N = 105 with nonalcoholic fatty liver) was studied to identify clinical, laboratory, and instrumental predictors of the corrected QT interval (QTc) and QTc prolongation, including LS and CAP. The results were validated on a subgroup of patients belonging to the derivation cohort , as well as on a completely different group of N = 149 subjects with CLD . QTc values were directly related to liver stiffness , heart rate , and age  and were significantly longer in females (p < 0.001). In contrast, QTc was not associated with the value of controlled attenuation parameter ; moreover, no discernible differences in QTc length were noted based on CLD etiology. QTc was prolonged in 24/349 patients (6.9%); age, HR, and LS were independent predictors of QTc prolongation . Furthermore, QTc values (after logarithmic transformation) were predicted by a model including age, gender, HR, and LS . These latter results were validated by both out-of-sample and out-of-time methods. In conclusion, TE findings strongly suggest that among patients with CLD, fibrosis, not steatosis, is a major determinant of QTc length.The severity of fatty liver at ultrasound has been associated with QT length, a finding invoked to explain the excess cardiovascular risk of patients with fatty liver. However, the ability of ultrasound to stage accurately the severity of fatty liver is limited, with fibrosis a major confounder. Here, we aimed to verify the alleged relationship between fat liver content and QT length using a technique apt at discriminating steatosis from fibrosis noninvasively, i.e., transient elastography (TE) with measure of liver stiffness (LS) and controlled attenuation parameter (CAP). A prospectively collected derivation cohort of 349 patients with chronic liver disease (CLD) of any etiology ( Nonalcoholic fatty liver disease (NAFLD) is an important health concern, being on a global scale the most prevalent chronic liver disease (CLD). Its severity ranges from simple steatosis, to nonalcoholic steatohepatitis (NASH) with or without fibrosis, to cirrhosis . Most ofThe development of CLD is often complicated by alterations in other organs and systems, including the heart. The so-called cirrhotic cardiomyopathy, defined as a chronic cardiac dysfunction observed in patients with cirrhosis, is characterized by blunted contractile responsiveness to stress, and/or altered diastolic relaxation with electrophysiological abnormalities, in the absence of any other known cause of cardiac disease . One of Based on these premises, in the present paper, we aimed to investigate the relative strength of the association of fibrosis and steatosis with QTc prolongation, both in NAFLD and in chronic liver diseases of different etiologies with or without evidence of fatty liver. To fulfil these aims, in a cohort of CLD patients, we quantified noninvasive steatosis and fibrosis at the same time the QTc interval was measured. Using these data, we developed and validated a model to predict the length of the QTc interval in such patients.Our research was conducted according to the principles of the Declaration of Helsinki. All the procedures were performed in clinical practice and, therefore, a specific approval from the Ethical Committee was not required. However, every patient signed an informed consent for the anonymous distribution of data for research proposal.Firstly, a cross-sectional derivation cohort was identified among consecutive patients attending the liver clinic of a university hospital. We included adult patients (older than 18 years), who received a diagnosis of chronic liver diseases from any etiology. We excluded patients affected by atrial fibrillation, atrial flutter, atrioventricular block, and right or left bundle block; those who had experienced a myocardial infarction; those who had undergone pacemaker implantation; and those who were receiving drugs known to prolong the QTc interval or antiarrythmic drugs. Patients receiving “conditional risk” drugs were allowed; “conditional risk” drugs are potentially responsible of QTc prolongation but only under specific circumstances .After the application of the inclusion and exclusion criteria, we identified 349 patients; 105 were affected by NAFLD, 200 by chronic viral hepatitis, 12 by alcoholic liver disease, 3 by inherited diseases, 14 by autoimmune hepatitis and, finally, 16 by cryptogenic liver diseases.A validation cohort of 149 patients was further selected, according to similar inclusion and exclusion criteria; out of them, 50 were affected by NAFLD, while 99 were affected by chronic viral hepatitis.The demographic and clinical data collected included age, gender, smoking and alcohol habits, past medical history, and concomitant treatment(s). Moreover, all patients underwent a thorough physical examination. The body mass index (BMI) was calculated as body weight in kg (measured with the patient wearing light underwear) divided by the square of the height in meters and interpreted according to the World Health Organization classification . The waiAll the patients underwent a transient elastography examination by FibroScan , after at least 6 hours of fasting. This exam was performed by a single expert hepatologist, blinded to the results of ECG, as previously reported . The ratA 12-lead ECG trace (length: 10 seconds) was recorded by a trained nurse with the participant in the supine position on the morning of the same day of the visit. The QTc value was obtained recording the electrocardiogram by an interpretive machine  and was considered normal when <450 msec in males and <470 msec in females . Restingχ2 test were used, as appropriate, to explore the associations of categorical variables. Cuzick's test was used to test the trend of a continuous variable between groups [out-of-sample validation of the regression model, by evaluating whether the results obtained were similar when the model was applied to two subsamples of N = 175 and N = 174 patients randomly selected from the derivation cohort . The concordance between predicted and measured QTc was verified in a Bland-Altman plot. Furthermore, we performed an out-of-time validation, by applying the model obtained from the derivation cohort to the validation cohort. The concordance between measured and expected QTc was also tested by Bland-Altman analysis. We calculated Lin's concordance coefficient between measured and expected QTc for both the validation methods.Anthropometric, clinical, and biochemical data were recorded in a database and analyzed by the statistical software package Stata, version 15.1 . The measures of centrality and dispersion of data chosen were medians and 95% CI. Medians were compared between groups by the Mann–Whitney and Kruskal–Wallis (K–W) tests. Exact Fisher's test and Pearson's n groups . The assThe level of significance chosen for all statistical analysis was 0.05 (two-tailed).The derivation cohort included 349 patients, whose main features are listed in p = 0.0001) and a lower prevalence of cirrhosis . As shown in In As shown in ρ = 0.137; p = 0.011), heart rate , and age . The relationship between LS and QTc was strengthened excluding patients with NAFLD , while it was not confirmed when only the NAFLD group was considered . On the contrary, QTc values had no correlation with fat liver content as assessed by CAP, neither considering the entire derivation cohort  nor the NAFLD group  or all other patients . Furthermore, in NAFLD patients, where the prevalence of LS values above a threshold strongly suggestive of cirrhosis was only 1.9%, QTc was similar when categorizing patients according to the presence or absence of cirrhosis and the presence or absence of severe steatosis. By contrast, in patients with CLD of other etiologies, QTc was significantly longer among those with cirrhosis, independent of the presence/absence of severe steatosis , but a similar proportion of patients with severe steatosis .QTc was prolonged in 24/349 patients (6.9%); out of them, 18 (75%) were affected by viral hepatitis, 5 (21%) by NAFLD, and 1 (7%) by alcoholic liver disease. In χ2 = 23.7, p < 0.001; F = 14.1, R2 = 0.198, p < 0.001).In a multivariable logistic regression analysis, age, heart rate, and LS were confirmed as independent predictors of QTc prolongation .To confirm the results obtained from the derivation cohort, we randomly selected 175 patients from the same cohort (sample A) and we evaluated whether the results of the multiple linear regression might be replicated in this subgroup of subjects. As shown in ρ = 0.417; p < 0.001; We used the equation obtained from the analysis reported in 2.To further validate our model, we applied the equation derived from the derivation cohort to a validation cohort. The validation cohort was composed by 149 patients , median age 60 (50-74) years. Fifty patients (33.6%) had NAFLD and 99 (66.4%) chronic viral hepatitis. The median BMI was 26.2 (23.6-29.9) kg/mρ = 0.533; p < 0.001), as further confirmed by Bland-Altman plot (As shown in man plot .QTc prolongation has been reported both in patients with cirrhosis and in those with nonalcoholic fatty liver disease. In the present study, we provide data suggesting that liver fibrosis is a stronger determinant of QTc prolongation than fatty liver, independent of the etiology of chronic liver disease. These findings need to be discussed at the light of the existing literature on this topic and of the limitations of the noninvasive techniques employed to determine the presence/absence of fatty liver and fibrosis.β-blockers reduce QTc length, while stressful events prolong it [Among similar classes of liver stiffness, we found similar QTc values independent of the severity of liver steatosis and the etiology of liver disease suggesting that, among patients with liver disease, QTc prolongation is not confined to a specific etiology. This is in line with previous reports from other groups , 15. Theolong it .In the present study, we also managed to demonstrate that LS, along with HR and age, is a predictor of QTc prolongation. This is clinically relevant because it might help in identifying a subset of patients affected by chronic liver diseases who are at higher risk for significant QTc prolongation; specifically, a prolonged QTc is more likely in elderly women with advanced chronic viral hepatitis, a profile to be kept in mind before prescribing drugs that may prolong the QT interval. It is true, however, that sudden cardiac death is a relatively rare event in the natural history of cirrhosis; therefore, the clinical relevance of QTc prolongation in CLD remains to be established.In conclusion, our data support the hypothesis of an association between QTc length and severity of liver damage in chronic liver disease and warn that the degree of fibrosis progression might be a major confounder to be taken into account when analyzing the relationship between QTc length and fatty liver.


The study showed that the number of beds in health institutes (p < 0.001) and per capita gross domestic product (GDP) (p = 0.025) had a positive effect on TB incidence, whereas population density (p < 0.001) and migrated population (p < 0.001) had an adverse impact on TB incidence in the study settings. High TB incidence districts were detected in urban and densely populated districts in Beijing. Our findings suggested that socio-economic predictors influence TB incidence. These findings may help to guide TB control programs and promote targeted intervention.Evidence shows that multiple factors, such as socio-economic status and access to health care facilities, affect tuberculosis (TB) incidence. However, there is limited literature available with respect to the correlation between socio-economic/health facility factors and tuberculosis incidence. This study aimed to explore the relationship between TB incidence and socio-economic/health service predictors in the study settings. A retrospective spatial regression analysis was carried out based on new sputum smear-positive pulmonary TB cases in Beijing districts. Global Moran’s I analysis was adopted to detect the spatial dependency followed by spatial regression models  along with the ordinary least square model were applied to examine the correlation between TB incidence and predictors. A high incidence of TB was seen in densely populated districts in Beijing, e.g., Haidian, Mentougou, and Xicheng. After comparing the R Mycobacterium tuberculosis, which mostly affects the lungs, although it can affect other organs and parts of the body. It is a curable and preventable disease, which is transferred via air  [Tuberculosis (TB) is a chronic infectious bacterial disease caused by atients) ,2. Furthatients) ; alcoholatients) ; demograatients) ,9,10,11 atients) ,13,14,15atients) . In receatients) ,17. It hatients) . Several studies have been conducted earlier regarding influencing factors contributing to TB incidence and prevalence in China; however, such studies in the Beijing region are lacking. In addition, multivariate regression models including linear regression , logistiAccordingly, investigating the disease clusters and the role of spatial heterogeneity in the relationship between affecting factors and TB incidence is essential for TB control and prevention strategy development. Thus, this study aimed to investigate the socio-economic predictors and distribution of tuberculosis based on TB notification data in Beijing using spatial regression analysis. 2, divided into 16 administrative districts with an estimated population of 21.7 million in 2017 [A retrospective ecological study was conducted in 16 districts in the Beijing region based on the reported new (sputum smear-positive) pulmonary tuberculosis cases from 2005 to 2014. Beijing lies on the northern tip of the North China plain at 39°56′ N and 116°20′ E, and is surrounded by the mountains. The total area of Beijing is 16,410.54 km3 population density for each central area of a district within a 3 km surrounding area), county/district level GDP (C_GDP) (each district’s GDP), and permanent resident population (PRP) were collected from the Beijing Statistical Yearbook, covering the years from 2005 to 2014 [Tuberculosis (TB) cases were the outcome variable of this study. Data on all reported cases of tuberculosis  between 2005 and 2014, were obtained from Beijing Information of Tuberculosis Prevention and Control registration database . Predict to 2014 . These vAll collected data were imported into Microsoft Excel 2010  and linked to the respective location in the geographic information system. To conduct a GIS-based analysis of the spatial distribution of TB, district/county level polygon maps at 1:100,000 scales were obtained from the National Geometric Center of China , and a dWe obtained ethical approval and clearance from the ethical review committee of Capital Medical University (SPHCMU), Approval No. IRB00009511, Beijing, China and a consent from each individual subject was not required because we used only aggregated data from the Beijing Center for Disease Control .All descriptive information of variables was summarized annually according to geographic area (districts), where incidence rates were calculated for each district using neighborhood census data as a denominator and reported TB cases as the numerator. I index value and Z-score, including the p-value, which evaluated the significance of that index. These values assess whether the distribution pattern is clustered, dispersed, or random. This method permits a test for the existence of global heterogeneity, in terms of spatial autocorrelation or spatial dependency [I) was used to investigate the presence of spatial as well as clusters of TB cases and to identify their possible locations. The calculation is based on the features’ locations as well as their attribute values [We used the ArcGIS tools to generate the Moran’s pendency . Spatiale values . I statistic for spatial autocorrelation is given as:i from its mean , economic factors , and health facility indicators . Therefore, we analyzed the average values that were used to explore the predictors of TB incidence and increase the stability of data and minimize the potential bias . The aveThen, we constructed the shapefile of the outcome and predictor variables in ArcGIS software and exported it into the GeoDa  for advanced geospatial analysis. GeoDa is the latest spatial data analysis software tool developed by the Center for Spatially Integrated Social Sciences (CSISS) to apply various types of exploratory spatial data analysis including data manipulation, mapping, and spatial regression analysis. We generated a spatial weights matrix in GeoDa software, which is necessary for the calculation of spatial autocorrelation statistics. Basically, spatial weights can be constructed in both ways; either based on contiguity from polygon map files or based on the distance between points. We selected contiguity based on spatial weights since our main interest lies in understanding the spatial interdependence between the outcome variable and a set of exposure variables in the nearby districts. GeoDa further provides two types of spatially contiguous weights, that is, rook’s weight (using common boundaries to define the neighbor), and queen’s weight . Finally, we used rook’s contiguity  weight fFirstly, we employed the classic ordinary least square (OLS) model to estimate the effect of various socio-economic and health facility variables upon the outcome variable. After learning about the presence of spatial dependence in the outcome and predictor variables, we understood that the assumption of independent observations and errors of this model might be violated. Thus, we employed and compared three regression models: ordinary least square (OLS), the spatial lag model (SLM)  and the The spatial lag model  has the following form:ε is the vector of regression disturbances, W is the spatial weight [Then, the spatial error model has the following form:l weight ,34,35.Of a total of 44,408 new sputum smear-positive pulmonary tuberculosis cases of Beijing districts from 2005 to 2014, we used 40,878 cases and the remaining 3530 cases were excluded due to unavailable resident information or because those patients did not reside in the Beijing region. Of the total 26,713 patients with TB, 44.1%  were aged between 16 and 30 years old, while 34.2%  were aged between 31 and 60 years old (a productive age group). In addition, 12.8% (5705) were aged over 61 years and only 0.9% (402) were aged under 6 years. A remarkable reducing trend in TB incidences was noted in the Beijing region from 2009 to 2014 . A higheI index with significant values (p = 0.05 level). The outcome variable, pulmonary TB  ranged from 39 to 885 (mean/SD) = 256.37/183.34). All descriptive information of the variables, including the maximum, minimum, mean, standard deviation and Global Moran’s I with significant values are displayed in I statistics for each study year separately. The global spatial correlation analysis exhibited the presence of positive spatial clustering of TB incidence in the Beijing region (Z-score from 0.374 to 1.741)  . The Spearman correlation coefficient analysis is applied to estimate the relationship between tuberculosis incidence and other independent variables. A significant positive correlation found between TB incidences and socio-economic predictors (at the 0.01 level in the two-tailed test of significance) . I and LM (SHRMA) tests were highly significant in both weights matrices, except for the robust LM lag , indicating that there a strong spatial dependence existed. Therefore, the robust LM test was applied for both the SLM and SEM. In order to select an appropriate spatial regression model from spatial regression models, the Lagrange multiplier (LM) diagnostics tests were employed to determine spatial dependence. Two spatial weights matrices  were used for this diagnostic test to make sure the results were robust or not . As for I score of −0.0631 (p < 0.001) was highly significant, indicating a strong spatial autocorrelation of the residuals. Additionally, both Lagrange multiplier (lag) and Lagrange multiplier (error) test results were significant, expect the Robust LM (lag); indicating the presence of spatial dependence. The robust estimation of the error term  is still significant, however, the robust lag test  is insignificant, which means that when a lagged dependent variable is present, the error dependence disappears. The coefficient of determination (R2) of the OLS model was (0.359), indicating that the risk factors during study period explained 35.9% of the total variance for TB incidence, also indicating that the OLS model was not the best fit for this group of data. From the estimation of the OLS model, four variables were found to be statistically significant with respect to TB incidence. Higher numbers of beds in the hospital and per capita GDP had a positive effect on TB incidence, while population density per 3 -km range from the center of the district and higher migrant population had negative effects on TB incidence  assumptions. We found a significant spatial clustering of the outcome and exposure parameters in the OLS models. Moran’s ncidence .2) was 0.3975, indicating that the model explained 39.75% of the variance in TB incidence. The decreasing values of log-Likelihood and AIC and the increasing value of R2 also suggested here a general improvement of the model fit in the SLM as compared to the OLS. This SLM results showed that numbers of beds in hospital and district-level GDP had a positive relationship, while per capita GDP, population density/3 km, permanent resident population, and migrat population had negative significant associations with TB incidence. Likewise, we extended the SEM to estimate the relationship between the exposures and the outcome variable. The spatial error parameter (λ) was statistically significant, as indicated by the p-value (<0.001). In SEM, the R2 value was found to be 0.4132, indicating that the model explained 41.32% of the variance in TB incidence. After identifying the presence of spatial dependency on the OLS model, we further re-estimated the spatial regression model (SLM and SEM) with the maximum likelihood estimation approach while controlling for the spatial dependency. We determined the spatial lag term of TB with the designed spatial weight file. The coefficient parameter (Rho ‘ρ’) revealed the spatial dependence inherent in our sample data in that measuring the average influenced the observations of their neighboring observations. The determination coefficient . The Breusch–Pagan test  and the likelihood ratio test  of spatial error dependence are still significant, which means that the spatial effects in the data were still not removed completely. However, both spatial models yield improvement than OLS model and the spatial error model appeared to fit better than the SLM. In SEM, the number of beds in the hospital and per capita GDP was significantly and positively associated with TB incidence, while district- level GDP, population density/3 km, and migrant population were significantly and negatively associated with TB incidence during the study period. However, per capita GDP was no longer negatively associated with TB incidence in the SLM model and showed a positive correlation. The number of health institutes had a positive correlation, while the permanent resident population had an adverse association with TB incidence during the same study period in SLM. However, these variable coefficients were not significant , permanent resident population, and migrant population had a negative correlation with TB incidence, however, those factors were positively associated with TB incidence as reported by previous studies of Sun, et al.  and Liu,In our study, health care facility indicators have had a weakly positive association with TB incidence. In contrast, a negative impact was found in the study of Sun, et al. . The expAnother finding of this study is the association between TB incidence and economic factors. The correlation of TB with per capita income was found to be insufficient relationship, while it a positive relationship was found with respect to with district-level GDP, indicating that the economic status of the individual as well as the overall county level is an important factor for improving the health status. Notably, it has already been established that TB is a poverty-related disease  so thereAlthough this study was a spatial analysis of socio-economic predictors and distribution of tuberculosis in the Beijing region, there are some limitations which should be acknowledged. First, under-reporting is an issue for any infectious disease surveillance system in China, like other countries. We extracted TB data from the official surveillance system, where cases might be missed through the routine notification system. Second, this study did not include several factors related to pulmonary TB incidence due to unavailability of the information at the district level, such as climate factors , health-related factors , and economic factors . The epidemiological study focuses on both time and space, which influence the disease occurrence. Therefore, a study focusing on a spatiotemporal analysis along with the correlation with environmental factors and TB incidence is urgently needed.This study investigated socio-economic predictors and distribution of smear-positive tuberculosis in the Beijing region. We found that TB incidence mostly occurred in urban and densely populated districts over the study period. However, the trend of TB incidence has been decreasing in Beijing. Consistently, we confirmed that the number of the hospital beds, district-level GDP, per capita GDP, permanent resident population, population density, and migrant population may have an impact on TB incidence. Our findings suggest that TB control measures should be focused on those factors in order to allocate public health resources more precisely to reduce the burden of TB incidence.


It may help optimize dietary interventions and improve the overall management of patients with HF.(1) Background: Burden scales are useful in estimating the impact of interventions from patients’ perspectives. This is overlooked in sodium diet/heart failure (HF). The aim of this study is to develop and validate a specific tool to assess the burden associated with low-sodium diets in HF: the Burden scale In Restricted Diets (BIRD). (2) Methods: Based on the literature and reports from patients, 14 candidate items were identified for the following dietary-related domains: organization, pleasure, leisure, social life, vitality, and self-rated health. The validation study was conducted prospectively. The questionnaire was refined via item reduction according to inter-item correlations and exploratory factor analysis. Internal consistency was determined using Cronbach’s alpha (Cα) and convergent validity by assessing correlations between BIRD and the health-related quality of life (HRQoL) Minnesota Living with HF questionnaire (MLHF). (3) Results: Of the 152 invited patients, 96 (63%) returned the questionnaire. The median score was 6.5 (IQR 2.0–14.0). The results showed good acceptability (non-response rates/item from 2.0% to 12.1%), an excellent internal consistency (Cα = 0.903) and a good convergent validity , 0.4 , and 0.45 ; all  Chronic heart failure (HF) is a major public health and social problem. Its prevalence increases with age, reaching approximately 10% after 70 years . This hiCompliance to diet is closely related to patients’ subjective perceptions and expectations. In this regard, chronic heart failure is a complex condition that requires important personal investment from patients to manage their disease. However, the alteration in their long-standing personal habits and lifestyle may lead to their perception of the dietary sodium restriction diet as a negative intervention . Indeed,The current existing scales for evaluating quality of life in patients with HF are fundamentally limited for assessing this burden, since they include few to no items inquiring about a patients’ diet, whether they be generic, like the SF-36 ; diseaseTo the best of our knowledge, there is no tool available for evaluating the burden experienced by patients with heart failure on a low-sodium diet, so there is a pressing need for accurate tools to measure this burden. Thus, developing a dedicated instrument would be beneficial to ascertain the concerns of HF patients’ and their physicians alike for identifying which patients are in need of more sustained monitoring or support for their diet. The objective of the present study, is therefore, to develop and validate a new scale—the “Burden scale In Restricted Diets” (BIRD)—to allow an adequate evaluation of the burden associated with dietary sodium restriction in heart failure patients.The BIRD questionnaire was designed based on standardized health care, health-related quality of life (HRQoL) questionnaire development, and validation methodology ,14. A muThe first stage included the creation of a verbatim report based on review of the literature, and qualitative information collected during semi-/unstructured interviews with patients with HF to discuss their complaints and distresses related to diet in HF. Based on this report and input from the multidisciplinary working group, the major identified concerns were meal preparation, pleasure, budget, leisure, social life, consequences at work, vitality, and self-rated health.An initial set of 14 candidate items were produced and grouped according to their content to constitute the initial draft questionnaire . WordingA validation study was conducted to assess the psychometric properties of the scale. A cross-sectional survey was conducted in more than 100 adult patients with medically diagnosed HF using the draft questionnaire. The questionnaire was pretested in the first 10 patients to evaluate the comprehensibility, and changes were made based on their comments. To be eligible, patients had to be able to read, be able to understand and speak the French language, and lack any cognitive impairment. Patients were prospectively enrolled in the Cardiology Department of the Henri-Mondor Hospital, Creteil, France. Given the nature of the study, without any change to patient care, the need for written informed consent was waived under French regulations; all patients received an information sheet with contact details, and authorization to use data could be withdrawn at any time. The study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki.Psychometric analysis included assessment of item characteristics, construct validity, internal consistency, known-groups validity, and convergent validity.s) were computed to examine the homogeneity of the scale  and to identify whether highly correlated items should be omitted for redundancy . A correlation network plot was built from those results to graphically illustrate relationships. A hot-deck multiple imputation was performed to impute missing data for subsequent analyses.Descriptive analyses were performed to study the distribution of individual items and global score, to inform on the acceptability , and to identify potential ceiling and/or floor effects when a majority of item responses were distributed at either end of the scale. Spearman’s rank correlation coefficients (rp < 0.0001) and the Kaiser–Meyer–Olkin measure of sampling adequacy (0.842), indicating that our sample was suitable for conducting exploratory factor analyses (EFAs). As recommended [Construct validity (factor structure) of the instrument was assessed through exploratory factor analysis  to examine the underlying constructs and characterize the scale dimensionality. Data were first examined with the Bartlett’s test of sphericity  was assessed by calculating Cronbach’s alpha . A coeffKnown-groups validity was investigated by studying whether the burden score would differentiate between adjacent severity subgroups. For that purpose, differences in burden score were assessed according to the New York Heart Association (NYHA) class and the intensity of the prescribed low-sodium diet . Scores were compared across groups using the nonparametric Kruskal–Wallis test for global comparisons and the Jonckheere–Terpstra test for trends.Convergent validity was studied by assessing correlations between the global burden score and the HRQoL Minnesota Living with Heart Failure questionnaire (MLHF), a validated 21-item questionnaire for assessing HRQoL in patients with HF . Spearmahot.deck, paran, and psych packages for hot-deck imputation, Horn’s parallel analysis, and Velicer minimum average partial correlation for number of principal components, respectively.Statistical analyses were performed using Stata v14.1 software  for descriptive and factor analyses and R 3.2.4 software  using the Since the original BIRD questionnaire was developed in French, a well-established methodology was applied to generate an English version. This included forward and backward translation while accounting for cross-cultural validation . LinguisOf the 152 patients invited, 96 (63%) completed and returned the questionnaire. Comparison between non-participating and participating patients for age, gender, and NYHA class did not reveal any significant differences (data not shown). Main characteristics of the sample, including sociodemographics, clinical and biological features, HF-related diet treatment, and Minnesota Living with Heart Failure (MLHF) scores by domains are shown in s = 0.47), 12 (rs = 0.53), and 2 (rs = 0.55). Lower inter-item correlations were apparent for items 1, 2, and, to a lesser extent, 12  answered all the questionnaire items. Among those who did not, missing data ranged from 1 (17%) to 5 (1%) of the items. Item statistics related to data quality, distribution, and mean scores are shown in tent, 12 . No inteA one-factor solution explained 79.8% of the total variance, with both the MAP criterion and parallel analysis supporting this solution. The unadjusted and adjusted eigenvalues  for the first three factors were 5.93/0.78/0.53 and 4.87/−0.04/−0.12, respectively. Items 1 and 2 were left out because of their insufficient loading (<0.4) and/or communality (<0.3) on the first axis. Factor analysis rerun after exclusion of these two items confirmed the scale unidimensionality, supported by the MAP criterion, parallel analysis, and the large proportion of total variance (88.0%) being explained by the first factor. These findings indicate construct validity and thus validate the calculation of a single BIRD score, which brings together all the items. A global 12-item burden score was then computed  . The comp = 0.055; test for trend p = 0.003). This supports the scale’s ability to discriminate according to clinical disease severity. A statistical trend for higher scores was also found in patients with the most restricted diet  vs. (3–6 g or >6 g) p = 0.06), supporting the ability of the scale to identify those who suffer the heaviest burden of a low-sodium diet. s = 0.37 , 0.40 , 0.45 ; all p < 0.05.The developed scale showed excellent internal consistency . Results for known-groups validity are shown in Health-related quality of life (HRQoL) and burden scales have proved to be useful in estimating the impact of diseases and treatments from the patient’s perspective on their physical, mental, and social health status. Several generic or disease-specific patient-reported outcomes are available to assess the self-rated health status of patients with heart failure. However, none capture the specific domains related to the sodium restriction often prescribed in HF. To the best of our knowledge, BIRD is the first validated questionnaire assessing specifically the burden of a low-sodium diet in patients with HF. BIRD was found to be psychometrically robust, with excellent internal consistency and good item-scale, convergent validity, and construct validity. BIRD also correlated significantly with components of the MHF, confirming its concurrent validity.Heart failure is associated with activation of the neurohormonal system, leading to sodium and water retention. All national and international guidelines currently recommend that HF management should include dietary sodium restriction . Based oThe notion of ‘burden’ has been introduced by the World Health Organization to help quantify the health of a population and to determine the priorities for public health interventions . The ‘buBIRD is a quick and easy-to-use tool allowing a single diet-related burden score to be calculated. It has the advantage of covering multiple and relevant aspects of the burden that can result from a low-sodium diet in a patient’s daily life. Its widespread administration will be facilitated by the aptness of the questionnaire, as demonstrated by the satisfying psychometric properties of the instrument in the present study, i.e., understandability, reliability, and validity, as well as by its easy-to-use and parsimonious structure, with only 12 items to collect. As such, it may serve as a strategic tool for screening patients suffering the highest burden from their diet and who might benefit from specific interventions, such as psychological and social help, close follow-up, etc. It may also foster negotiation and cooperation between patients, physicians, health authorities, and agro-alimentary industries by providing a common tool for quantifying diet-related constraints. Finally, it is noteworthy that the items constituting the BIRD questionnaire relate to organizational, social, and general health status aspects which would most likely also be affected in other conditions requiring restricted diets. Thus, it would be of great interest to study the validity and clinical utility of the instrument in other settings and for other conditions, e.g., diabetes and celiac disease, and, ultimately, to compare the resulting burden scores using this common reference scale.Limitations associated with this study include the monocentric recruitment and the relatively limited sample size that restrained the possibility of subgroup analyses. Larger confirmatory studies using the BIRD questionnaire are warranted to further explore the potential effects of age, disease onset, culinary culture and habits, comorbidities, coexistence of other diet and restrictions, etc. on the burden of sodium restriction in HF. Second, 37% of invited patients did not complete and return the questionnaire. Yet, our response rate appears consistent with, and even somewhat higher than, those generally observed in surveys where participants are required to send questionnaires by postal mail, as in the present study. Relatedly, a selection bias resulting from such non-participation cannot be ruled out, though likely of limited magnitude, as there was no significant difference in demographics and NYHA classes between participating and non-participating patients. Finally, due to the cross-sectional design of the study, we also lacked the ability to investigate the predictive value of the tool for future treatment compliance and/or subsequent cardiologic events. Further research efforts will include the conduct of prospective studies to address these elements.In conclusion, there is a need for physicians to recognize the individual burden of patients with HF under sodium restriction. Quantification of this burden by the BIRD questionnaire may help optimize dietary interventions and improve the overall management of patients with HF.


Xylella fastidiosa, which is widespread in the outbreak area; however, the “Leccino” variety of olives has proven to be resistant with fewer symptoms and lower bacterial populations than the “Ogliarola salentina” variety. We completed an empirical study to determine the mineral and trace element contents  of leaves from infected trees comparing the two varieties, to develop hypotheses related to the resistance of Leccino trees to X. fastidiosa infection. All samples from both cultivars tested were infected by X. fastidiosa, even if leaves were asymptomatic at the time of collection, due to the high disease pressure in the outbreak area and the long incubation period of this disease. Leaves were binned for the analysis by variety, field location, and infected symptomatic and infected asymptomatic status by visual inspection. The ionome of leaf samples was determined using inductively coupled plasma optical emission spectroscopy (ICP-OES) and compared with each other. These analyses showed that Leccino variety consistently contained higher manganese (Mn) levels compared with Ogliarola salentina, and these levels were higher in both infected asymptomatic and infected symptomatic leaves. Infected asymptomatic and infected symptomatic leaves within a host genotype also showed differences in the ionome, particularly a higher concentration of calcium (Ca) and Mn levels in the Leccino cultivar, and sodium (Na) in both varieties. We hypothesize that the ionome differences in the two varieties contribute to protection against disease caused by X. fastidiosa infection.Olive quick decline syndrome (OQDS) is a devastating disease of olive trees in the Salento region, Italy. This disease is caused by the bacterium  Xylella fastidiosa [Xylella fastidiosa is transmitted by xylem-feeding insects and causes well-known diseases such as Pierce’s disease (PD) of grapevine and citrus variegated chlorosis (CVC) of citrus. Additional host plants of economic and landscape relevance include almond, oleander, peach, coffee, oak, and blueberry [Vitis vinifera and Citrus reticulata to X. fastidiosa infection [X. fastidiosa strains revealed the absence of genes encoding Type III secretion system machinery, as well as the lack of apparent Type III secretion effectors, which are responsible for suppressing host plant defense responses [X. fastidiosa lives in xylem vessels, which are mainly composed of dead cells [Olive quick decline syndrome (OQDS) is a severe disease that was first reported in September 2013 in Salento, a region in the south of Apulia, Italy. The etiological agent of the disease is the bacterium lueberry . The prolueberry ,6. Diffenfection ,8,9. Genesponses . Moreovead cells . For thiX. fastidiosa, but show few or no symptoms of the disease. One example is Vitis rotundifolia (or Muscadine grape), native to the southeastern region of North America, that has evolved resistance to the disease. In this region, Pierce’s disease is so severe that it prevents the commercial cultivation of many cultivars of Vitis vinifera [Vitis girdiana as resistant, which means it can support up to one hundred times higher bacterial concentrations without disease development [Vitis arizonica, also from an area of high infection pressure, appears to be very resistant to X. fastidiosa [While some species show severe disease, other species growing in the same environment show tolerance, resistance, or even immunity to the pathogen . These hvinifera . Ruel anelopment . Additiostidiosa . HoweverOlea europaea (olive) “Leccino”, although infected, appear asymptomatic or show very mild symptoms when compared with the highly susceptible and prevalent variety “Ogliarola salentina”, which is severely damaged and succumbs to infection. In particular, the canopy of Ogliarola salentina trees affected by the disease shows progressive and complete dieback, while infected Leccino trees show a better vegetative growth with less aggressive and more sporadic desiccation around the canopy [X. fastidiosa subsp. pauca strain De Donno revealed that the pathogen triggers a differential response involving a re-modelling of cell wall proteins [Vitis species and varieties of citrus in which multiplication and translocation of X. fastidiosa is inhibited [The OQDS is characterized by initial leaf scorch and scattered desiccation of small branches that over time get worse and extend to the whole canopy . Neverthe canopy ,15. Tranproteins . An up-rproteins . These sproteins , are theproteins , similarnhibited ,17,18,19X. fastidiosa in vitro and during infection in planta. In previous studies, the analysis of the ionome of field-grown grapevines, blueberry, and pecan, and greenhouse-grown Nicotiana tabacum during X. fastidiosa infection have revealed significant changes between infected and uninfected plants, as well as between symptomatic and asymptomatic leaves, showing a complex interaction between different elements in the host [X. fastidiosa are modulated by mineral elements. Bivalent cations, such as calcium (Ca) and magnesium (Mg), play a structural role in cell–cell and cell–surface attachment in the host, by acting as a bridge between the negative charges of xylem vessels and the negative charges of bacterial cells [X. fastidiosa, like biofilm formation, adhesion, and twitching motility [X. fastidiosa cells from biofilm and planktonic states showed a different profile of mineral elements, with biofilm cells accumulating Ca, copper (Cu), potassium (K), Mg, and zinc (Zn), when compared with planktonic cells [Mineral and trace elements play a role in a myriad of cellular functions, acting as protein cofactors in many processes . Therefothe host ,28,29. Pal cells . Additiomotility ,32. In fic cells .Xylella-infected area in southern Italy, where we characterize the leaf ionome of two olive cultivars showing different disease responses to X. fastidiosa infection. Our working hypothesis was that the mineral profile of each cultivar plays a role in the success of the infection and/or in the development of symptoms. The very high levels of Xylella infections in the sampled fields make it unfeasible to obtain with absolute certainty uninfected control olives in these orchards. The study provides insights into some potential disease resistance mechanisms of the Leccino variety.Here, we describe an empirical field survey, carried out in privately owned olive groves located in the X. fastidiosa-infected , compared with Ogliarola salentina , compared with Ogliarola salentina   , Mn (43%), Na (30%), and Zn (39%) and lower levels of Fe (−47%) and P (−15%)  , comparel cases) , comparep < 0.001) in infected symptomatic leaves (p < 0.001) and Zn  levels were significantly higher    . In Fiell cases) .p-value < 0.001), status , and a significant interaction for field*variety  and field*status . In the case of Mn, we observed a significant effect for field , variety , status , and a significant interaction for field*variety , field*status , variety*status , and field*variety*status . For Na, significant effects were observed for variety , status , and significant interaction for field*variety , field*status , variety*status , and field*variety*status . These data support the idea that analyzing a control from a different uninfected field outside the outbreak area would not provide a useful comparison for this study, as field has an effect on two of the major elements that are different.The factorial univariate ANOVA analysis of the interaction between three individual elements, Ca, Mn, and Na, with the independent variables field, variety, and status  shows that for Ca, there is a significant effect for field  the difference should be statistically significant in Leccino relative to Ogliarola salentina in both fields, (2) the magnitude of the change should be in the same direction in both fields. Assessing levels by these criteria, the element that consistently changed was Mn, with a higher level in the Leccino relative to Ogliarola salentina. The other elements that are different in both fields are Fe and Zn; however, these elements are increased in one field and decreased in the other. The reason for this contrasting behavior between fields is unknown, but we speculate that it cannot be protective. The analysis of soil compared with leaf ionome suggests that the plants are tightly regulating the levels of these elements, as one field has higher available Mn, and the other has lower Mn levels, yet Leccino maintains higher concentrations of the element. Therefore, the only element that is associated with resistance and we can suggest is providing potential protection for Leccino is Mn. In addition, a recent study by Scortichini et al. , analyzialentina . On thisalentina  have sugismutase , oxalateismutase , and theismutase ,48,49. Pismutase , since iismutase , howeverNicotiana tabacum model [X. fastidiosa [Xylella fastidiosa-associated diseases are referred to as leaf scorch diseases, based on the common symptom of necrotic tissue at the margin of pathogen-infected leaves. A long-standing hypothesis states that leaf scorch is a consequence of obstructed water flow and the production of tyloses and gums by the host, that attempts to hinder the progress of the infection [X. fastidiosa are quantitatively and qualitatively different from that of water stress induced by reduced water availability, it has been shown both that the pathogen induces water stress and that external water stress conditions enhance the development of the disease [Atriplex halimus response to water stress [A. halimus is a xerohalophyte plant species able to cope with low external water potentials [Our previous studies have demonstrated that ionome remodeling occurs before the first symptoms of disease in the um model . The outstidiosa . Xylellanfection . Althoug disease ,53. Unde disease . Thus, ar stress . A. halitentials . It has tentials ,58. Soditentials , becausetentials . An incrX. fastidiosa, compared with non-infected, and this increase is even greater in the presence of symptoms [X. fastidiosa infection [X. fastidiosa infection show an increase in gene expression for Ca transporters in the infected plants, but not in response to water deficit alone [X. fastidiosa show upregulation of genes involved in Ca signaling [X. fastidiosa and wzy mutant, and RNAseq analysis showed an upregulation of genes related to Ca sensing and signaling, in the wild-type strain, that was absent in plants when infected with the wzy mutant, which is unable to cause disease [X. fastidiosa-induced Ca changes and this is activating a cascade that results in the development of disease symptoms.Studies on a tobacco model of infection and initial field studies in grapes, blueberries, and pecans showed that Ca is higher in samples infected by symptoms ,52. In fnfection , and Ca nfection . Data prnfection ,64. Ca infection , as the nfection . In addinfection . Given tnfection . Analyseit alone . Similarignaling . In addiignaling  explored disease . Interes disease . InitialX. fastidiosa infection. Since this is a newly established pathosystem, we lack details about host–pathogen interaction and the mechanisms of resistance to the pathogen. The analysis of the ionome reveals differences between the varieties. Although we did not analyze uninfected trees as they are not present in the fields sampled, we did observe that the Leccino variety has higher Mn levels, and this element regulates numerous pathways that could modulate disease symptoms. It is also notable that additional factors such as age of trees, severity of symptoms, and specific agronomical practices in the individual fields could be affecting the ionome composition. To mitigate these factors, the analysis was restricted to trees from within the same field, thus presumably subjected to the same agronomic practices, and we did not compare with uninfected controls from different regions that would be subject to even more of these confounding factors. This information provides a framework for using the ionome to gain insight into varieties that can be grown that are resistant to disease, using the elemental composition of the plant and perhaps by modulating of the soil characteristics to help slow the progression of this disease. The ionome characterization showed changes with the progression of the symptoms. In particular, the changes in Ca levels in the Leccino show that the previous observed response in tobacco, grapes, pecans, and blueberries is conserved in this pathosystem.This study of two varieties in the field extends our knowledge about the differential response to X. fastidiosa-infected  using the protocol previously described by Harper et al. [® Fast Advanced Master Mix  on a CXF 96™ Real-Time System . Reactions were performed using 100 ng/μL total DNA. Ten biological replicates for each cultivar in Field 1 and four biological replicates for each cultivar in Field 2. A pool of ten leaf petioles representing ten portions of the plant, five infected symptomatic and five infected asymptomatic, was used for bacterial detection and quantification in each plant. Each sample was run in duplicate, and the data were averaged.Extraction of total DNA from olive samples was performed according to the cetyltrimethylammonium bromide (CTAB) protocol reported by Loconsole et al. (2014), using leaf petioles from the same infected asymptomatic and infected symptomatic tissues used for ionome determination. The presence of r et al. , with TaX. fastidiosa DNA. Ten-fold serial dilutions of an inactivated bacterial suspension with an initial OD600 of 0.5, corresponding to ca. 108 CFU/mL, were prepared to obtain dilutions ranging from 107 to 101 CFU/mL. Each dilution was spiked in homogenized plant tissues of a not Xf–infected olive prior to DNA extraction. Bacterial concentration from Leccino and Ogliarola salentina samples was inferred by the standard calibration curve using Cqs from qPCR.To estimate the bacterial population within the tissues, we established a standard curve using known concentrations of g to remove any particulates, samples were analyzed by inductively coupled plasma with optical emission spectroscopy  with simultaneous measurement of Ca, Cu, iron (Fe), potassium (K), Mg, manganese (Mn), sodium (Na), sulfur (S), phosphorus (P), and Zn. Minerals and trace element concentrations were determined by comparing emission intensities to a standard curve created by certified standards .Characterization of ionome of olive leaves was done as previously described , with so2 > 0.95 (data not shown). When combining data from multiple varieties, R2 varied from 0.71 to 0.95 (data not shown). The higher the R2, the more the element remains unchanged in variety and field. On this basis, the most reliable elements for detection, with an R2 greater than 0.95, were P and K. Data were normalized based on these internal denominators (P and K concentration) and converted to dry weight based on the linear regression equation .To assess the ionome of the two varieties, an analysis of five samples randomly selected from the two fields were used to identify a mineral element that could be used as an internal denominator for data normalization. Variable dry weights  were analyzed and showed a linear response in total elements measured with correlation for individual samples of R2) solution at pH 8.2, was determined by flame atomic absorption spectroscopy . Soluble boron (B) was extracted by treating samples with a dilute aqueous solution of calcium chloride (CaCl2) (ratio 2:1). The content of the element was determined by spectrophotometry using the azomethine-H method. The active limestone content was determined by cold reaction with ammonium oxalate and titration with potassium permanganate (KMnO4).Topsoil samples, 10–15 cm in depth, were randomly collected from four spots at each field used for our survey. Spots were chosen as pair replicates, sampled in the areas occupied by trees of each of the two olive varieties. To homogenize and remove plant debris and stones, the soil was first mixed and sieved through a 2 mm mesh. The determination of standard chemical and physical properties was conducted according to the accredited Italian soil study methods. Total nitrogen content was determined by mineralization and distillation procedure according to the Kjeldahl method . The con2 solution at pH 8.2 and complexometric titration with triethanolamine. Organic carbon was determined by oxidation with potassium dichromate (K2Cr2O7), in the presence of sulphuric acid (H2SO4), and titration with iron (II) sulphate heptahydrate, according to Walkley–Black method. Assimilable metals, that is, Fe, Mn, Cu, and Zn, were extracted with a solution of diethylenetriaminepentaacetic acid/CaCl2/triethanolamine at pH 7.3, following the procedure described by Lindsay and Norwell [w/v).Cation exchange capacity (CEC) was measured with a buffered BaCl Norwell . Assimil® 2016 for Windows software . Individual mineral and trace element concentrations in each variety and field were analyzed by pairwise comparisons using the two-tailed Student’s t-test. Statistical significance was accepted for p-values < 0.05. A comparison of the ionome of the cultivars in the same field was investigated to identify possible phenotypic markers that affect the susceptibility of the individual varieties, using principal component analysis. Heat maps, and hierarchical analysis were generated using CLUSTVIS web tool [p-values < 0.05.Statistical analysis was performed with the analysis toolpack of Microsoft Office Excelweb tool , using u


Williams syndrome (WS) is a clinical condition, involving cognitive deficits and an uneven language profile, which has been the object of intense inquiry over the last decades. Although WS results from the hemideletion of around two dozen genes in chromosome 7, no gene has yet been probed to account for, or contribute significantly to, the language problems exhibited by the affected people. In this paper we have relied on gene expression profiles in the peripheral blood of WS patients obtained by microarray analysis and show that several robust candidates for language disorders and/or for language evolution in the species, all of them located outside the hemideleted region, are up- or downregulated in the blood of subjects with WS. Most of these genes play a role in the development and function of brain areas involved in language processing, which exhibit structural and functional anomalies in people with this condition. Overall, these genes emerge as robust candidates for language dysfunction in WS. GTF2I, BAZ1B, and LIMK1. In particular, GTF2I, which encodes a regulator of transcription, has been repeatedly related to the behavioral and cognitive disabilities that are typically found in this condition and that have an impact on language function  is a clinical condition resulting from a hemizygous deletion of 1.5 to 1.8 Mb on 7q11.23, which encompasses nearly 30 genes . The afffunction . Its adjfeatures . Interesntiation . Regardim memory , and itsm memory . Still, m memory . RecentlIn this paper we have conducted a more focused research on the potential dysregulation of genes related to language outside the WS region as a possible explanation of the distinctive language profile of the affected people. Similarly to language- readiness). Overall, the genes comprising this second subset fulfill several criteria. First, they have changed (and/or interact with genes that have changed) after our split from Neanderthals/Denisovans, including changes in their coding regions and/or their epigenetic profile. Second, they play some known role in brain development, regionalization, wiring, and/or function. Third, they are candidates for language dysfunction in broad cognitive disorders, particularly, autism spectrum disorder (ASD) and schizophrenia (SZ)  development and language evolution  encompasnormal deThe gene expression profiling data of peripheral blood were obtained from our previous study , availabp = 1.1e-7 by Fisher’s exact test). We found that candidates for language  development and language evolution are significantly dysregulated in the blood of subjects with WS  and/or for SLI . As other members of the Dock family, DOCK4 regulates cytoskeleton assembly and cell adhesion and migration (Dock4 in mice abolishes commissural axon attraction by Shh (ZNF385D to the co-occurrence of reading disability and language impairment (CEP63 is required for normal spindle assembly, being involved in maintaining centriole number and establishing the order of events in centriole formation (NFXL1, which is predicted to encode a transcription factor, confer a risk for SLI (Nearly one third of the language-related genes found downregulated in the blood of subjects with WS are candidates for DD (igration . Specifiigration , via intigration . Knockdon by Shh . The genn by Shh , althougn by Shh  and SZ (n by Shh . GWAs hapairment , but alspairment . CEP63 iormation . Besidesormation , the genormation , a featuormation . Finally for SLI . The gen for SLI .DUSP1 is involved in vocal learning in songbirds (PVALB encodes a calcium-binding protein that is structurally and functionally similar to calmodulin and that is involved in hippocampal plasticity, learning and memory (PVALB expression in interneurons has also been found in mouse models of ASD (CNTNAP2 is a direct target of FOXP2, the renowned “language gene” (PLAUR have significantly fewer neocortical parvalbumin-containing GABAergic interneurons, with this reduction correlating with impaired social interactions (PLAUR is a target of FOXP2 too (ITGB4 encodes the integrin beta 4 subunit, a receptor for the laminins, including FLNA (CMIP (Regarding the candidates for language evolution that we have found downregulated in the blood of subjects with WS, ongbirds , 2012. Pd memory . Interesd memory . Inhibitd memory . Importad memory , which as of ASD , specifis of ASD . CNTNAP2ge gene” , and regge gene” . Also miractions . PLAUR iOXP2 too , but alsOXP2 too  and a caOXP2 too . ConcernOXP2 too . Finallying FLNA , an actiing FLNA  FLNA binNA (CMIP , a candiNA (CMIP . InteresNA (CMIP .SETBP1, as well as FGFR1 and SIX3. SETBP1 is also a candidate for Schinzel-Giedion syndrome, a clinical condition entailing occasional epilepsy and severe developmental delay (SIX3 contributes to regulate the relative size of the telencephalon versus the thalamus (Lastly, among the genes found to be upregulated in the blood on WS subjects, we found the SLI candidate al delay . Mutatioal delay . The Intal delay . Finallythalamus . Interesthalamus , one robthalamus , but it thalamus .1 all these genes are expressed in the brain, particularly in the thalamus and the cerebellum (The results of our functional enrichment analyses  show tharebellum . The tharebellum  and chanrebellum . People rebellum . In the rebellum , as wellrebellum .To conclude, it is true that deciphering the exact molecular causes of language dysfunction in WS is still pending, particularly, because at present none of the genes hemideleted in this condition has been demonstrated to play a central role in language processing. Nonetheless, in this paper we have shown that the genes that are dysregulated in subjects with WS are significantly enriched in core candidates for language disorders and language evolution. These genes emerge as robust candidates for language dysfunction in WS. Future research should try to delve into the expression patterns of these genes in the brain of people with WS, as well as into their role in neurotypical brain development. Likewise, altering these genes in animal models of WS should help gaining a better understanding of their biological role and ultimately, of their contribution to language dysfunction in WS.https://www.ncbi.nlm.nih.gov/geo/query/acc.cgi?acc=GSE89594.Publicly available datasets were analyzed in this study. This data can be found here: AB-B conceived and wrote the manuscript. RK conducted the expression studies and analyzed the data. Both authors contributed to manuscript revision, and read and approved the submitted version.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.


There is an increasing interest in the effect of nonpharmacological interventions on the course of patients with Alzheimer's disease (AD). The objective of the present study is to determine the benefits of a structured, multidomain, mostly computer-based, cognitive training (MCT) οn the cognitive performance of patients with early-stage AD. n = 25) or to a wait list control group (n = 25). The training program group received computer-assisted MCT and linguistic exercises utilizing pen and paper supplemented by cognitive-linguistic exercises for homework. The duration of the MCT intervention program was 15 weeks, and it was administered twice a week. Each session lasted for approximately one hour. Objective measures of episodic memory, delayed memory, word recognition, attention, executive function, processing speed, semantic fluency, and naming were assessed at baseline and after the completion of the program in both groups.  Fifty patients with early-stage AD participated in the study. Patients were randomly allocated either to the training program group , semantic fluency (SF), clock-drawing test (CDT), digit span forward (DSF), digit span backward (DSB), trail-making test A (TMT A), and trail-making test B (TMT B). Comparison between the training group and the controls showed that MCT had a significant beneficial effect in delayed memory, naming, semantic fluency, visuospatial ability, executive functions, attention, and processing speed.  The study provides evidence of a beneficial effect of MCT with an emphasis on cognitive-language performance of patients with early-stage AD. Considering the limited efficacy of current pharmacological therapies in AD, concurrent computer-based MCT may represent an additional enhancing treatment option in early-stage AD patients. Alzheimer's disease (AD) is a slowly progressive neurodegenerative disorder, affecting memory, executive function, visuospatial skills, and language –4. DepenA number of nonpharmacological approaches, aiming at brain neuroplasticity, such as cognitive training , 12, cogAccording to systematic literature review , cognitiLimited evidences of positive effects of various cognitive-improving techniques on cognitive functions, however, have been reported , 17. MorAnother issue under consideration, though, is that most of the cognitive-training programs depend on the therapist and many sessions are required. As such, they might not be ideal when it comes to patient comfort. For this reason, more recent studies suggest the use of computer training as opposed to traditional training with the use of paper and pencil . In partOn the other hand, Man et al. investigated the effectiveness of a computer-based memory-training program versus the same program administered by paper and pencil, in people with questionable dementia . The resTaking the aforementioned into consideration, in the present study, we used a multidomain cognitive training (MCT) with an emphasis on language. We believe that such a training has many advantages: (a) it focuses on both cognitive functions and language skills; (b) it is user-friendly to patients with AD, as the computer is connected to a special input panel using the commercially available RehaCom software package; (c) the cognitive performance of the patient can be assessed even after each session; (d) the level of difficulty of the tasks does not depend on the therapist; (e) it adapts to the needs of each patient; and (f) it provides an objective measurement of the patient's performance, limiting the possibility of a performance under/overestimation.In particular, in the present study, we were interested in the beneficial influence of MCT on the neuropsychological performance of patients with early-stage AD, by using a computerized program that would focus on several cognitive domains simultaneously, accompanied by language exercises with pen and paper, which concentrate mainly on language deficits. The study is based on the primary hypothesis that patients who are receiving the 15-week computer-assisted cognitive-linguistic training intervention with an emphasis on alleviation of episodic memory, information processing speed, executive functions, attention, confrontation naming, semantic fluency, and syntax would show improved performance on standardized neuropsychological and linguistic measures compared to the control group which will attend the standard clinical care. Our secondary hypothesis was that the beneficial effects would translate to improved activities of daily living and functional communication.Participants were included in the study if they fulfilled the following criteria: (1) a diagnosis of AD according to the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's and Related Disorders Association (NINCDS-ADRDA), (2) mild (early-stage) AD  and language abilities , the following were used: (a) Montreal Cognitive Assessment ; (b) trPatients were randomly assigned  to eitheFurthermore, special prominence was given to the improvement of patients' language skills, and therefore, the second part of the MCT included language exercises with pen and paper. Since there is no software package available in Greek for language skills, we collaborated with a linguist for the creation of a structured language intervention. The language intervention contained exercises of morphology, syntax, semantics, naming, verbal fluency, and word recall with a progressive increase in difficulty in each category. Patients moved at different levels and achieved mastery at their own pace, while the language therapist, throughout the whole program, was taking into consideration each patient's individual needs. Each participant was given extra cognitive and language tasks for practice at home, in a weekly basis, in order to give them the opportunity to work on their own and to get a clearer view of their skills and their difficulties. Both groups were evaluated within one week of completing the MCT.The research protocol was approved by the Ethics Committee of the Medical School of Larissa, University of Thessaly, and it was conducted in accordance with the principles of the Declaration of Helsinki. Written consent was obtained from all the participants of the present study (or their caregivers) after having been informed of the nature of the study they would take part in.U test in the case of scale variables. To evaluate the cognitive performance progress in each group separately over the period of 15 weeks, we compared the paired mean difference of the two assessments (baseline versus endpoint) in each group, using the paired sample t-test in case of normal distribution and Wilcoxon signed-rank test in case of nonnormal. The effect of the intervention was estimated by comparing the mean difference of the two assessments (baseline minus endpoint in each group) between the two groups (training group versus controls). ANOVA was applied in case of normal distribution. Otherwise, the Mann–Whitney U test was used. Cohen's d and the effect size of the intervention were calculated according to the site https://www.uccs.edu/lbecker/. The level of significance was set at 0.05 for all the analyses. All statistical calculations were performed using the SPSS for Windows (version 21) statistical software .Baseline group characteristics are presented as mean, standard deviations, and absolute and proportion values. Normality was assessed using Kolmogorov-Smirnov graphs. Differences between the intervention and control groups at baseline assessments were estimated via the use of Pearson's chi-square and Fisher's exact test in the case of nominal variables and with Mann–Whitney n = 25) or to be placed in the control group condition  to receive usual standard clinical care.From December of 2016 until July of 2017, a total of 106 mild AD patients attending the Clinical Laboratory of Speech and Language Therapy of the Technological Educational Institute of Epirus were screened for participation in the study. However, 56 patients were excluded for specific reasons , and theThe first two groups received the MCT from February 1 to April 15, 2017, and the other three groups received MCT with emphasis on linguistics from August 1 to November 15, 2017. All of the groups were then evaluated one week after the completion of the MCT with emphasis on linguistics (posttreatment).Demographic and clinical characteristics of both groups at baseline are presented in p = 0.0085) and TMT A (p = 0.001), which deteriorated (p ≤ 0.001), recognition (p = 0.0284), clock-drawing test (p = 0.01), digit forward test (p ≤ 0.001), digit backward test (p = 0.001), TMT A (p ≤ 0.001), and TMT B (p = 0.017). Although they generally improved, the endpoint performance of the training group in word learning (p = 0.15) had not significantly improved  in each group showed that the control group remained stable over the observation period of 15 weeks in most of the neuropsychological tests, except for delayed memory (riorated . On the improved .p ≤ 0.001), BNT (p ≤ 0.001), delayed memory (p ≤ 0.001), word recognition (p = 0.008), TMT A (p ≤ 0.001), TMT B (p = 0.003), DSF (p ≤ 0.001), CDT (p ≤ 0.001), and DSB (p = 0.004), while no significant difference was noted for the recall of the study (Comparison between the two groups (training group versus controls) in the mean difference of the two neuropsychological assessments (baseline minus endpoint in each group) presented a significant effect of the intervention on the SF (he study . The absThe present study provides preliminary evidence that MCT improves cognition and language functions in general. Specifically, our results showed that MCT had a significant impact on delayed memory, visuospatial abilities, and executive functions. Considering the limited pharmacological therapies available for AD, concurrent computer-based MCT may represent an additional, personalized tool for the management of AD patients.The results of the present study confirmed our first hypothesis, since all cognitive domains were improved after the computer-assisted cognitive-language-training intervention program and patients who underwent the MCT had better performance than the control group. Furthermore, our secondary hypothesis was supported. The training group had verbal positive feedback on daily activities and functional communication.Our results are similar to those of previous studies that reported notable improvement in delayed memory , visuospOur results hint towards the considerable efficacy of MCT in naming, semantic fluency, and attention/processing speed in the training group. Moreover, a mild improvement at recall and recognition was also observed, without reaching the statistical significance threshold however. To the best of our knowledge, the effect of cognitive training in these specific domains had not been previously investigated.AD destroys neurons and their connections in parts of the brain involved in memory. Later on, it affects cerebral areas responsible for language, reasoning, and social behavior. Eventually, many other areas of the brain are also damaged –43. SincTo sum up, our study revealed a significant effect of MCT in almost every neuropsychological test. The existing cognitive training , 20–22 hε4 status, along with other environmental factors that may affect the neuropsychological performance of AD patients [Certain limitations of the present study need to be acknowledged. Firstly, our study had a relatively short follow-up period. Thus, a longer follow-up period would give more robust and accurate results . Moreovepatients , 46. Morpatients . In addiThis study showcases the beneficial impact of MCT with emphasis on linguistics and cognitive performance on patients with early-stage AD. Considering the limited efficacy of the current pharmacological therapies in AD and the limited impact of other cognitive trainings as well, computer-based MCT may represent an additional enhancing approach in early-stage AD patients. Moreover, this data is promising, in view of developing training methods to delay cognitive and language decline in early-stage AD patients. Further studies applied in larger cohorts with a priori sample size calculation are of great necessity in order to properly elucidate the effect of MCT in the progress of these patients. Emphasis should be placed on different MCI subgroups and the efficacy of multidomain cognitive MCT in linguistic deficits. If a suggestion may be done, future studies should also take aim at cognitive and language deficits when patients are diagnosed with MCI before it progresses to early-stage Alzheimer's disease, so as to properly investigate whether MCT helps in preventing AD.


Positive attitude is an important cognitive component of optimism. Although optimism has been widely studied in adolescents’ health, there is limited knowledge about social and behavioral determinants of their positive attitude. The aim of this study was to identify the main predictors of a positive attitude towards life and self in adolescence. Data were collected in 2010 from 2562 Polish adolescents, aged 15 to 17 years old, within the Health Behavior in School-Aged Children survey. A positive attitude was measured using the 4-item Positive Attitude Scale (PAS). Univariate analysis of variance was conducted and then hierarchical linear regression models adjusted for gender, age and family affluence were estimated. The mean PAS score was 13.25 (SD = 3.74), on the scale ranged 0–20. Eight out of 18 variables were included in the final model, which explained 25.1% of PAS variability. Communication in the family and with peers, as well as neighborhood social capital showed the strongest impact on positive attitude in adolescents. Physical activity, eating breakfast and school performance were also found to be important predictors. The results of the study highlight the need to include the development of interpersonal competences, promoting physical activity and supporting school performance, in adolescents’ mental health promotion programs, particularly in girls. Adolescence is an exceptionally plastic period of life, in which personality traits and interaction with family, peers and the community are considered as significant aspects of development. Studies of adolescent health and well-being pay high attention to positive development and the enhancement of individual traits and home, school and community environments ,2. TheseIn regard to school performance, the literature review by Suldo et al.  showed aRegarding the above-mentioned studies describing the relationship between social relations, health behaviors, school performance, and adolescents’ optimism, it seems to be important to incorporate an analysis of social and behavioral determinants of a positive attitude, which contribute to the development of dispositional optimism. We assume that communication in the family, relations with peers, neighborhood social capital, health-enhancing, and health risk behaviors, academic achievements and school-related stress influence adolescents’ positive attitude. However, we should consider the reverse associations, which were proven in the above-mentioned studies ,22,23,25Are there significant relationships between health behaviors with adolescents’ positive attitudes towards themselves and their life?Do these associations persist, considering the influence of social factors and school performance?Which of the health-related behaviors impact adolescents’ positive attitude?Are positive associations with selected factors gender specific?We sought answers to the following questions:The presented study is based on data from the Health Behavior in School-Aged Children survey, the World Health Organization Regional Office for Europe collaborative cross-national survey (HBSC) conducted in 2010 in Poland. The sample selection and organization of the school-based survey was done according to the international research protocol . In PolaThe presented study is based on data from the Health Behavior in School-Aged Children survey, the World Health Organization Regional Office for Europe collaborative cross-national survey (HBSC) conducted in 2010 in Poland. The sample selection and organization of the school-based survey was done according to the international research protocol . In PolaThe Positive Attitude Scale (PAS), developed by Mazur et al.  on the b-I am proud of my achievements.-I always find a reason to be happy.-My belief in myself gets me through difficult times in my life.-My life has meaning.The following positively worded items are included in the PAS:The respondents were asked to assess whether the given statement describes them accurately or not, using six categories of responses, without a neutral category, from 0—it describes me very inaccurately—to 5—it describes me very well. Based on these four questions, a crude (0–20) and a standardized z-score index were developed . The first one was used in descriptive analyses, while the second one in the regression model. Higher scores are interpreted as a positive result. Missing values constituted 1.4% and were replaced by the conditional mean estimated for individuals who responded identically to the remaining PAS questions. In the study sample, the positive psychometric properties of the PAS were confirmed. The reliability of the PAS, evaluated using Cronbach’s alpha, was 0.815.A total of 17 potential positive attitude predictors, grouped into categories, were analyzed: sociodemographic variables, health-related behaviors, school performance, and social relations. The characteristics of the sample in terms of these variables is shown in Family affluence was measured using the Family Affluence Scale (FAS), which included four questions about the number of computers and cars in the family, the student’s own room, and holiday trips with the family outside the place of residence in the preceding year. The FAS is treated as a quasi-continuous scale (0–7 points); it is a standard tool in the HBSC survey, used in analyzing social inequalities in health .It was assumed that the student’s functioning at school was related to the performance of developmental tasks, and it is generally a source of stress. A single question on school achievements was included (0—below average—to 3 – very good) along with the scale of perceived school-related stress. The students used a five-point scale to identify how much they agree with four statements, e.g., I find studying difficult (0—strongly disagree—to 4—strongly agree). The reliability of that scale was good in the examined sample .Social relations were examined based on two communication scales relating to family and peers and the assessment of the social capital of the neighborhood. The scale of clarity of family communication derives from a larger research tool: Family Dynamics Measure II (FDM II) by Barnhill . The resAmong health-related behaviors, selected health-risk and pro-health behaviors were identified. Physical activity was examined using the MVPA  indicator taken from Prochaska’s screening test . It indiAmong eating habits, breakfast regularity and consumption of fruits and vegetables, as well as not recommended food items (sweets and sweetened beverages) were identified. Eating habits as variables were re-coded to 0–1 variable, where “1” indicated having breakfast every day, consuming fruits and vegetables every day, eating sweets and drinking sweetened beverages no more than once a week.Assessment of health risk behaviors in the preceding 30 days included questions about tobacco smoking, alcohol consumption, getting drunk, and marijuana smoking. These questions were adapted for the HBSC protocol from the questionnaire of the European School Survey Project on Alcohol and Other Drugs . The resThe first step consisted of comparing crude mean PAS indexes in sub-groups of adolescents’ gender, age, and family affluence. The significance of differences between various sub-samples was examined with ANOVA. For the purposes of mean PAS index comparisons, continuous scales representing independent variables were categorized into three levels, and the average level was set based on about 50% of average cases. The calculation of correlations of variables among continuous scales was also part of the simple univariate analysis. The second step included an estimation of three linear regression models, in which the standardized PAS index was the dependent variable.2 determination coefficient were calculated to check how close the data were to the fitted regression equation. The statistical software IBM SPSS Statistics for Windows, v. 21.0.  was used for analysis.To explore the potential impact of behavioral factors adjusted for socio-demographic factors in subsequent models (steps), it was checked whether there is any more important predictor than behavioral and whether health behaviors remain significant. The factors were entered into the model in the following order: (1) the impact of health-related behaviors adjusted for demographic and socioeconomic variables, (2) school performance variables, (3) social relations variables. The general model was compared with models created for boys and girls. Standardized beta regression coefficients and the Rp < 0.001). The mean PAS index was 13.36 (SD = 3.79) for 15-year-olds and 13.12 (SD = 3.67) for 17-year-olds (p = 0.073). Family affluence measured using the FAS correlated  with the PAS; r = 0.077 (p < 0.001). The correlations between the variables are shown in The raw PAS index had a range of 0–20 points. The mean score was 13.25 (SD = 3.74), which accounts for 66.3% of the maximum score. The mean score was 13.55 (SD = 3.62) for boys and 12.98 (SD = 3.81) for girls , and academic achievements were positively correlated (r = 0.278). Social relations variables were correlated with the PAS. Communication in the family at a high level was positively correlated (r = 0.366). For relation with peers, the correlation coefficient was r = 0.194, and the correlation coefficient for the social capital of the neighborhood was relatively high too (r = 0.232). The results of correlations also provided an opportunity to analyze the relationship between the positive attitude predictors. For example, attention was drawn to the relationship between school achievements and psychoactive substance use. Pearson’s correlation coefficients were significantly negative: tobacco smoking r = −0.250, alcohol consumption r = −0.205, being drunk r = −0.188, and cannabis use r = −0.135. Socio-demographic factors such as age, gender and FAS correlated with some other independent variable and were considered as confounders. Boys reported a significantly higher PAS score than girls, while the relationship with age and FAS was close to being significant (p = 0.07). It was concluded that the assumption for confounding was met.The school performance factors included academic achievements and school stress. Social factors consisted of communication in the family and with peers and social capital in the neighborhood. Significant associations were noted in both genders . School 2 = 0.128). After they were added, differences between boys and girls became apparent. The influence of physical activity and eating habits remained significant, though standardized regression coefficients were reduced. Given that the associations with substance abuse are not significant and that academic achievements and substance use were strongly correlated, it may be that the impact of risk behaviors on a positive attitude may be indirect. The relationship between alcohol drinking and the PAS level was close to the significance threshold (p = 0.053); after the additional explanatory variables had been added, it became insignificant.The first simple model with sociodemographic variables, health-related behaviors, and substance use explains only 5.7% of the PAS variability. It indicates a stronger influence of pro-healthy behaviors than harmful ones. Two variables referring to school performance significantly enhanced the quality of the adjustment of the second model (Rr = 0.172). Neighborhood social capital remained in the final model, despite the correlation with communication in the family (r = 0.252). Correlations are shown in The final model, encompassing communication in the family, relations with peers, and the neighborhood social capital, explains 25.1% of the PAS variability. Following the introduction of the new variables, the impact on family affluence loses its predictive power. However, it should be pointed out that the quality of communication in family correlated with family affluence , which is a 4-item scale, was applied. Similar attempts to develop positive thinking skills scales were undertaken by other researchers .Our study showed that a moderate level of the possitive attitude was reported by Polish adolescents in the age group of 15–17 years. The mean score was 13.25 (SD = 3.74), which accounts for 66.3% of the maximum PAS score in a range of 0–20 points.A positive attitude was associated with pro-health behaviors, mainly physical activity and eating breakfast while avoiding psychoactive substance use was not significant. Social factors such as communication in the family, relations with peers, and neighborhood social capital had an important role too. Moreover, good academic achievements and controlled levels of school stress were related to adolescents’ positive attitude.With regard to social factors, communication in the family and relations with peers as well as the social capital of the neighborhood appeared to be strong predictors of a positive attitude. The extent of the contribution of these factors was different in boys and girls. The findings of the current study are in line with previous studies that demonstrated that positive self-concept, low depressive symptoms, and high perceived parental support and school connectedness were most strongly associated with adolescents’ optimism . In addiComplex analysis of the influence of neighborhood environment on mental health with regard to optimism has been shown by Ruiz et al. . They haSchool performance also had a strong influence on adolescents’ positive attitude. With regard to the four questions contained in the PAS, it may be noted that two of them referred to achievements and to coping skills of an individual . The scale may be considered to measure satisfaction with performing developmental tasks, which are appropriate for the respondents’ age, such as school performance. The results showed a strong correlation between the self-assessment of school achievements and positive attitude. Adolescents who assessed their academic achievements higher had better results on the PAS, which leads one to believe that satisfaction with school performance is a starting point for positive self-perception of individual psychological resources. Such positive effects were shown in another study by Vanno et al. . School-In the model describing adolescents’ positive attitude determinants, the influence of health risk behaviors was much weaker compared to health-enhancing behaviors. However, in a simple analysis of means of substance use, higher PAS indexes were obtained in those who practiced abstinence. In the multivariate analysis, alcohol abstinence remained in the group of independent predictors of positive attitude only in girls. However, attention should be drawn to the clear negative correlations between school achievements and psychoactive substance use, which is in line with the results of other studies . The finAmong pro-health behaviors, physical activity was one of the stronger factors enhancing adolescents’ positive attitude. In a monograph on the psychology of physical activity, Biddle and Mutrie  quoted tThe recent HBSC survey conducted in 2017/18 in Polish adolescents show the complex relationships between behavioral and social factors and their impact on the variability of psychological well-being among adolescents . PhysicaThe limitations of this study come from the cross-sectional nature of this research, which does not allow causal factors to be identified. The same factors that have been identified as determinants of adolescents’ positive attitude could be stronger in optimistic people. Therefore, we should consider the reverse associations, which were proven in other studies ,20,23,25Adolescent optimism is associated with a wide variety of well-being and positive health outcomes, including mental and physical health, motivation to health-related lifestyle change, perception of social support, and school performance. Positive attitude towards life and self, in general, is an important cognitive component of optimism. Knowledge about the relationship between positive attitude and health behaviors, such as physical activity, social relations with family, peers, and neighbors, and school performance should be taken into consideration while designing health promotion programs for adolescents. Optimism is an important individual trait related to young people’s health and well-being, and a positive attitude, as its cognitive component, may be modified and developed in adolescence. Physical activity is an important factor influencing a positive attitude, along with positive social relations with family, peers, and neighbors, and school achievements. Based on the findings of this study, the increase in adolescents’ positive attitude could be expected after combining initiatives to promote physical activity and interpersonal communication competences development in pupils’ friendly school and supportive neighborhood environments.