.001).For the career aspiration measurement model, the results showed that three standardized factor loadings were significant, and higher than 0.50, indicating that the three subscales contributed significantly to the measurement of career aspirations. The SEM results indicated that the hypothesized structural model for career aspirations adequately fitted the data. The set of four predictor variables in the model explained 76.1% . These findings describe the role of resilience and future orientation as mediating variables which aid in understanding the relationship between paternal education and forms of self-esteem, and the career aspirations of Thai university students.In addition, the results obtained from the SEM indicate that self-esteem has a positive indirect effect on career aspirations through future orientation and resilience  and other factors in the model.Finally, since this study focused only on public universities, further research should include participants from private universities or other groups, e.g., groups based on vocational education or age, and consider testing invariance of this model across different cultural groups and various disciplines.Despite its limitations, this study indicates the relationships between career aspirations and paternal education, self-esteem, resilience, and future orientation of Thai university students. It also supports the continued use of the structural equation model in empirical research on career development.S1 Questionnaires(DOCX)Click here for additional data file.S1 Dataset(XLSX)Click here for additional data file.


Experimental studies on animals are conducted in almost all areas of medical research. The experiments offer insights into diseases and expand biomedical knowledge. Animal experiments are also imperative for studying acupuncture treatment mechanisms and the exploration of innovative acupuncture techniques. Laser acupuncture (LA), as a promising alternative to traditional manual acupuncture (MA), has the characteristics of painless and controllable stimulation. Today, society is more aware of animal welfare than previous generations. The use of noninvasive LA as a substitute for invasive MA in basic experimental research of acupuncture should be encouraged. Thus, we conducted an overview of animal experiments in the research field of LA from January 1978 to April 2020. After careful research, 52 studies were included in the work. Among these studies, both single-point and multipoint LA studies have been reported. To make noninvasive LA better in replacing invasive MA in experimental animal research of acupuncture, further experiments should focus on exploring uniform criteria for selecting laser parameters and revealing the extent to which the curative effect of LA depends on the property of acupuncture points rather than the characteristics of photobiomodulation. A varien (PBM)” . With non (PBM)” . Althougn (PBM)” , in justn (PBM)” . Evidencn (PBM)” , postopen (PBM)” , chronicn (PBM)” , musculon (PBM)” , and astn (PBM)” . Technicn (PBM)”  can be cn (PBM)” .In this article, we will review the animal experimental investigations concerning LA research to analyze the application status and development prospect of LA in basic research of acupuncture.We conducted an English-language search of databases, including PubMed, Web of Science, EMBASE, and Cochrane Library. Database searches were performed using the following terms: (acupuncture OR acupoint OR moxibustion) AND (laser) AND . Literature from January 1978 to April 2020 was included. Animal experiments were our main concern. By reading obtained references seriously, we present the final included citations in this review. The search strategy is shown in 647 records were identified. After careful research, 52 articles were found directly involved in the experimental animal research on LA. Among these publications, the choice of experimental animals is mostly rodents (rats and mice), followed by cats, rabbits, and gorillas. Both single-point and multipoint laser acupuncture studies have been reported. The research results show that LA has the effects of analgesia, anti-inflammatory aspects, regulating endocrine, promoting blood circulation, etc. However, the current animal experimental research of LA only involves a small number of acupoints. There is no uniform standard for the intensity of laser stimulation at acupoints as of yet.Using lasers to explore the mechanism of action of a single acupuncture point or a combination of multiple acupuncture points has promoted acupuncture development. In TCM  theory, each acupoint has its own characteristics according to the meridian to which it belongs and the position where it locates. The application of various acupoint stimulation methods may have different effects on acupoint function. Basic research of LA on single acupoint will help to improve the efficacy of LA in clinical practice.μm + 650 nm laser were found to increase the pain threshold of rats. Mast cell degranulation rate was believed to play an important role in laser irradiation-induced analgesia by being positively correlated with analgesic effects. Erthal et al. [Zusanli (ST-36) is one of the most commonly used acupoints in clinical practice; according to TCM theory, ST-36, which is located at the stomach meridian on the lower leg, has a close relationship with gastrointestinal function. It is an essential point in health care, and it has been widely used in the prevention and treatment of various diseases. Acupuncture treatment at ST-36 has been frequently investigated in animal experiments. Laboratory studies have proved that ST-36 has the effect of regulating autonomic nerve activity , has furl et al.  evaluatel et al.  demonstrl et al.  LLL treal et al.  found thl et al. . In addil et al.  indicatel et al.  insertedl et al.  exploredcun above the wrist crease. Stimulating PC-6 is essential to treating some heart diseases, mental disorders, nausea, and vomiting [μm CO2 laser significantly improved bradycardia while the 650 nm semiconductor laser does not produce such an effect. However, when the two lasers are combined, the effect is positive. Instead of focusing on the type of laser, Friedemann et al. [2 laser stimulation at different acupoints on HR and mean arterial blood pressure in anesthetized rats. PC-6, ST-36, Quchi (LI-11), and Taichong (LR-3) were involved in the research. The results suggest that CO2 laser stimulation of all acupoints could regulate the cardiovascular functions in rats. Among them, laser stimulation at PC-6, ST-36, and LR-3 has the effect of increasing HR and mean arterial pressure, while stimulation at ST-36 has the opposite effect. A joint effort [Neiguan (PC-6) is a point on the pericardium meridian which lies between the tendons of palmaris longus and flexor carpi radialis muscles, 2 vomiting , 27 causvomiting  has beenvomiting  preliminvomiting , 31 fromn et al.  describet effort  from Chit effort  to find t effort  has inveShenmen (HT-7), located on the transverse crease of the wrist, is an important point in the heart meridian. HT-7 has been frequently used for treating neuropsychological impairments such as insomnia, amnesia, dementia, and anxiety neurosis –39. ReseThere are fewer reports of animal experiments on LA at other single points. The conclusions drawn from these studies may be unconvincing due to the lack of repeated experimental studies, but they still made an indispensable contribution to the mechanism elucidation and widespread application of LA.Baihui (GV-20) is one of the most commonly used points in acupuncture clinical practice. It is an acupoint of the Du meridian and is located on the highest place of the head. Baihui is a vital point for treating neurological and psychiatric diseases such as stroke, dizziness, headache, poor memory, and anxiety . Animal Stimulating another Du meridian acupoint, which is called Mingmen (GV-2) on the waist with LA, has also been reported  to have μm lasers significantly improved arthritic cartilage in mice, and the induction of heat shock protein (HSP) 70 in the arthritic chondrocytes was thought to be a potential mechanism for this effect. Wu et al. [2 laser irradiation significantly inhibited the expression of inflammatory cytokines in the dorsal horn of the rat spinal cord. This result is consistent with their latest publication [Dubi (ST-35) is an acupoint located on the lateral knee eye, which belongs to the stomach meridian. It is a key point for knee disease. Zhao et al.  treated u et al.  further lication , which dTaixi (KI-3), which is located in the ankle area, is an acupoint on the kidney meridian which plays a crucial role in curing kidney disease. The clinical application and mechanism of KI-3 have been widely researched. An animal experiment performed by Zeredo et al.  proved tKunlun (BL-60) is an acupoint on the bladder meridian, which is located at the ankle opposite Taixi. BL-60 is often used in combination with other points to treat stroke, lower back pain, and edema. Zhu et al.  observedback-shu points. These points have effects of benefiting the internal organs. BL-23 (Shenshu) is one of the back-shu points which has a close relationship with kidney function. Zhang et al. [2 was demonstrated to be the most effective dose among those applied .The points of bladder meridian, which are located on the back, are called g et al.  stimulatback-shu point that benefits spleen function. Cornejo-Garrido et al. [BL-20 (Pishu) is another o et al.  demonstro et al.  further In clinical practice, the application of multipoint is more common than of single acupoint. Synergistic and complementary effects produced by the compatibility of different acupoints have greatly improved the clinical efficacy of acupuncture treatment. In 2001, a milestone of LA's technological development was the introduction of multichannel LA, which makes simultaneous stimulation of different acupuncture points possible  for the first time. Since then, more studies focusing on the mechanism of acupoint combinations have been reported in animal experiments of LA. The combination of two different acupoints is the most basic way of acupoint compatibility, and it is also the focus of basic research of LA on multipoint. Usually, these two acupoints have a certain correlation in TCM theory.α activation and excavating extracellular matrix (ECM) macromolecules. In some studies LA has also been reported to have antiedema and antihyperalgesia effects [μm laser and 650 nm laser irradiation on ST-36 and GV-14 boosted the recovery of peripheral WBC counts in the rats with leucopenia [μm laser, 650 nm laser, and 10.6 μm–650 nm compound laser upregulated the number of nucleated cells in the bone marrow, promoted cell cycle proliferation, reduced apoptosis, and improved the intramedullary hematopoietic system. Furthermore, in a recent study [μm and 650 nm LA at BL-20, BL-23, and SP-6 had a positive effect on the regulation of hyperglycemia and insulin resistance in T2DM rats.Sanyinjiao (SP-6) is a point on the spleen meridian. Spleen in TCM is associated with the stomach. Both are responsible for the absorption of food and liquids and transform them into nutrients available to the human body. SP-6 and ST-36  are comm effects . Stimula effects  demonstr effects  investig effects . LA at Gucopenia . Dazhui ucopenia  on this nt study , LA was LA can be used in combination with other acupoint stimulation methods. In a case report conducted by Magden et al. , the aut2. However, it is inconsistent with some studies [2 power density, 4 mW output power, 0.4 cm2 spot size, and 0.48 J dose per session, and LA was found to be effective in reducing periarticular swelling when compared with placebo laser. In classical acupuncture, acupoints located in different parts of the body are stimulated with metal needles of various sizes. In the process of LA, lasers of different colors are selected for treatment. One option is the green laser, for example, which is not as widely applied as red, near-infrared, or violet laser in the field of LA [During the development of LA, continuous exploration and innovation of its technology have been observed, and the scope of its application is also expanding. Different from ordinary light sources, the laser has deeper penetration depth and generates particular energy, which can be used to stimulate acupuncture points as an alternative to a metal needle. It is crucial to pursue the curative effect without compromising safety. Thus, low-level laser stimulation, which is characterized by low output energy and no photothermal effect, is recommended in LA treatment. Studies , 77 have studies , which s studies  investigld of LA , 77. Dueld of LA . Althougld of LA , and yelld of LA . The mosld of LA –85. In pld of LA  proved tld of LA . Furtherld of LA . The radHowever, some problems remain in current studies. Judging from the literature included in this study, the experimental animal research of laser acupuncture is still relatively limited. Only a small number of the acupuncture points are involved in the experimental animal research of LA, and there is no uniform standard for the laser parameter selection of LA. The stimulation intensity of LA treatment is also quite different. Moreover, studies have shown that in addition to traditional acupuncture, LA has a photobiomodulatory effect, but the research on how much the therapeutic effect of laser acupuncture depends on the property of acupoints is lacking. In the future, more acupuncture points should be involved in the animal experiment research of LA, and more attention should be paid to exploring the selection criteria of laser parameters in LA treatment and revealing the therapeutic effects of LA depending on the property of acupoints.