Fatigue and pain are the most common side effects impacting quality of life (QoL) in cancer survivors. Recent insights have shown that perceived injustice (PI) can play a substantial role in these side effects, but research on cancer survivors is scarce. Furthermore, guidelines for recognizing clinically relevant levels of PI in cancer survivors are missing. The aims of this study are to provide a clinically relevant cut-off for PI and to explore relationships between personal characteristics, symptoms, and QoL with PI. This multicenter, cross-sectional study uses the Injustice Experience Questionnaire (IEQ), Numeric Pain Rating Scale (NPRS), Patient-Specific Complaints (PSC), Multidimensional Fatigue Index (MFI), and European Organization for Research and Treatment of Cancer QoL Questionnaire-C30 (EORTC-QLQ-C30). A clinical cut-off for PI was identified based on the 75th percentile of IEQ scores. Univariate and multivariate regressions explored the relationship between PI and personal characteristics , symptoms , and QoL . Cancer survivors (n = 121) were included, and a cut-off of 20 was identified. Significant indirect associations were found between chemotherapy, NPRS, PSC, MFI, and EORTC-QLQ-C30 with PI. In the multivariate model, only MFI  and age  maintained a significant association with PI.  Currently, 1 in 5 men and 1 in 6 women will develop cancer during their lifetime, with a global burden of disease accounting for 19.3 million new cancer cases yearly . Cancer The biopsychosocial side effects of cancer diagnosis and treatments cannot be underestimated , with juRecent systematic reviews have highlighted the inter-correlated nature of PI with pain-related outcomes ,19, psycGiven the already established importance of PI in breast cancer survivors ,10, the Being a cancer survivor is defined by The European Organization of Research and Treatment of Cancer (EORTC) Survivorship Task Force as: ‘any individual who has been diagnosed with cancer, has completed his or her primary treatment (with the exception of maintenance therapy), and has no evidence of active disease .Being ≥18 years old.Being native Dutch speakers and readers.This multicenter cross-sectional study follows Dutch law and the principles of the Declaration of Helsinki. Cancer survivors were recruited by convenience sampling from various randomly selected treatment centers, mainly private practices, which specialized in oncological rehabilitation across the Netherlands between December 2017 and March 2020. Participants with any type of cancer, at any stage of rehabilitation, and of all sexes were included in this study when fulfilling the following criteria:Participants were excluded if they were diagnosed with metastasized cancer or any comorbidity such as a medical or psychiatric disease, precluding them from understanding and filling in the questionnaires. All eligible participants provided written informed consent prior to enrollment. Subsequently, they received an information letter and a standard set of questionnaires to fill out on paper within three days.Information on age, sex, cancer type, cancer history, medical treatment, comorbidities, education, and current work status were collected. The IEQ provided an inventory for the patient’s frequency of 12 different pain-related thoughts regarding the unfairness of their injury on a 5-point scale ranging from 0 (never) to 4  . A highePain intensity was assessed using a Numeric Pain Rating Scale (NPRS) ,39,40. TFatigue was assessed by the Multidimensional Fatigue Index (MFI) . The MFIThe Patient-Specific Complaints instrument (PSC) was used to assess problems during daily activities ,44. The The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire–C30 (EORTC-QLQ-C30) is a 30-item instrument that was developed for people with cancer and examines several aspects of health-related QoL in cancer patients. Only items 29 and 30 of this questionnaire are needed to assess global health status/QoL. These two questions have a 7-point scale ranging from 1 (very poor) to 7 (excellent). A higher total score represents a higher degree of QoL ,47. The SPSS version 28.0  was used for statistical analyses. Descriptive statistics were executed for personal characteristics, symptoms, and QoL. The Kolmogorov–Smirnov test was used to examine whether the variable residuals were normally distributed. Frequencies were reported as the number of cases with a corresponding percentage. Normally distributed variables are expressed as the mean ± standard deviation (SD), with not normally distributed variables as the median and interquartile range (IQR). Outliers and extreme values were detected . Sullivan et al. (2008) defined that the clinically relevant cut-off score corresponds to the 75th percentile of the distribution of IEQ scores in clinical samples with chronic pain . Based op < 0.20 for the univariate regression effects was used to include the independent variable in the multivariate linear regression analysis. For the categorical variables, the category with the lowest significance level was used for that variable. The multivariate linear regression was performed with a backward elimination procedure. For this, the independent variable with the highest p-value was removed until all remaining variables had a significance value of p < 0.05 for their effect. All assumptions were checked for the final model. Missing data were handled pairwise, and the statistical significance level was set at p < 0.05 (two-tailed) for all analyses. Univariate linear regressions were performed with the IEQ scores as the dependent variable and personal characteristics, symptoms, and QoL as the independent variables. Categorical variables were transformed into dummy variables. If only one category was possible within one person, a reference category was chosen. If a participant fit into different categories, all categories were maintained as dummy variables. A significance level of A total of 121 participants were included in this study. The descriptives are presented in The median of the IEQ score was 13.0 (95% CI: 9.0–20.0). The NPRS showed a median score of 1.5 (95% CI: 0.0–3.0) and the MFI 61.0 (95% CI: 47.0–71.8). The median score of the PSC was 58.0 and 56.0 (95% CI: 50.0–63.0) for the EORTC-QLQ-C30 . There was no multicollinearity available between the different variables included in the further analyses .A clinical cut-off score of 20 was identified for cancer survivors by taking the 75th percentile of the IEQ  16]. Ba. Ba16]. p = 0.029; 95% CI: 0.346 to 6.295). Based on these results, it was revealed that hormonal therapy or immunotherapy is associated with lower levels of PI compared to chemotherapy, radiotherapy, and surgery, predicting higher levels of injustice. No significant effects were found for sex , age , or the type of cancer  with IEQ scores. Interestingly, every other type of cancer predicted higher levels of PI compared to breast cancer. On the other hand, all indirect effects of the symptoms and QoL with IEQ scores were significant , daily activity complaints , and fatigue . This indicates that higher scores on pain intensity, daily activity complaints, and fatigue are related to higher IEQ scores. By contrast, a negative indirect significant effect of −0.167 was found for QoL . In other words, higher scores of QoL are related to lower IEQ scores.Univariate linear regression analyses of personal characteristics with IEQ scores demonstrated a significant indirect effect of 3.321 with chemotherapy (nificant . Positivp < 0.20) in the following decreasing order of significance: MFI, EORTC-QLQ-C30, NPRS, PSC, type of treatment, age, and cancer type. Following the backward elimination, only fatigue  and age  were found to have a statistically significant direct model effect in the final multivariate model  were met for the final model.This is the first study to investigate a clinically relevant cut-off score for PI and explore the relationship between personal characteristics , symptoms , and QoL  with PI in cancer survivors. A clinically relevant cut-off score of 20 for PI was identified and measured with the IEQ. The regression models demonstrated significant direct effects with age and fatigue, with higher scores for fatigue and lower age being related to higher levels of PI. Indirect significant effects were found for chemotherapy and for all symptoms and QoL outcomes. These results indicate that higher scores on pain intensity, daily activity complaints, and fatigue are related to higher PI levels, but higher scores on QoL are related to lower PI levels. This is in line with previous research in different populations looking into the relationship of PI in people with pain ,19. In the final model, only age and fatigue appeared to significantly affect PI in cancer survivors. These findings indicate that fatigue and age are important direct associates of PI. To the best of our knowledge, associations between age and PI have never been explored in cancer survivors before. No significance was found for an indirect association between age and PI. However, age was found to be directly related to PI based on the multivariate model, which also contained fatigue as an independent factor. Therefore, there also seems to be a link between age and fatigue, which is not surprising, considering that the prevalence of cancer-related fatigue is higher in older people compared to younger people . Due to This study also indicates that more fatigue is seen together with higher levels of PI in cancer survivors. Previous research has not investigated PI and fatigue, except in one paper in which PI was found to be significant in all direct and indirect relationships with fatigue and sleep disturbances in breast cancer survivors . It is kEven though pain intensity and daily activity complaints/cancer-related QoL were not significantly related to PI based on the multivariate model, the results of the univariate analyses still suggest the possibility of these factors being (indirectly) associated with PI in cancer survivors. Correlation statistics also confirm this assumption, as there is a significant correlation between PI and these factors. Previous research found the same positive association between pain intensity and the level of PI in different populations, such as chronic pain ,68,69,70Besides relationships with PI, a clinically relevant cut-off of 20 on the IEQ was defined. Previously, Sullivan et al. (2008) defined a clinically relevant cut-off score of 30 on the IEQ in individuals who had sustained musculoskeletal injuries . He descThe definition of a population-specific cut-off score for the general cancer survival population makes the identification of clinically relevant levels of PI when measured on the IEQ, possible in clinical practice and research. As mentioned before, cancer survivors have significantly higher opioid use than non-cancer patients ,84, whicUp until now, the literature has suggested that the use of cognitive-behavioral interventions, pain acceptance , and eduThis is the first study focusing on PI in the general cancer survivor population defining a population-specific cut-off. Further research is needed to validate this cut-off for further use in clinical research and practice. Moreover, this is the first exploration of the association between personal cancer-related factors (type of cancer and treatment) with PI. Due to the unavailability of data, it was not possible to consider the perception of PI , the time since cancer diagnosis, the specific type/dose of surgery, chemotherapy, or radiotherapy, as well as the order of the curative treatment in the analyses, which all could have an impact on the level of PI. Moreover, known important measures such as depression, anxiety, and pain acceptance are missing as possible relevant predictors of PI in cancer survivors.Since the recruitment was based on the patient’s willingness to participate, selection bias could be possible. Moreover, an under- or overrepresentation of groups within the sample is possible due to the use of convenience sampling, making it difficult to generalize the results of this study to all cancer survivors. Considering the explanatory character of this study, no power calculation was conducted a priori. Additionally, with the cross-sectional design of this study, no claims on causality between PI and personal factors, symptoms, and QoL can be made. Still, this exploratory study calls for future longitudinal research to further examine these relationships.A clinical cut-off of 20 for the score of the IEQ was defined for the cancer survivor population. Significant direct associations were found for PI with age and fatigue PI in cancer survivors. However, associations with PI in cancer survivors should be further examined to explore causal interactions.


Five myostatin alleles of 2046 calves were involved in the study. Among the myostatin alleles, the effect of Q204X was statistically proved (p < 0.01 and p < 0.05) on the 205-day weaning weight, muscle score of back, muscle score of thigh, loin thickness score and overall muscle development percentage. It would be advisable to pay more attention to this allele in the breeding program.The objective of this study was to evaluate the effect of different myostatin gene, which can be responsible for muscle development. In this study, the F94L, Q204X, nt267, nt324 and nt414 alleles of the myostatin gene (MSTN) were examined in relation to birth weight (BIW), calving ease (CAE), 205-day weaning weight (CWW), muscle score of shoulder (MSS), muscle score of back (MSB), muscle score of thigh (MST), roundness score of thigh (RST), loin thickness score (LTS), and overall muscle development percentage (OMP) of Charolais weaned calves in Hungary. Multi-trait analysis of variance (GLM) and weighted linear regression analysis were used to process the data. Calves carrying the Q204X allele in the heterozygous form achieved approximately 0.14 points higher MSB, MST and LTS, and 1.2% higher OMP, and gained 8.56 kg more CWW than their counterparts not carrying the allele (p < 0.05). As for the F94L allele, there was a difference of 4.08 kg in CWW of the heterozygous animals, but this difference could not be proved statistically. The other alleles had no significant effect on the evaluated traits.The slaughter value of live cattle can be assessed during visual conformation scoring, as well as by examining different molecular genetic information, e.g., the  The value of slaughter animals, that is, the carcass composition and meat quality of meat-producing farm animals, such as slaughter cattle, can be reliably evaluated with post-slaughter muscle and fat measurements and laboratory tests. In beef production, however, slaughterhouse evaluation and laboratory meat quality testing are often impossible in the trade, as the animals are marketed on a live basis. Despite failing the mentioned objective evaluation possibilities, both the sellers and the buyers must be able to appraise, visually or in other ways, the meat production value of these animals.The meat production value of slaughter animals can be evaluated with a high degree of accuracy based on several seen, measured and estimated conformation traits. A large number of research results from literary sources support the fact that the age, weight, sex, conformation, condition, muscle mass and shape of live animals provide reliable information about their meat production; however, some environmental factors can also play an important role . The menmyostatin, which is an extracellular cytokine mostly expressed in skeletal muscles and known to play a crucial role in the negative regulation of muscle mass [An indicator of slaughter value could be cle mass ,5.MSTN found that F94L was the only polymorphism consistently related to increased muscling. Wiener et al. [myostatin allele with the 11-bp deletion (MH) segregating in the South Devon breed affected several traits related to beef production. The MH allele was associated with heavier calves at birth but slower growth, leading to lighter adult animals. Allais et al. [Q204X or nt821) over noncarrier animals was approximately +1 SD in the Charolais and Limousin breeds but was not significant in the Blonde d’Aquitaine. In the Charolais breed, for which the frequency was the greatest (7%), young bulls carrying the Q204X mutation presented a carcass with less fat, less intramuscular fat and collagen contents, and a clearer and more tender meat than those of homozygous-normal cattle. Hales et al. [F94L (homozygous) variant. According to Ceccobelli et al. [MSTN in Marchigiana bulls showed slight superiority in the carcass weight  and meat quality parameters, although not always with statistical significance.Sellick et al.  studyingr et al.  found ths et al.  found thi et al. , the hetmyostatin on meat production in cattle, especially in double-muscled cattle [myostatin alleles [Looking at the relevant literature, even though there are many research results available on the effect of d cattle ,12, relad cattle ,14,15, i alleles . AccordiMSTN alleles in the Hungarian Charolais population, even certain allele variants in the Charolais breed, has not been studied so far.To our knowledge, phenotypic characteristics of calves related to myostatin alleles such as F94L and Q204X and others  on birth weight, calving ease, 205-day weaning weight and muscle score of some body parts , and overall muscularity showing muscle development and trend of these traits in the Charolais beef cattle population in Hungary.The objective of the present study was to evaluate some Data processed during the work were collected from the pedigree database, the National Association of Hungarian Charolais Cattle Breeders. The available and evaluated initial database contained pedigree, weaning, conformation traits and molecular genetic information. In the study, there were 2046 EU-registered weaned Charolais calves  born between 2015 and 2021.MSTN mutations.During the study, the birth weight of calves (BIW), calving ease of dams (CAE), 205-day weaning weight of calves (CWW), muscle score of shoulder (MSS), muscle score of back (MSB), muscle score of thigh (MST), roundness score of thigh (RST), loin thickness score (LTS) and overall muscle development percentage (OMP) as phenotypic traits of weaned calves were evaluated in relation to The conformation traits were scored at the weaning. The scoring of the mentioned body parts was carried out according to the Conformation Scoring Guideline of the National Association of Hungarian Charolais Cattle Breeders . Each anThe calving ease of cows was scored as follows: normal light calving = 1, calving with assistance = 2 and difficult calving = 3.The molecular genetic information of the 2046 weaned calves was determined with the Weatherbys Scientific Bovine VersaSNP 50K chip. The description of the method and the possibilities of interpreting the results are described in detail by .myostatin protein , F94L, Q204X, nt267, nt324 and nt414 were examined [F94L, Q204X, nt267, nt324 and nt414 alleles in the homozygous or heterozygous form, or not. The distribution of these alleles by sex of calves is shown in The genetic database contained information on 117 different alleles. In the course of this study, five relevant alleles of the gene encoding the examined ,20. Baseexamined ,22,23, iBefore evaluating the database, the basic statistical parameters of the examined traits  were calculated. The Kolmogorov–Smirnov test was used to check the normality of the data, and Levene’s test was used to check the homogeneity of the variances .myostatin alleles (mentioned above), were incorporated into the model as fixed effects [hijklmn = trait of a weaned calf of “h” year, “i” sex, “j” F94L, “k” Q204X, “l” nt267, “m” nt324 and “n” nt414 genotypes; μ = average of all observations; Yh = effect of birth year of calves; Si = effect of sex of calves; Fj = effect of F94L allele; Qk = effect of Q204X allele; Nl = effect of nt324 allele; Mm = effect of nt324 allele; Tn = effect of nt414 allele; and ehijklmn = random error [To evaluate the database, the multifactor analysis of variance  was applied . During  effects . The ninom error .For all nine traits, the data of the calves born in the same year were analyzed and averaged by year. Weighted one-way linear regression analysis was used to estimate the phenotypic trends. The dependent variable was the evaluated trait, the birth year of calves was considered as an independent variable, and the weight was the number of individuals per year.Among the nine evaluated traits, Pearson’s phenotypic correlation values (r) were also determined.The data were prepared using Microsoft Excel 2003 and Word 2003. The evaluation of the database was performed with the statistical software package SPSS 27.0 .p < 0.01) and played a decisive role (62.27–96.74%) in the development of the phenotype (p < 0.01). Among the myostatin alleles, the effect of Q204X was statistically proved (p < 0.01 and p < 0.05) on the traits CWW, MSB, MST, LTS and OMP. The other alleles had no effect on the evaluated weaning and muscularity traits.For all traits, the influence of the sex and birth year of the calf was statistically verifiable  of the examined traits was as follows : BIW 43.Q204X allele in the heterozygous form in the studied population gained 8.56 kg more weight than their counterparts not carrying the allele. From the point of view of the F94L allele, there was a difference of 4.08 kg in favor of the heterozygous individuals, but this difference could not be verified statistically. The weight of the individuals carrying the nt324 and nt414 alleles in the homozygous form was higher  than the noncarriers, but these differences were not significant either.Regarding CWW, the calves carrying the Q204X allele in the heterozygous form achieved approximately a 0.14 point higher MSB, MST and LTS, and a 1.2% higher OMP than their noncarrying partners. Despite the fact that the F94L allele had no statistically verifiable effect on muscularity parameters, it was striking that noncarrier calves showed higher values in almost all muscularity scores than heterozygous carriers. In the case of the nt267 allele, the muscularity score of the heterozygous calves was higher—although not significantly—than that of the noncarrier individuals, and in the case of the nt324 and nt414 alleles even more so in the homozygous carriers.Regarding the muscularity scores, it could be established that calves carrying the p < 0.05 and p < 0.01), and fairly well matched (R2 = 0.57−0.93) regression functions were obtained. In the case of BIW and CWW, the slope of the straight lines (b) was in a positive increasing direction, while in the case of the other traits it was in a negative decreasing direction. Here it must be noted that, in the case of muscularity parameters, the annual decrease is very small, typically −0.05 or −0.07 points/year.In the case of all traits, we observed considerable differences between the individuals born in different years. This was also supported by the results of the phenotypic trend calculation , accordip < 0.01) correlation between the muscularity scores.Based on the obtained phenotypic correlation values , it coulmyostatin gene (MSTN) or sometimes called growth and differentiation factor 8 (GDF8) is a major negative regulator of skeletal muscle mass and differentiation, but MSTN also exists in smooth muscles [MSTN on bone development has been established [MSTN causes a variety of metabolic changes affecting glucose and lipid metabolism and total bile acid content [MSTN and susceptibility to a skin disease [The  muscles . In addiablished . Moreove content , as well content . An asso disease .MSTN protein and are strongly associated with the double-muscling phenotype [It is well known that there are several mutations in the coding region that have been detected as disruptive mutations  and they are thought to inhibit the function of the henotype ,31.F94L allele, a missense variant, was characterized by the substitution of cytosine by adenine at the nucleotide position of 282 in exon 1, which led to causing substitutions of leucine (Leu) for phenylalanine (Phe) at the 94th amino acid in the MSTN gene. Interestingly, the F94L mutation was not considered to cause a loss of MSTN function, which led an intermediate muscling in Charolais cattle [The s cattle .Q204X allele of this gene is a disruptive variant, and heterozygous carriers in the Charolais population had a greater mean carcass weight and conformation estimated breeding values (EBVs) [The s (EBVs) , but this (EBVs) .myostatin gene caused by the nt267, nt324 and nt414 MSTN mutations.We are interested in further three silent mutations, i.e., the polymorphisms of the myostatin alleles, Q204X was statistically proved to have an effect on the 205-day weaning weight, muscle score of back, muscle score of tight, loin thickness score and muscle development percentage. Calves carrying the Q204X allele in the heterozygous form in the studied population were heavier than those not carrying this allele. However, animals carrying the F94L allele in the heterozygous form were also heavier, but the difference was not significant. The weaning weights of calves carrying the nt324 and nt414 alleles in the homozygous form were higher than the noncarriers, but these differences were not significant either.In our study, during the evaluation of the effect of Q204X allele on meat production related traits. Contrary to our results, several previous studies [myostatin group, we only found information on the effect of the double-muscled related allele nt821 in existing sources [nt267, nt324 and nt414 alleles was previously described by Dunner et al. [Similar to the results of our work, several previous sources ,21,34 co studies ,16 found sources ,35,36; hmyostatin alleles in heterozygous form can have a favorable effect on weaning traits. Contrary to the results of Allais et al. [Q204X allele on birth weight in the examined Charolais herd. Similar to the results of Esmailizadeh et al. [F94L allele on birth and weaning traits was not found to be significant. Our results are in line with Zhao et al.’s [MSTN-gene-edited Chinese Yellow cattle had improved growth traits compared with wild-type counterparts; however, the birth weight yielded no significant difference among groups, but, with increasing month age, the weight gain rate of MSTN-gene-edited cattle was significantly higher.The results of our work are similar to the findings of Casas et al. , accordis et al. , we coulh et al. , the effet al.’s  findingsIn this study, the weaning weight of Charolais calves were similar to the data found in most of the relevant literary sources ,38,39.MSTN polymorphisms have negative effects on their reproductive traits, for example, calving difficulties (dystocia) [The ystocia) . First, ystocia)  studied ystocia) , CharolaOn the basis of the calving ease score observed during our work, it seems that there was fewer difficult calving in the studied herd than what was found in the literature ,43 in thWe found very little information available in the literature about the conformation of Charolais calves related to their muscularity. Arango et al.  and VallE291X variant) carcasses of Marchigiana bulls [nt267, nt324 and nt414 alleles. As previously stated by Ceccobelli et al. [MSTN gene polymorphisms in Charolais cattle, to our knowledge, no such data exist in the literature.A better muscular conformation in heterozygote  of the MSTN gene in (Bos indicus) cattle, which are associated with phenotypes of wither height, heart girth and hip height, but not with body weight or body length.It seems that d cattle . Recentld cattle  found twThe differences by birth year and sex of calves in weaning weight obtained during our work are very well known in the literature ,48. HoweSimilar to our results, Gutiérrez et al.  and ChudQ204X had the greatest effect on calving, weaning and muscularity-related traits, we think it would be advisable to pay attention to this allele in the breeding strategy, to increase the proportion of carriers from generation to generation. It would be advisable to repeat this test periodically, because, based on literature data too, it seems that the allele in its homozygous form could cause calving difficulties.Since F94L allele was not detectable in our study, contrary to some literary reports, which could be a consequence of the proportion of animals carrying the allele (about 5.5%) being very small in the studied population. On the other hand, based on previous studies, the better phenotypic performance of individuals carrying the allele was more evident in the fattening and slaughter traits.Based on the results, the favorable effect of the nt324 and nt414 alleles was quite high  in the examined Charolais population. However, in the literature, there was very little information about their effect on phenotypic performance. Based on our results, it seems that homozygous carrier individuals may have better growth performance-related traits than noncarrier individuals. Therefore, it would be advisable to pay more attention to this allele.The proportion of calves carrying the


To investigate the association of dietary patterns, number of daily meals and anthropometric measures among women in age of menopause.This was a transversal study with 320 women over 50 years old from Caxias do Sul, Brazil. The outcomes were body mass index (BMI) and waist circumference (WC). Multiple linear regression was performed.Three dietary patterns: regional, fruits and vegetables, and common Brazilian was identified by Principal Component Analysis. After adjustment, higher adoption of the regional dietary pattern was associated with increased BMI  and WC . The highest number of meals per day (>=5/day) was associated with reduced BMI  and WC , and a mid-afternoon snack BMI  and WC . The regional dietary pattern was inversely associated with have five or more meals per day  and have a mid-afternoon snack . The fruit and vegetables dietary pattern was positively associated with have five or more meals per day .The regional dietary pattern has resulted in higher BMI and WC measures and contributes to decreased meals per day, behavior associated with higher anthropometric measures. The occurrence of excess weight increases with age, especially in women ,2 and leposteriori statistical methods . Although there is a recommendation to divide food intake into a larger number of meals during the day to better control or lose weight , the stuConsidering the importance of know the dietary patterns of Brazilian menopause women, the lack of studies on the association between dietary patterns and number of daily meals and the controversial evidence regarding the impact of eating frequency on body weight, this study aimed to identify dietary patterns and to investigate their association with BMI and waist circumference and the number of daily meals in Brazilian women in age of menopause. In addition, we also investigated the association between daily meals and anthropometric measures.It is a transversal analytical study conducted with a sample of women over 50 years old enrolled in the Coexist Project program in Caxias do Sul (RS). The Project offers to the community continuous activities focusing on leisure physical activity, and biological, social, emotional and spiritual aspects. The activities are organized and guided by Physical Education professionals.Data collection was done along the years 2014 and 2015. A random sample of 10% of the women included in the study was used for quality control to evaluate the research’s internal validity. In addition, a simplified questionnaire was administered by telephone. The study was approved by the Ethics Committee at the University of Caxias do Sul (Registry no. CAEE 17990213.9.0000.5321). The participates received all information through a Free and Informed Consent Form.The size of the sample needed to estimate the prevalence of abdominal obesity was calculated using the following parameters:  number oProject Coexist in Caxias do Sul is formed by 72 groups, with around 40 women each, 90% of them over 50 years old. The selection of the participants was made by systematic sampling in multiple stages. First, the 72 groups were numbered according to their geographic location; then, the total number of groups (72) was divided by the number of necessary groups , which rFor the next stage, all the women over 50 who participated in the 16 selected groups were invited to participate. Women who have physical problems that difficult to take anthropometric measures or show cognitive difficulties to answer the questionnaire were excluded. All the women who accepted to participate and fulfilled the eligibility criteria were included. On average, 20 women per group were included, totaling 320 women participants. We had ten recuses in the process.Information on economic, demographic, behavioral, anthropometric and food consumption characteristics was obtained through standardized questionnaires, pre-coded and pre-tested, carried out by previously trained interviewers.The anthropometric variables were BMI and WC. Weight was measured by a portable digital scale (Plenna) with a capacity of up to 150 kg. Women were weighed, standing up, barefoot, with minimal clothing, with their arms resting alongside their bodies. When measuring height, women had to be standing up, barefoot, with minimal clothing, with their arms resting alongside their bodies and looking upfront. Height measurements were taken using a vertical anthropometer, fixed on a smooth wall with no skirting board, positioned to provide an accurate height measure. BMI was calculated by the weight/height ratio in kg/m². BMI was analyzed as a continuous variable .WC was measured in centimeters at the medium point between the iliac crest and the inferior costal margin . MeasureDietary patterns were determined using a food frequency questionnaire (FFQ) validated for the adult population of Porto Alegre, Brazil , made upThe number of daily meals was measured by a standardized questionnaire that investigated the habitual consumption of the following meals: breakfast (6-7 a.m.), mid-morning snack (9-10 a.m.), lunch (12-1 p.m.), mid-afternoon snack (4-5 p.m.), dinner (8-9 p.m.), evening snack (11 p.m.-12 a.m.), middle of the night snack (3-4 a.m.), and, also, whether they had any other snacks between meals. The total number of meals in a day  and each isolated meal was analyzed.Demographic and socioeconomic characteristics investigated were: age, measured by full years and categorized as such: 50 to 60; 61 to 70; 71 or more; marital status: married, single, widowed, divorced; skin color/ethnicity: white or non-white; education: none, one to five years of education, six to eight years, nine years or more; and, family income measured by the number of minimum wage salaries earned: 0-2 salaries, 2.01-5 salaries, more than 5 salaries. Behavioral characteristics were: smoking ; and the practice of at least 30 minutes of moderate physical activity: 0-2 times per week and 3 or more times per week.Data entry followed a double-entry protocol into EPI-DATA software . Dietary patterns were identified through Principal Components Analysis (PCA). At first, 31 food groups were formed using these criteria: nutritional composition, positive and significant correlation between items p ≤ 0.05, as well as cultural aspects in their consumption.After that, the applicability of the method was evaluated using Kaiser-Meyer-Olkin   and BartThe sample was described using absolute and relative frequencies. The mean values for BMI and WC were calculated for each variable, and associations with exposure variables were estimated by ANOVA and Student’s T-test. Multiple linear regression was performed to investigate the association between interest expositions  and outcomes (BMI and WC). Variables that presented a significance level of 20%  in the simple linear analysis were considered potential confounders in the association between main exposure variables and outcomes. The association between meals per day  and dietary patterns was explored using simple linear regression analysis. In all the association analyses, a significance level of 5% was taken into consideration. The analyses were done using STATA version 12.0 .posteriori sample calculation (Alpha of 0.05 and beta of 0.20) showed that the sample of 320 women had power for demonstrating mean differences around 1.5 kg/m2 for dietary patterns and eating frequency with BMI; 4 cm for dietary patterns and WC; and 3.5 cm for eating frequency and WC.The final sample was 320 women. A The mean age was 67 years (SD = 8.32), mean BMI was 29.09 kg/m² (SD = 4.77) and WC 89.12 cm (SD = 11.31). Most of them were married, white/Caucasian, had less than 6 years of formal education and family income of less than 5 minimum wage salaries (73.1%). Most of them were non-smokers, and only 36% of the women practiced physical activity three or more times each week. There is a significant association between marital status and WC; widowed women had higher mean values for WC .Most women had five or more meals per day (67.5%), breakfast (96.9%) and mid-morning snacks (68.4%). All of them had lunch, most of them had a mid-afternoon snack (86.3%) and dinner (95.9%). Most women said they did not have an evening snack (57.8%) and a middle-of-the-night snack (95.9%) (data was not tabulated).Three dietary patterns identified could be observed in After adjustment, the highest adherence to the regional dietary pattern was associated with the outcomes. The increase of 1 in the regional pattern’s consumption score resulted in an increase of 0.56 kg/m² in the BMI and 1.28 cm in WC. On the other hand, consuming five or more meals per day was inversely associated with BMI and WC and the consumption of a mid-afternoon snack .Finally, there was an inverse association between the consumption of a mid-afternoon snack and the adherence to a regional dietary pattern  and between the consumption of five or more meals per day . There was a positive association between the consumption of five or more meals per day and the fruits and vegetables dietary pattern  (data was not tabulated).This study contributes to the scientific literature on understanding the relation of eating habits and excessive weight gain on aging, primarily by showing the association of a regional eating pattern, composed both by traditional foods, considered healthy by food guidelines and by processed foods understood as a western influence on eating habits, associated with higher BMI and WC. This finding highlights the complexity of individual eating habits, mainly of older people, who, on the one hand, still keep their culturally traditional eating habits but also include more modern and globalized eating habits. As far as it is known, this study is the first to associate dietary patterns and the number of meals per day, showing that these two eating habits are associated and may together contribute to the etiology of obesity internationally.th Century, presented as the mixing of traditional foods such as pasta, bread, meats, vegetables, and fruits commonly found in this region (grapes and tangerine) with processed foods such as margarine, sugary drinks (soda), fried foods, and pastries. Other studies with menopausal women had found similar traditional dietary patterns, including a mix of healthy and industrialized foods in different countries . This pattern denoted the influence of western dietary patterns into the habits inherited from the Italian immigrants who colonized this region at the end of the 19ountries ,23.The adherence to this regional pattern was directly related to BMI and WC in our study. These associations can be explained, in part, by the high energy density foods included in this pattern, mostly rich in carbohydrates with a high glycemic index, and fat, such as pasta, bread, jam, sugar, meat and fried foods; as well as ultra-processed foods, such as soda and margarine. Studies have linked rising obesity rates to the consumption of an increasingly energy-dense diet. Energy-dense foods, often high in refined grains, added sugars, and added fats, are palatable, inexpensive, and convenient. However, they have been associated with increased energy intake and poor diet quality . At the In addition, the regional dietary pattern was inversely associated with the number of meals per day. We have not been able to find studies that investigated the association between dietary patterns and the number of meals per day. However, it is plausible to explain this finding because the foods included in the regional pattern are also energetically dense and seem to provide more extended periods of satiety, culminating in a lower number of meals per day .Fruits and vegetables dietary pattern was composed mainly of these foods and also whole grains. Other studies found similar dietary patterns ,23,27. HThe common Brazilian dietary pattern was composed of foods usually consumed by Brazilians. Other studies conducted in the southern parts of Brazil have found similar results. Hoffmann and cols. (2015) have found a similar pattern called “Brazilian” composed of rice, beans, and milk . Ternus In addition to identifying eating patterns, the results of this study also point out that an increase in the number of meals per day and adding a snack in the middle of the afternoon seem to result in lower BMI and WC in menopausal women, despite inconclusive evidence found in systematic revisions on the subject ,13. A trIn addition, women who reported habitually having a mid-afternoon snack have presented lower anthropometric measures. However, this finding might be only highlighting the importance of a mid-afternoon snack concerning the total caloric intake in a day  because This study has some limitations. First, the information bias is a limitation inherent to the foods reported. Second, the methodology of identifying dietary patterns involves choices that might be subjective to the researcher, for example, the choice of the criteria with which to group foods and the type of rotation used in the factorial analysis. Different choices could lead to different dietary patterns. Third, the KMO value found in this study was lower than the ideal indicated in the literature. Nevertheless, the analysis of it is possible to consider the coherence of patterns found compared to the existing literature and the biological plausibility in their association with the investigated endpoints, both the anthropometric figures and the frequency of food consumption. Fourth, the women are participants of a project that improves healthy habits, such as physical activity. Thus these women could be healthier than the general population.In conclusion, three dietary patterns were identified in this population: (i) regional, (ii) fruits and vegetables, and (iii) common Brazilian. The regional dietary pattern, composed of culturally habitual food consumed in the region and industrialized food, was associated with higher BMI and WC. Furthermore, this dietary pattern was also associated with a decrease in the number of meals per day, showing that women who adopted this dietary pattern also had fewer meals per day and had higher anthropometric measures. On the other hand, adopting the dietary pattern of fruits and vegetables, formed by foods considered healthy and low in calories, was associated with an increase in the number of meals per day, which was associated with lower anthropometric measures. Finally, the consumption of five or more meals per day is inversely associated with BMI and waist circumference and the consumption of a mid-afternoon snack.


Both groups of participants were asked to finish the Wong and Law Emotional Intelligence Scale (WLEIS) and the Adversity Response Profile® (ARP) before and after the SL programme. The results showed that there were no significant differences in WLEIS and ARP scores (at the pre-test) between the experimental and comparison groups. The results further revealed that students in the experimental group had better improvements in WLEIS and ARP than those in the comparison group after they completed SL. These findings provide valuable insights and implications for incorporating components of SL into interventions for youths to improve their ability to process emotions and overcome adversity.This study aims to determine the effect of service learning (SL) on the trait emotional intelligence and adversity quotient of Chinese undergraduate students in Hong Kong. The SL programme lasted six months (at least 80 service hours). In a pre-test–post-test experimental design, students who participated in the SL during that time period were classified as the experimental group ( The development of trait emotional intelligence (EI) and adversity quotient (AQ) is the golden age in adolescence and early adulthood . The levThere is a negative association between emotional development and undesirable behaviours, such as substance abuse and violence ; therefoHowever, higher education tends to focus on the development of students’ intelligence and cognitive abilities, rather than the cultivation of trait emotional intelligence and adversity quotient. The lack of appropriate emotional responses and negative learning experiences hinders the subsequent development of self-confidence, endurance, resilience , communiExperiential learning, which includes service learning (SL) and work-integrated learning, has become increasingly popular in higher education . These nEI through SL has been promoted and studied in higher education in the West . HoweverResearch Question 1: Would Chinese undergraduate students’ trait emotional intelligence  improve by the intervention programme (SL) compared to students who never participated the SL programme?Research Question 2: Would Chinese undergraduate students get better in their adversity quotient  through the intervention programme (SL) compared with students who never participated in the SL programme?Intelligence is a broad concept. It not only refers to cognition, but also emotions . The emoThere is a theoretical difference between trait EI  and ability EI  . Trait EMayer and Salovey ,16 develSelf-emotion appraisal refers to an individual’s capability to recognise and understand what they are feeling and express emotions as intended. Other people’s emotion appraisal refers to the capability to comprehend, perceive and identify the emotions of others. Regulation of emotion refers to the capability to monitor, assess and perform to adjust feelings. Use of emotion refers to the capability to utilize emotions, such as turning emotions into positive actions and better performance. Elias and Moceri  believedAdversity means an unfortunate event or situation or a state of serious and persistent difficulty . AdversiStoltz  develope® (ARP) developed by Stoltz [In this study, the Adversity Response Profiley Stoltz  was utilControl refers to the ability to perceive the possibility of changing a situation. It measures how well a person thinks he/she has control over adverse events. It is a powerful indicator of resilience and health.On the one hand, origin asks whether adversity and frustration are caused by someone or something and then how much responsibility a person should have for adversity and setbacks. On the other hand, ownership means the degree of willingness to take responsibility for improving a situation. It is a powerful indicator of responsibility and the possibility of action.Reach refers to the perception of how far a difficulty extends into other domains of life. It is a powerful indicator of burden and stress levels. Moreover, it indicates how far adversity and frustration go into other areas of life.Endurance means the perceived length of time adversity will last . It lookSchools play an important role managing and providing student activities that can help them develop their adversity quotient . DevakumService learning is a form of experiential learning and it consists of two key components: service and learning . ServiceService learning is associated with academic objectives in the curriculum, student achievement and socio-emotional growth and responses to difficulties . For exaIncorporating SL into curricula and connecting the components of emotional intelligence  and adveTo be authentic, these learning experiences are always grounded in reflective practices, which help students connect to core content knowledge and its real-world applications . EmotionThe objective of the current study was to examine if a SL programme at a university in Hong Kong would be useful and positive in boosting students’ trait emotional intelligence and adversity quotient. For example, the service experiences offered to the community include help and support to disadvantaged community members. The measure of trait emotional intelligence and the measure of adversity quotient were administered at pre-test and post-test.M age = 23.34, SD = 0.99; 69 male: 49.6%, 70 female: 50.4%) and 133 participants in the comparison group  were included and identified in the study. No group differences by age and gender were observed. The results shown in A total of 315 undergraduate students from the same university joined in the pre-test, and 272 of those undergraduate students also joined in the post-test. Of these 272 participants who joined in both the pre-test and post-test, 139 participants completed the SL programme during that period. These 139 participants served as the experimental group. The remaining 133 participants who had never attended programmes associated with SL served as the comparison group. Therefore, 139 participants in the experimental group  were translated as necessary so that both a Chinese version and an English version were available.Participants gave demographic data, including gender, age, years in university , length of part-time work experience and related income.Self-emotion appraisal ;Others’ emotion appraisal ;Use of emotion ;Regulation of emotion .On the WLEIS , particip < 0.001). The scores for the overall and the subscale (on specific dimensions) are computed and presented as means. In the pre-test results of this study, acceptable internal consistency reliabilities were obtained: SEA (0.941), OEA (0.954), UOE (0.976), ROE (0.982) and overall emotional intelligence scale (0.736). Exploratory factor analysis identified four factors  corresponding to the ROE, UOE, OEA and SEA dimensions, which explained 27.053%, 24.005%, 21.531% and 18.583% of the variance, respectively. Principal component analysis (PCA) revealed that the four-dimension model was suitable and applicable for use in our sample ;Origin and ownership ;Reach ;”).Endurance . In the pre-test results of this study, acceptable internal consistency reliabilities were obtained: control (0.816), origin and ownership (0.955), reach (0.913), endurance (0.900) and overall Adversity Response Profile (0.905). Exploratory factor analysis identified four factors  corresponding to origin and ownership, reach, endurance and control domains, which explained 36.565%, 16.058%, 13.658% and 8.027% of the variance, respectively. Principal component analysis revealed that the four-domain form was suitable and applicable for our sample  and participants who withdrew from the study (n = 19).The post-test was performed as a continuation and subsequent assessment  of the 291 participants. It took place between 6 and 15 September 2021. Both questionnaires were again self-filled and also the questionnaires were sent to the same 291 participants. Ultimately, data from 272 participants were successfully traced and matched between the pre-test and post-test. The attrition rate of 6.52% was satisfactory compared to other longitudinal studies . There wParticipants provided written informed consent. They were informed of the research purpose and that their participation was voluntary. Moreover, they were free to withdraw at any point during the research without consequence, and no reward was provided.The front page of the questionnaire indicated that all data collected would be kept for statistical purposes only, and their answers would remain strictly confidential. Although participants replied with their answers anonymously, they were requested to write the same code number  on each reply. By doing so, replies from the same participant collected at the start and completion of the SL programme could be matched. The details, including instructions and guidance, were given at the opening of the questionnaire.The SL programme is one of the General Education elective modules, offered to Year 2 and Year 3 full-time undergraduate students. The beneficiaries of the programme include vulnerable groups such as seriously sick or recovering patients and their families, hearing-impaired students and students with learning disabilities. They were assigned similar service content, and there was no systematic difference between the community services assigned. Aside from getting acquainted with the local neighbourhood and vulnerable groups, SL participants were able to apply the knowledge and techniques they learned in class to develop their aptitudes through a series of SL tasks. Ultimately, this project could help university students develop their trait emotional intelligence and adversarial quotient.The duration of the SL programme was 6 months, and it had three phases: (1) Preparation: March–June, (2) Execution of assigned tasks: June–August (80 h minimum) and (3) Feedback and review: September. In pre-service, the pre-employment preparation and workshops were conducted (4 lessons: 2 h 45 min each). Subsequently, students were divided into a group of four. During the service phase, the course teachers and organisation staff supervised and advised students at a 1:4 ratio. Each service group was required to meet with the course teacher six times (3 h each) for the duration of the community service. In these meetings, the course teacher provided supervision and support for the SL activities, such as psychological counselling and resource provision. In the post-service period, participants gave an oral presentation and submitted a reflective essay. The supervisors facilitated students’ reflection by raising questions such as what were the positive outcomes of the activities and what changes they recognized in their lives or perceptions.On the one hand, students who participated in SL considered SL an opportunity to support and help students with intellectual disabilities. On the other hand, recipients were happy to know that someone cared about them. Groups of four students would provide day services in the school’s dormitory. Services included training and support for students with learning disabilities. At the start, the service period was scheduled to run from early July to late August 2021. However, students were requested to assist in the residence halls in late June so that they could be familiarized with the residence hall students. Students were also asked to submit their activity proposals in early July.Data analysis was performed using SPSS Version 27 , with no loss of data. The necessary steps were performed, such as data cleaning to correct coding errors and illogical data values (if required).t-tests and one-way analyses of variance (ANOVAs) were conducted to compare different levels of each demographic variable on the WLEIS and ARP scores. These analyses were conducted separately for the pre-test and post-test scores. There are no significant differences in WLEIS and ARP scores (pre-test and post-test) between the two groups in age (p > 0.05), according to one-way analyses of variance (ANOVAs). Also, there were no significant differences in WLEIS and ARP scores (pre-test and post-test) between the two groups in gender and years of study (p > 0.05), according to t-test.t-tests indicated that there were no statistically substantial differences in EI and AQ scores between the experimental and comparison groups before the service-learning activities. Nevertheless, at the post-test, there were statistically significant differences in EI scores  and AQ scores  between the two groups after the intervention programme. The first set of analyses was performed to confirm the impact of the SL programme on students’ EI and AQ. In the pre-test, eight independent A sequence of mixed between-within ANOVAs was executed to contrast the two different groups on the pre-test and post-test evaluations of participants’ EI and AQ scores. In the following analysis, the within-subject factor was set as Period , the between-subject factor was fixed as Group  and the dependent variables were the four dimensions of EI and the four domains of AQ. F (1270) = 732.472, p < 0.001; OEA, F (1270) = 611.942, p < 0.001; UOE, F (1270) = 569.308, p < 0.001 and ROE, F (1270) = 649.270, p < 0.001 of EI, and control, F (1270) = 31.549, p < 0.001; origin and ownership, F (1270) = 26.537, p < 0.001; reach, F (1270) = 31.452, p < 0.001 and endurance, F (1270) = 28.724, p < 0.001 of AQ kept significant when age and gender were controlled in the analyses. Post-hoc comparisons exhibited that the experimental group had higher marks for SEA, OEA, UOE and ROE of EI as well as for control, origin and ownership, reach and endurance of AQ at post-tests but not at pre-tests.In this study, we examined whether Chinese university students’ trait emotional intelligence and adversity quotient would be altered owing to being cultivated through community service learning. The experimental design compared a group of students enrolled in a SL class  and another group of students who were not enrolled in the class (control condition). The comparison was based on their emotional intelligence and adversity quotient before and after the experiment. The results showed that SL promoted the development of trait emotional intelligence and adversity quotient among Chinese university business students. The study found that students’ reflection in the programme is most effective and beneficial for youths’ development in dealing with emotions and adversity. It is because the participants had the opportunity to reflect on the entire process of the SL programme, and they were also asked to present what they found during the SL experience.Martinez  and BillThe outcomes of the current research are consistent with the study of Martinez , who fouOur findings were consistent with the findings of Martinez , who shoManring  pointed Our findings are consistent with the research of Astin and Sax , who fouOur findings are consistent with those of Manring , who indHamner et al.  and GarmThe studies revealed that, through SL, students gradually improved their problem-solving and decision-making skills , autonomOur research results are consistent with the finding of Godfrey et al.  that SL Responsibility does not mean excessive blame and perfectionism. Adversity quotient emphasises the balance between the two . By partThis finding is consistent with Hulaikah and Degeng’s research , which sOur findings were supported by Hamner et al. , who indThis research has four limitations. Firstly, the sample of 272 participants from one major in one university is smaller than the entire population; hence, the generalisability of the findings may be limited. In future research, more samples should be recruited to attain better representativeness.Secondly, the study data were obtained from self-report questionnaires. Hence, differences in sharing methods may have caused exaggerated effects. In addition, participants may not objectively reply to their own trait emotional intelligence or adversity quotient accurately, and the measures do not include a validity measure for detecting inconsistent responses or social expectations. Thus, future research can explore using behavioural indicators of these constructs, ratings provided by course teachers and classmates and feedback from programme beneficiaries to gain insights into the effectiveness of SL.Thirdly, the conclusions are based on students from only one SL course for Chinese business students in Hong Kong. Thus, future researchers are encouraged to examine the generalisability of these findings to other types of SL, students and sociocultural settings.Lastly, This SL program is relatively short, but the improvements are surprising. In fact, the roles of teachers, families, and peer groups are very important factors affecting the emotional development of adolescents. More objective indicators, such as family background and support from schools and teachers, should be considered in the future.The study offers ideas and direction for professionals in higher education interested in service-learning programmes as a tool to improve university students’ trait emotional intelligence and adversity quotient. The findings of the study indicate that undergraduate students demonstrated improvements in these areas after participating in a 6-month SL programme. The outcomes are consistent with Wang et al.’s  evidence


Few reports have directly compared the outcomes of patients with acute ischemic stroke (AIS) who are managed in a stroke care unit (SCU) with those who are managed in an intensive care units (ICU). This large database study in Japan aimed to compare in-hospital mortality between patients with AIS admitted into SCU and those admitted into ICU.Patients with AIS who were admitted between April 1, 2014, and March 31, 2019, were selected from the administrative database and divided into the SCU and ICU groups. We calculated the propensity score to match groups for which the admission unit assignment was independent of confounding factors, including the modified Rankin scale (mRS) score. The primary outcome was in-hospital mortality, and secondary outcomes were the mRS score at discharge, length of stay (LOS), and total hospitalization cost.P = 0.106). LOS was significantly shorter  and expenses were significantly lower in the SCU group than in the ICU group . mRS scores (score of 1–3 or 4–6) at discharge were not significantly different after matching. Stratified analysis showed that the in-hospital mortality rate was lower in the ICU group than in the SCU group among patients who underwent thrombectomy.Overall, 8,683 patients were included, and 960 pairs were matched. After matching, the in-hospital mortality rates of the SCU and ICU groups were not significantly different (5.9% vs. 7.9%, In-hospital mortality was not significantly different between the ICU and SCU groups, with significantly lower costs and shorter LOS in the SCU group than in the ICU group.The online version contains supplementary material available at 10.1186/s12883-023-03454-6. In a stroke unit (SU) , multidiLarge regional variations in the SCU establishment exist , and sevThis retrospective study was approved by the ethics committee of Chiba University Hospital . The study was performed in accordance with the 1975 Declaration of Helsinki. The requirement for informed consent was waived because of the anonymity of the data. This study used the Diagnosis Procedure Combination (DPC) database, and data were obtained from hospitals that were included in the DPC system and volunteered to participate in the study . The DPCData are available to researchers on request for the purpose of reproducing the results or replicating the procedure by directly contacting the corresponding author.A flowchart of the sample selection procedure is shown in Fig. The primary outcome was in-hospital mortality. The secondary outcomes were mRS score at discharge , total LThe exposure variables were ICU or SCU admission upon hospital admission, defined by the presence of an ICU or SCU revenue center code in the administrative DPC data.We extracted the following baseline characteristics: age, sex, body mass index, ambulance use, weekend admission, history of cerebrovascular disease, total dependence on ADL, mRS score on admission, severe impairment in consciousness  on admission, AIS type (cardioembolic infarction or other), on-admission treatment , medical history , and hospital admission volume of patients with AIS. The Japan Coma Scale has four categories: alert, one-, two- and three-digit codes, with each digit code having three subcategories  . A JapanThe following on-admission treatments were also recorded: medications , treatments , and post-admission surgery .Formatting and preprocessing of the original DPC data were conducted using Python version 2.7.15 . All the statistical analyses including Pearson’s chi-squared test, Welch’s t test, Student’s t test, the Mann‒Whitney U test, and propensity score analysis, were conducted using R version 3.6.2 .We performed propensity score matching because nonrandom assignment to either an ICU or an SCU was likely to produce selection bias , 26. TheTreatments after admission, in-hospital mortality, LOS, and expenses before and after matching were compared using Pearson's chi-squared test, Welch’s t test, Student’s t test, and the Mann‒Whitney U test, as appropriate. Statistical significance was set at P < 0.05.A series of sensitivity analyses were conducted. First, we performed propensity score matching analyses among patients with 1) an mRS score of 0–3 points before the stroke, 2) an mRS score of 4–6 points before the stroke, 3) severe impairment in consciousness (JCS ≥ 20), 4) total dependence in ADL at admission (defined by the Barthel Index of zero), and 5) mechanical ventilation during admission. Second univariate linear regression analysis was performed for all (unmatched) patients using in-hospital mortality as the dependent variable and all baseline variables, including ICU admission, were selected as the independent variables. Subsequently, statistically significant variables were included in a multivariate logistic analysis.We performed stratified group analyses of factors associated with stroke prognosis for interactions with ICU admission and mortality. Age (stratified at 80 years) , sex, stAfter applying the exclusion criteria, 8,683 patients were eligible Fig. . Of thesThe baseline characteristics are shown in Table Table P = 0.106)  Table . LOS was6) Table . The perSensitivity analyses showed that, among patients with severe stroke, the in-hospital mortality between the two groups was not significantly different  who were admitted into either SCU or ICU. The 27 hospitals included in this study had both an ICU and SCU, are tertiary stroke centers and considered tertiary health facilities, and finalize necessary specialized procedures for both stroke and life support treatments. Using propensity score matching, we found no significant differences in baseline characteristics between the two groups. There was no significant difference in in-hospital mortality between the two groups, but patients in the SCU group had significantly shorter LOS and lower expense. For the mRS scores, mRS scores of 5 was significantly higher in the SCU group than in the ICU group. However, as the mRS score of 6  tended to be higher in the ICU group than in the SCU group, the number of patients with mRS scores of 4–6 was not significantly different.In several reports, it has been recommended that severe stroke with vital sign instability  is an indication for ICU admission , 16. SevIn this study, the ICU group required significantly more resources than the SCU group. The difference is partly explained by the fact that ICU admission fee per day is higher than that for SCU in Japan. In addition, the LOS in the SCU group was shortened by approximately 5 days, which may also partially account for the lower expense. Generally, all the ICU-level procedures, including ventilator or ECMO procedures can be used in the SCU, if necessary. However, because of the low therapeutic threshold of ICU staff for life-saving procedures or the differences in the training level for stroke, ICU-level therapies may tend to be used more often or for longer period for patients in the ICU with the same AIS severity, which may cause the differences in cost . As admiSeveral factors may explain the favorable effects of SCU admissions. The key components of the SCU are the development of evaluation procedures , early management , simultaneous rehabilitation with organized multidisciplinary collaboration, and early assessment for discharge . AlthougStratified group analyses demonstrated significant effect modifications due to several confounding factors. In previous reports, researchers have described the controversial effects of age and sex differences on the prognosis of patients , 35. In In a cohort of patients with AIS who underwent thrombectomy, serious AIS with sudden vital changes due to the recurrence of stroke or post-infarction hemorrhage was more common , 42. HigThis present study was the first study to compare the outcomes of patients with AIS who are managed in SUs with those who are managed in general ICUs, using a large database. The result of the study proposed the additional information in the selection of admission units for patients with AIS, and provided new evidence of the need for its aggressive implementation of SUs in countries where SU is not widespread.The present study has several limitations. First, as this study used administrative DPC data, it lacked detailed information, such as the National Institutes of Health Stroke Scale score , viThis propensity score-matched observational study showed that, in general, the in-hospital mortality of patients with AIS managed in the SCUs was not significantly different from that of patients managed in ICUs, with significantly lower cost and shorter LOS in the SCU group than in the ICU group.Additional file 1. In-hospital mortality based on stroke severity in each admission category.Additional file 2. In-hospital mortality in patients with AIS to whom mechanical ventilation was administered.Additional file 3. Univariate and multivariate analyses of factors (unmatched) associated with in-hospital mortality.Additional file 4. Stratified analysis of in-hospital mortality in the matched sample.Additional file 5. In-hospital mortality based on stroke type.


Autistic men and women are more likely to experience health issues than the general population, although the available epidemiological studies addressing co-occurrence conditions are limited. This is the first Spanish epidemiologic study addressing the health profile and poor-health exacerbating factors in individuals of all ages with autism spectrum disorder (ASD).We analyzed 2,629 registries extracted from Autism Spain’s sociodemographic registry (November 2017–May 2020). A descriptive health data analysis was conducted to assess the prevalence of other conditions associated to ASD in the Spanish population. Nervous system disorders (12.9%), mental health diagnoses (17.8%), and other comorbidities (25.4%) were reported. Men-to-women ratio was 4:1.Women, elder individuals and those with intellectual disability (ID) were at an increased risk of health comorbidities and psychopharmacological exposure. Women were also more prone to severe intellectual and functional impairment. Nearly all individuals had difficulties in their adaptative functioning, especially those with ID (50% of the population). Almost half of the sample received psychopharmacological treatments starting from infancy and early childhood, mostly antipsychotics and anticonvulsants.This study represents an important first approach to the health status of autistic people in Spain and can contribute to the development of public policies and innovative health strategies. Autism spectrum disorders (ASD) encompass several neurodevelopmental chronic conditions with early childhood onset that may be, or not, accompanied with an intellectual disability (ID) or language impairment , 2. The Currently, available and official population databases in Spain consider only broad health categories such as developmental , 12 or mCognitive and behavioral symptoms of ASD have a severe and life-long impact on the quality of life (QoL) and personal outcomes of people living with this condition ; World HPeople with ASD are also more prone to mental health issues than neurotypicals , 26. A cSeveral barriers and disadvantaging factors may compound the aforementioned ASD-related health disparities and limit people’s access to healthcare services , 29. SpeDespite this evidence, most health problems beyond ASD-related symptoms have been overlooked for decades. Only a few studies have systematically addressed them in the last years , 26, 36,Here, we present the first Spanish epidemiologic study describing the health status of a large cohort of children, adolescents, and adults with ASD, including physical and mental health co-occurring conditions. We aim to analyse how their health is influenced by sex, age, and concurrent ID.We conducted an observational retrospective analytic study with a cohort of autistic individuals in Spain based on demographic and health data from a national registry collected by Autism Spain . Autism Autism Spain’s ASD registry contains information about people with a confirmed clinical diagnosis of ASD of any age. Most of them are users or members of autism supportive associations linked to Autism Spain and receive support from them . The data collection period fell between the date of the first and last entries into the registry (November 2017 and May 2020).Forty-one ASD associations participated in this study and provided data related to 2,623 autistic people. Six participants contributed independently to the registry. Inclusion criteria were: (a) having a confirmed clinical diagnosis of any pervasive developmental disorder (PDD) , the International Classification of Diseases 10th Revision (ICD-10 or earlier diagnostic criteria) or ASD (according to the recent DSM fifth edition) , 39, ICDThis study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of the Autonomous University of Madrid (CEI-105-2039). All individuals provided written informed consent to participate and allowed the publication of the results. Personal data were handled according to the current General Data Protection Regulation 2016/679 of the European Parliament (EU-GPDR) and the Council of 27 April 2016 and with the Spanish Organic Law 3/2018 of 5 December 2018 on Data Protection and Guarantee of Digital Rights. Due to the retrospective nature of this study, there was no influence on any medical decision, including treatment prescription.Data from the registries was analysed according to the following sociodemographic and health variables:Sociodemographics–Sex and age. Boys and girls and adolescents (age 18 or younger) and adults (older than 18).–Health data. Health information is based on the clinical data included in health records and reports provided by the participants. Only those health conditions formally diagnosed by a specialized health practitioner  according to international classification systems [DSM-IV ] were in–Diagnosis of any disorder within the autism spectrum (hereinafter “ASD”): according to DSM-IV , DSM-5 , or ICD-–-occurring conditions: divided into mental health disorders and other general medical conditions with a clinical confirmed diagnosis.CoThose conditions with a stronger pathophysiological link to ASD, such as genetic  and nerv–: corresponding to an intelligence quotient (IQ) score <76 estimated with any standardized intelligence test . ID level was then classified as profound (IQ < 20), severe (IQ = 20–40), moderate (IQ = 41–55), mild (IQ = 56–75), border (IQ = 76–85), or absent (IQ > 85), according to ICD-10 subcategories  of the Spanish Ministry of Social Rights and 2030 Agenda. This is a summary score of the individual’s functional limitations due to physical, mental, intellectual, or sensorial impairments. When reaching a percentage of ≥25%, social factors that limit equal, effective, and full participation in society, are added to the calculations. Those provided with a certificate equal or upper to a 33% percentage are eligible to apply for a government subsidy . This stAutism Spain’s registry  and Chi-square test . Statistical significance was set at P < 0.05. When possible, point-estimates of effect-size (odds ratio for variables with two categories and Cramér’s V for variables with more than two categories) with 95% confidence intervals (CI) for each inferential test were also conducted. Data analysis was performed by IBM’s Statistical Package for the Social Sciences (SPSS®) for Windows version 24 .Participant data were analysed by descriptive statistics. Absolute and relative frequencies were used to describe categorical variables. The continuous ones were expressed by the mean and standard deviation (SD). Inferential tests were conducted to compare variables according to sex, age, and ID level: Student’s Autism Spain’s registry contained information about 2,629 individuals with a confirmed diagnosis of ASD. Mean age was significantly higher for women than for men . Almost one third of the study population were adults , and approximately half of them  were older than 25 and up to 60 years old  had received it before age 21. Public health care  and diagnostic services at non-governmental organizations related to ASD  were the most common diagnostic sites  and the 2008–2010  periods (see We found that mean age at diagnosis time was 7.5 years (SD = 6.5), and almost all participants  had been tested with an IQ formal test. Mean IQ score was 76.1 (SD = 30.9) for the whole study population, and it was higher in men than in woman . Approximately half of the individuals had no ID accompanying the ASD diagnosis  , while the other half  presented this concurrent condition in different severity levels . In most cases some degree of functional impairment that provided access to public support was identified .Adaptative skills had been officially assessed for most of the study population , Fragile X Syndrome (ICD-10 code: Q99.2)  and Down Syndrome (ICD-10 codes: Q90.X)  were the most frequent ones  corresponded to a wide range of distinct chromosomic anomalies. A total of 338 (12.9%) individuals had a nervous system disorder. Epilepsy and recurrent epileptic seizures (ICD-10 codes G40.X)  were the most frequently reported in this category  of the studied sample had one or more mental health diagnoses apart from ASD with or without ID, namely: impulse-control and disruptive behavior disorder (ICD-10 code: F63) , anxiety disorder (ICD-10 code: F41) , attention deficit and hyperactivity disorder (ICD-10 code: F90.X) , obsessive compulsive disorder (ICD-10 codes: F42.X) , and eating disorders (ICD-10 codes: F50.X) , among others  of the participants were currently taking psychopharmacological drugs, mainly antipsychotics  and anticonvulsants   .N = 138; 5.2%), three , or more than three  comorbidities were reported for the same individual. The main ones were sleep-wake disturbances (ICD-10 code: F51.3) , dermatitis and eczema (ICD-10 code: L30.9) , overweight and obesity (ICD-10 code: E66.X) , and intestinal disorders (ICD-10 codes: K55-K63)   people. In some cases, two (.1%) see .P = 0.0002; P < 0.0001). The percentage of women with this type of difficulties almost doubled that of men (see Women presented more severe forms of ID (moderate-to-severe levels) than the male subgroup ( men see .P < 0.0001) and other medical conditions . Mental health co-occurring disorders showed the same trend, although not reaching statistical significance , and they also received more psychopharmacological treatments than men   see .P < 0.0001), mental health (P < 0.0001), and other health comorbid disorders (P < 0.0001) as well as the number of individuals with psychopharmacological prescriptions (P < 0.0001) increased with age. However, the prescription of melatonin (P < 0.0001) and methylphenidate (P < 0.0001) showed the reverse tendency, reaching its highest in infancy and childhood, and childhood and adolescence, respectively,  and other medical co-occurring conditions  (see P < 0.0001) and OCD  were more common in the group with ID, whereas ADHD and personality disorders had been diagnosed to a greater extent among those without ID  (P < 0.0001) except for methylphenidate, which showed the reverse tendency   see . Mental  0.0001) . Psychop95–6.32) .P < 0.0001). More individuals with ID had been certified with the highest percentages of disability in proportion to those without ID  it has decreased and oscillates rather between 3.5 and 5 years . TherefoA men-to-women ratio of 4:1 was observed in our sample, in line with traditional epidemiologic reports , 47. HowOnly a couple of genetic syndromes (Down and Fragile X) were identified, which explained less than 1% of the cases in our study. Recent evidence suggests that complex polygenic mechanisms and environmental factors contribute approximately the same to the etiology of autism , 56.Regarding other pathologies accompanying ASD, we suspect that the prevalence of nervous system disorders, mental health diagnoses and other comorbidities in our sample may be underestimated since it falls far below that of other countries (around 70%) –23, 57. However, the categories found in greater representation in this study do correspond to those usually reported by other European studies on the health of people with autism , 58.Regarding pharmacological treatments, we found that psychiatric polypharmacy was significantly higher in participants with ASD and ID, as well as in the women and elderly subgroups. In addition, the number of individuals with psychopharmacological prescriptions was higher than the total number of neurological and psychiatric confirmed diagnoses that require drug administration. Also, we noticed a sudden rise in the number of children (≥6 years old) under psychotropic treatment that was not mirrored by in the number of mental health co-occurring confirmed diagnoses. Likewise, the higher proportion of youngsters treated with methylphenidate than the actual number of ADHD cases in the sample is as well intriguing.According to international guidelines and recommendations, antipsychotics, antidepressants, and anticonvulsants should not be prescribed to manage any core autism symptomatology . A case-As in the present study, the ASD-associated medical conditions identified so far belong to a wide range of medical areas and are subject to both sex- and age-related disparities , 30, 33.On the other hand, most of the analysed cooccurring conditions showed, as expected, an increasing trend with age. The percentage of individuals with more than one neurological disorder, mental health disorder or general condition already doubled or tripled in the >25 years-old group compared to younger ages. Considering that no adults in our study population were older than 60, our findings led us to suspect premature comorbidity onset in ASD compared to the general population. In connection to this result, emerging studies have suggested an association between ASD and accelerated aging after reporting the early onset of age-related disorders such as seizure, hypertension, hyperlipidemia, and chronic kidney disease, especially in the presence of ID. This health status decline is accompanied by progressive less autonomy, poorer adaptive skills and the use of polypharmacy , 35.Mental health issues can, as well, profoundly affect QoL at younger ages. According to a recent European longitudinal study, depression and anxiety symptoms in children and adolescents with ASD significantly reduced their perception of wellbeing . The samThe risk for health-related issues also depends on the presence of ID , 71. GloDue to the retrospective nature of our research, there are some related limitations that must be taken into account when interpreting the results.Although only clinically confirmed health issues according to international classifications had been included, changes in diagnosis criteria of those coexistent conditions over time and missing data could have biased our results.Also, the sample representativeness is limited because most of the participants where related to autism organizations or specialized supporting services. We were not able to obtain enough information from autistic people who were not related to that network, so it is not clear whether our results can be generalized to the whole ASD population in Spain, even being coincident, in some extent, with those obtained in similar studies in Europe , 58.This sampling bias may be especially relevant for women and older participants. As already mentioned, we have observed from our registry that the socio-economic, educational and health context of women applicants is usually more disadvantageous compared with male counterparts and globally, adults  with ASD are underrepresented in research, and so they are in the present study.Finally, comparisons with the non-ASD population could not be made, and for some analyses, such as the distribution of genetic disorders, our sample size was too small to allow making any inferences.According to our findings and the related scientific literature, it is urgent to enhance the autistic community access to health, improving prevention, identification and management of the conditions that affect their physical and emotional wellbeing. This should include up-to-date training for health professionals regarding ASD, as well as providing resources and guidance to prevent, diagnose and treat comorbidities in a timely and effective manner, including more routine health check-ups and promoting healthy lifestyle changes.In the future, it will be as well necessary to explore how the aforementioned and other co-occurring conditions impact autistic people’s QoL, their emotional well-being and adaptive functioning, and are subject to sex-based differences.To increase sample representativeness, further epidemiologic studies with large cohorts are also needed, especially with elder adults and those who are not related to the ASD specialized organizations or do not usually receive any support services. There is a lack of scientific information on the health profile of people with ASD who do not have access to those networks, probably because they have less information and opportunities to participate in health research too. The specific ASD conditions that favor membership in associations could also be linked to health variables, or maybe these organizations support their members in a way that influences their health needs . Data frFrom a public health perspective, other risk factors such as poor nutritional habits, little physical activity, long-term psychopharmacological treatments and institutionalization increase health problems morbidity among autistic people . It has Although the conclusions are still speculative, there seems to exist an association with maternal lifestyle and subsequent diseases , exposure to specific nutrients and pollutants during pregnancy, advanced parental age and birth complications associated with neonatal hypoxia/ischemia , 75–77. s the autistic community perspective about those challenges and barriers.Even though autistic people utilize more health care resources , they are also more likely to report unmet medical needs, low satisfaction regarding the medical attention received and poor inter-personal communication with health care providers . There iQualitative and quantitative mixed methods should be applied to identify the key factors that affect the health status and wellbeing of autistic people, taking advantage of the strengths of both approaches and enriching the research results , 79.Also, improving participatory research is necessary, where people on the autism spectrum have an active role in prioritizing the research objectives and how to reach them, and provide feedback to be subsequently analysed and interpreted , 81.To contribute to these efforts, our study has described the health challenges that require urgent awareness and at least some of the main factors  that increase the vulnerability of people on the autism spectrum and deteriorate their wellbeing and QoL. There is a need to determine what factors besides ID contribute to shaping adaptive functioning in autism and QoL, for instance, mental and physical health status, social and workplace inclusion, access to educational, social participation, specialized support resources, and equality of opportunities. The extent to which global health status influences all these outcomes, especially in adulthood and middle age and beyond, remains to be clarified, and it is one of the main priorities considered in the public policies related to ASD around the world , 62.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethics Committee of the Universidad Autónoma de Madrid (CEI-105-2039). Written informed consent to participate in this study was provided by the participants or their legal guardian/next of kin.RV-F, MP-S, and CH-L contributed to the study conception and design, and were involved in the material preparation, acquisition, analysis, and interpretation of the data. RV-F and MP-S involved in the drafting of the manuscript. GB-R involved in the analysis and interpretation of the data. CH-L, MV-C, GB-R, and FC-M made substantial contributions to the final draft of the manuscript. All authors read and approved the final manuscript for its publication.