P < 0.001). The incidence of first-ever stroke was lower by 64.18% in 2020 than in the previous 5 years (P = 0.002) and by 65.42% in 2020 than in the previous 10 years (P = 0.001). Mortality from first-ever stroke in 2020 was not significantly different from that in 2019, but it was noticeably lower than that for the previous 5 and 10 years. However, rates of hospitalization and diagnosis by neuroimaging remained stable across the study period. These findings suggest that the home quarantine helped reduce outdoor activities at low temperatures, restrict gatherings, reduce alcoholism and high-fat diet, and lower pollution caused by factories. These changes were advantageous for helping high-risk groups to reduce the burden of stroke.This study aimed to explore trends in the burden from stroke associated with home quarantine during the COVID-19 pandemic. Patients with a first-ever stroke registered between January 1 and April 20 from 2010 to 2020 were included in this study. We compared the incidence and the rates of mortality, hospitalization, and diagnosis by neuroimaging for first-ever stroke among a low-income population in rural China during the study periods. Overall, 377 first-ever stroke patients were analyzed in this study period; men accounted for 59.2%. Compared with 2019, the incidence of first-ever stroke was 73.5% lower in 2020 ( The World Health Organization officially classified the novel COVID-19 outbreak as a global pandemic on March 11, 2020. As of April 22, 2020, the cumulative number of affected patients worldwide was more than 2.3 million. Not only has COVID-19 had a serious impact on health and the economy worldwide, but it has also brought about major changes in people's lives. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is extremely contagious. Over the last several months, governments across the world have issued self-isolation orders as a result of the COVID-19 outbreak. In China, the government issued a rule on January 23, 2020 to seal off the city of Wuhan, with a subsequent nationwide compulsory isolation order. These actions played an impressive role in blocking the spread of SARS-CoV-2.Some studies have reported that patients with existing cardiovascular diseases may be at greater risk of developing severe COVID-19 . An ItalThe study population came from the Tianjin Brain Study , 5, whicSince January 23, 2020, strict measures for controlling the COVID-19 epidemic have been enforced and strengthened after the lock-down strategy implemented in Wuhan, China . On JanuTianjin is one of four municipalities in China, which includes 15 administrative districts. Overall, 136 patients were diagnosed with SARS-CoV-2 infections from 13 administrative districts in Tianjin during the study period. However, Jizhou District is one of two districts with zero infection cases of SARS-CoV-2 in Tianjin.The research protocol was approved by Tianjin Medical University General Hospital Ethics Committee, and all patients provided written informed consent.Information on stroke patients was collected by the stroke surveillance network, which has been described previously . BrieflyInformation was obtained by questionnaire about patients' age and education. Data regarding stroke subtypes, whether a diagnosis was made using computed tomography, and whether patients were hospitalized were collected within 24 h after patient admission was obtained by related medical records. In this study, patients were divided into three age groups: <45, 45–64, and ≥65 years. Education levels used years as the unit of measurement. Patients were divided into three education level groups: 0, 1–6, and ≥7 years.First-ever stroke was defined as the first occurrence  of a rapidly developed focal  disorder of cerebral function of vascular origin that lasted more than 24 h .Stroke was categorized into three subtypes: hemorrhagic stroke, ischemic stroke (IS), and uncategorized stroke. Hemorrhagic stroke was defined as an intracerebral hemorrhage (ICH) or subarachnoid hemorrhage. IS was defined as a thrombotic brain infarction due to temporary or permanent occlusion of a feeding artery or of venous thrombosis. Uncategorized stroke was defined when patients' strokes could not be categorized as hemorrhagic stroke or IS or when there was a lack of evidence of neuroimaging. Patients with transient ischemic attacks, subarachnoid hemorrhage, and silent stroke, a kind of stroke detected only by imaging, were excluded in this study. Stroke was diagnosed by a professional neurologist based on typical clinical symptoms combined with imaging findings. Patients without neuroimaging in this study were diagnosed as having full clinical strokes with significant clinical symptoms and signs. For this study, all-cause mortality of stroke patients was used for mortality data.t-tests and presented as means and standard deviations. Categorical variables are presented as frequencies and 95% confidence intervals (CIs); differences between groups were compared using chi-squared tests. All participants were categorized into three age groups  and three education groups based on the number of years of formal education . The incidence of first-ever stroke events every year from 2010 to 2020 were calculated separately using the corresponding person-years. The age-standardized incidences were calculated with the direct method using the world standard population by 10 age groups: <35, 35–39, 40–44, 45–49, 50–54, 55–59, 60–64, 65–69, 70–74, and ≥75 years  between January 1 and April 20 were also included in this study. Continuous variables, including age and education level, were analyzed with Student's 75 years .P < 0.05. SPSS version 19.0 for Windows  was used for analyses.Changes in rates were calculated as follows: (rate in 2020—rate in reference years)/rate of reference years, and results are expressed as percentages. Differences in the incidence and rates of mortality, hospitalization, and diagnosis by neuroimaging between 2010 and 2020 were analyzed using the chi-squared test. Statistical significance was defined as n = 223) of subjects. The average age was 65.7 years old overall (65.21 years for men and 66.42 years for women). The mean education level was 4.32 years (4.92 years for men and 3.44 years for women). There were 309 cases of IS (accounting for 82.0% of cases) and 62 cases of ICH (accounting for 16.4% of cases). Of these cases, 86.5% of patients were diagnosed by neuroimaging, but the rate of hospitalization was only 43%  and the previous 10 years (2010–2019), all P < 0.05. The overall incidence of first-ever stroke was significantly lower in 2020 than in the previous 5 years  and in the previous 10 years . These decreases were observed in both men  and women , but there was a greater difference observed for women. Moreover, the decreasing tendency was observed among those patients aged 45 years and over and with ischemic stroke across times. Of these, the greatest decrease was observed in patients aged 45–64 years, with a decrease of 81.24% from that in 2019 (P = 0.003). However, during the study period, the incidence of first-ever stroke remained stable for those patients aged <45 years and for those with ICH. There were no significant changes in mortality from first-ever stroke between 2019 and 2020, but mortality was noticeably lower than that for the previous 5 and 10 years across the sexes, age groups, and stroke types, except for patients aged <45 years and those with ICH.Compared with the incidence of first-ever stroke in 2019, that in 2020 was 73.5% lower overall [The rates of hospitalization and diagnosis by neuroimaging remained stable across the study period .In this study, we assessed the effects of compulsory isolation during the COVID-19 pandemic on the burden of stroke in rural China in a low-income population. We compared the current incidence and rates of mortality, hospitalization, and diagnosis by neuroimaging for first-ever stroke during the COVID-19 pandemic in 2020 to those for previous years among a low-income population in rural China. We found that the incidence in 2020 was much lower than that in other time periods from 2010 through 2019 both in men and in women, in those aged 45 years and older, and for IS regardless of whether the reference was 2019, 2015–2019, and 2010–2019. Similar results were observed in mortality for 2015–2019 and 2010–2019. However, the rates of hospitalization and diagnosis by neuroimaging remained stable across the study period.As the main cause of death worldwide, epidemiological trends of stroke have been receiving much attention. With the development of treatment and nursing technology, the fatality rate of stroke will gradually decrease and the patient's prognosis will be improved. In addition, the popularization of medical insurance will increase the detection rate of mild strokes. From 2010 to 2020, China's economy and medical level indeed have achieved rapid development. However, our previous research in this population found that first-ever stroke incidence increased by an average of 10.7% per 1,000 USD increase in overall per capita gross domestic product adjusted for purchasing power parity and by 12.0% per 1,000 Yuan increase in per capita net income –15. HoweIt is well-known that drinking alcohol and consuming a high-fat diet are risk factors for stroke –18. HoweThe Spring Festival is the biggest festival in China and occurs on the first day in the lunar calendar. The longest vacations in China are during Spring Festival, which often continues for 7 days. During that time, whole families not only hold a dinner party every day, but they also visit relatives, neighbors, and friends to pay a New Year call. This visitation and reunion results in drinking alcohol, consuming a high-fat diet, and extra excitement and tension. Consequently, Spring Festival is the peak time of stroke onset every year. Thus, home quarantine to a large extent caused people to avoid other people, drinking alcohol, and consuming a high-fat diet, which has been shown to be a risk factor for stroke –18.3, a year-on-year decrease of 7.0% (Moreover, outdoor temperature seems to be related to cerebrovascular events risk. A previous study reported that the mortality of stroke was related with temperature, and cold temperatures were the main cause of increased stroke burden . Another of 7.0% . The ris of 7.0% . Short-t of 7.0% . TherefoFinally, a previous study has reported that viral infections can increase the risk of stroke and that the risk of stroke decreases by 24% after influenza vaccination , 29. A SDuring the period of the COVID-19 pandemic, the primary health care system in China played an important role in blocking transmission. Local rural physicians measured body temperature, handed out disinfection materials, and propagated the knowledge of prevention daily door-to-door. This practice was implemented to find new stroke patients early during this special period and thereby avoid delays in medical services due to isolation and allow patients to obtain timely medical treatment. In this study, it was observed that, compared with the same 4-months period in the past 10 years, the rates of hospitalization and diagnosis by neuroimaging in 2020 did not decrease during the COVID-19 pandemic. This result shows that home quarantine did not affect medical care-seeking behavior for stroke patients.There are several limitations of this study. First, the study population was from 18 villages in Tianjin, which is not representative of the whole population in China. However, the large population study design and long study period may have reduced the impact of limited representation on the study results. Second, the observation period in 2020 only included the first 4 months. Thus, this result is not representative of the whole year. We would like to continue to follow to the end of the year and assess the whole impact of the pandemic on the burden of stroke in 2020. Finally, the data were analyzed using only descriptive statistics; we did not adjust for any potential confounders that could have affected the estimates of these changes. This statistical method could have partially affected results in this study.This paper is the first report to demonstrate trends in the incidence and mortality of stroke associated with home quarantine during the COVID-19 pandemic in a low-income population in China. The incidence of first-ever stroke in 2020 was much lower than that from 2010 to 2019. A similar trend was observed for mortality when compared with that in 2015–2019 and 2010–2019. Moreover, the rates of hospitalization and diagnosis by neuroimaging in 2020 remained stable across the study period. Thus, home quarantine may play a beneficial role in preventing stroke in rural China. In addition, even though COVID-19 was a huge challenge for the health system, medical services have not been affected in China. These findings suggest that the home quarantine helped reduce outdoor activities at low temperatures, the restrict gatherings, reduction alcoholism and high-fat diet, and decrease pollution caused by factories, etc. These changes may have been advantageous for helping high-risk groups to reduce the burden of stroke. It is crucial to explore simple and valid approaches to reduce the burden of chronic non-communicable diseases.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Tianjin Medical University General Hospital Ethics Committee. The patients/participants provided their written informed consent to participate in this study.XN, JLi, and JW were involved in conception and design and data interpretation for this article. JLiu, QY, XZ, QL, YY, DG, WM, JT, and ZL were involved in data collection, case diagnosis, and confirmation for this article. JLiu, QY, and XZ were involved in manuscript drafting. JW was involved in data analysis for this article. JW and XN were involved in the critical review in for this article. All authors contributed to the article 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.


Globally, traditional food security fears have been supplemented by concerns about food system sustainability that link current agricultural production practices to damages of environmental ecosystems and the world’s climate, thus threatening the natural resource base of future generations. This paper aims at creating a better understanding of the evolution of diet sustainability from 1961 to 2013. Data from the Food and Agriculture Organization of the United Nations were used to investigate the situation for the world as a whole as well as for its macro-regions Africa, Asia, the Americas, Europe and Oceania. We define diet sustainability by (a) the share of daily per capita calorie intake derived from vegetable/plant products and (b) the variety of vegetable/plant products consumed, measured by the Simpson diversity index. Moreover, total calorie consumption is considered. Then the correlations between diet sustainability and (a) macro-regional life expectancy rates and (b) food system greenhouse gas emissions are calculated. The results show that diet sustainability has not changed much during the last 50 years. Moreover, the nexus between diets and health and climate outcomes is not fully evident at the macro-regional level. Therefore, Malthus 2.0, i.e., scientific food pessimism, should be avoided. In particular, the limitations of dietary contributions to human and planetary health ought to be more widely acknowledged. Planet Earth’s natural resources, such as land, freshwater, raw materials etc., have to be shared among an increasing number of people . At the same time, human life expectancy has continuously increased . ConsequOne particular concern is about human diets and their resource implications. Globally, agriculture already accounts for up to 40% of global land use, 70% of freshwater withdrawals and 30% of greenhouse gas emissions . The queWhile food security fears have been with humans for their entire existence, the British scholar Thomas Malthus, at the turn of the 18th century, introduced the notion of the “population trap”. Rapid population growth would eventually outstrip agricultural production, thus leading to shortages of food supply and starvation . Today, there are various other reasons for “pessimism on the food front”, the most important ones being : (i) theIn short, besides the more traditional food security fears, many more recent concerns about food system sustainability have emerged which link current agricultural production practices to damages of environmental ecosystems and world climate, thus threatening the natural resource base of future generations. Hence, the current perception is that the very activity of food production that is meant to keep humans alive will kill them eventually in the long run.According to the Intergovernmental Panel on Climate Change (IPCC), net anthropogenic greenhouse gas (GHG) emissions of the global food system  accounted for 21%–37% of worldwide total GHG emissions during 2007–2016 . The gloAt the same time, diet-related health effects are ever more radically communicated. For instance, the EAT-Lancet study  p. 447)7] :Sustainable diets are those diets with low environmental impacts, which contribute to food and nutrition security and to healthy life for present and future generations. Sustainable diets are protective and respectful of biodiversity and ecosystems, culturally acceptable, accessible, economically fair and affordable; nutritionally adequate, safe and healthy; while optimizing natural and human resources.This definition includes environmental, social and economic dimensions. However, given its broad and unspecific approach, the definition is difficult to use as a practical measurement concept. A systematic review of the measurement of sustainable diets was undertaken by Jones et al. . The resRearing animals as a source of food requires large amounts of space and water for keeping them and for growing their feed . The feeGovernment recommendations on sustainable dietary guidelines from several countries are summarized by Gonzales-Fischer and Garnett . They shDietary diversity is beneficial because consuming a wide variety of food increases the likelihood to satisfy a broad spectrum of nutrient needs in a context where a single food contains only a limited range of nutrients . Hence, While dietary diversity is a commonly used concept , varietThis article aims at creating a better understanding of the evolution of aggregate diet sustainability during the last 50 years. Data from the Food and Agriculture Organization of the United Nations (FAOSTAT) were used to investigate the situation for the world as a whole as well as for its macro-regions Africa, Asia, the Americas, Europe and Oceania. Diet sustainability is defined using two indicators that reflect the supposed healthiness and climate impacts of the food consumed. At the same time, the total amount of calories that are consumed worldwide and in the individual macro-regions are considered. Then the correlations between diet sustainability and (a) macro-regional life expectancy and (b) food system GHG emissions are provided. After a discussion of the results, the paper concludes that diet sustainability has not changed significantly during the last 50 years for the world as a whole and in most of its macro-regions.At the macro-regional level, average diets are broad aggregates that reflect structural differences in the composition of calorie intakes across different but geographically similar countries. Such macro-level diets cannot account for intra-regional consumption heterogeneities, i.e., variations of diets within the macro-regions. However, such macro-regional diet indicators should be useful to track average diet changes within the same regions over time, which is the purpose of this study.a)the share of daily per capita calorie intake derived from vegetable/plant products (range from 0 to 1);b)the variety of vegetable/plant products consumed, measured by the Simpson diversity index  (range fc)total annual food calories consumed in a given macro-region and year, reflecting the contributions of both total population in this area and its per capita calorie intake per day.Thus, this study investigates the evolution of the world’s macro-regional diets between 1961 and 2013, using three indicators:The Simpson or Berry Index is a diversity measure that takes into account the evenness of calorie consumption or, in other words, the relative distribution of calories across individual foods as well as the total number of products consumed . The index measures whether the nutritional energy consumed is derived more or less equally from a large number of food (high diversity) as opposed to a situation where only a few foods contribute most of the energy intake (low diversity) . This meD) as follows:n is the number of calories consumed in a particular year derived from a particular plant product and N is the total number of plant products consumed in one year (richness).We calculate diet diversity .Food balance sheet supply data can be regarded as a useful and valid proxy measure for human per capita consumption. They reflect the total supply of a food item in a country (production + imports − exports + changes in stocks) available for human consumption in a particular year, divided by the total population of that country in that year . HoweverIn general, FAO data are used as decision basis for policies in agriculture and food by governments and organizations around the world. FAO data collection is subject to quality control and the published data fulfill the commonly required quality criteria such as relevance, accuracy and reliability, timeliness and punctuality, coherence and comparability, and accessibility and clarity . HoweverThis section presents the results in three parts. First, the summary of the state of the world’s average diet and the evolutions of the macro-regional diets are presented and discussed. Then the situation in the different macro-regions as well as the one of the world’s and the decade-by-decade change in the average diets are provided. Finally, we present and discuss the results from the correlation analysis between the different sustainability and health indicators.15 kcal per year to 7.59 × 1015 kcal per year; not shown in The world average diet became more based on animal products and remained all but unchanged regarding the variety of vegetable products consumed . The shaMacro-regional consumption patterns and trends are not uniform see . In Afrix-axis, the diversity within the plant calories consumed on the y-axis and the total amount of calories supplied/consumed as the size of the bubble for each year. The evolution paths of diet sustainability for each macro-region are depicted in The African diet evolved without a clear trend and rather unsystematically which may reflect potential data reliability problems within this macro-region. Overall, the plant-calorie share decreased by 0.5% over the observed 52-year period while the diversity index increased by 0.2%.U curve pattern. While the share of calories deriving from plant products continuously decreased, plant-diet diversity decreased from 1961 to a low of 0.789 in 1990 and then it increased again steadily until 2013. The total changes over the 52 years are −10.7% for the plant-calorie share and 0.9% for the diversity index.The Asian diet evolution displays a distinct The diet of the Americas displays a continuous improvement in both measures of sustainability until 1990. After that, the calories derived from plant products (77.9% in 1990) decreased again to 76.2% in 2013, resulting in an overall increase of 3.8% over the 52 years. At the same time, diet diversity steadily improved with a total increase of 2.0%. The European diet continuously became less plant calorie-based from 1961 to 1990 (70.2%) and then increased again steadily in 2013. Overall, this measure decreased by 3.5% over the observed 52-year period. During the same time, the diversity index increased by 8.1%.The diet in Oceania, as in the Americas, shows a clear trend of improvement in both measures. The calorie share derived from plant products improved by 13.6% from 1961 to 2013. Over the same period, dietary diversity increased continuously by 17.1% overall. Finally, the evolution of the world diet displays a decrease of both measures from 1961 to 1990. After this year, the plant-product share continues to decrease while the dietary diversity score continuously improved again. The total changes during the 52-year period are −2.9% for the plant-calorie share and −0.8% for the diversity index. Life expectancy (at birth) rates improved in all macro-regions over the period analyzed. According to Riley  and the Life expectancy and disability depend on multiple factors. The leading causes for death in 2017 were ischemic heart disease, neonatal disorders, stroke, lower respiratory infections, diarrhea, road injuries and chronic obstructive pulmonary disease . The leaThe links between diet diversity and life expectancy as well as between plant-product content and life expectancy are contrary to expectations both for the absolute values and for changes over time. According to Health determinants comprise lifestyle factors , biological and genetic factors , environmental factors  and, finally yet importantly, also luck  ,23. HencAs mentioned above, food systems contribute 21%–37% of global anthropogenic GHG emissions of which agricultural production, including indirect emissions resulting from land-cover change, contribute 52%–86% of total food system emissions . In Regionally, agricultural production can differ from food consumption. In 2013, the shares of food in agricultural production value were: Africa 98%, Americas 97%, Asia 96%, Europe 99.5% and Oceania 85%. In the same year, net food exports represented −11% of production in Africa, 12% in the Americas, −5% in Asia, −2% in Europe and 50% in Oceania. For 1961, no comparable data are available in the FAOSTAT Production and Trade databases (online).2eq): Oceania 1,939, Americas 1,153, Africa 816, Europe 779 and Asia 527. These values are agricultural production emissions from the FAOSTAT Emissions database (online) adjusted for food shares and net exports.Macro-regional per capita food system GHG emissions in 2013 amounted to  to 2013 (719 kg CO2eq) according to the FAOSTAT Emissions database (online).However, it should also be mentioned that world agricultural per capita GHG emissions fell by 19% from 1961  or remained virtually unchanged in this regard (Asia). Moreover, the nexus between diets and health, and diets and climate outcomes is not fully evident at the macro-regional level. The correlations between macro-regional life expectancy and diet sustainability are negative and therefore contrary expectations. This confirms that the link between human diets and overall health is weak since human mortality and morbidity have multiple, non-diet related causes. In particular, improvements in the medical systems and medicinal availability have contributed to longer and healthier lives—factors that are unrelated to food intake.However, as mentioned above, during the analyzed 52-year period total world calorie consumption more than tripled while global population only increased by a factor 2.3. As a result, in 2018, 39% of the world adult population is considered overweight and another 13% obese [At the same time, our analysis shows that there is a negative correlation between a macro-regional diet’s plant-product calorie share and its per capita food system GHG emissions. However, at 0.6 the correlation is not strong and in particular Europe has low emissions despite a relatively higher share of animal-originated calories in its diet. Moreover, global agricultural per capital GHG emissions fell by almost 20% between 1961 and 2013. In the future, food system GHG emissions are probably better tackled at the supply side by tightening production standards in particular for ruminant products, which would cause their costs and prices to rise and their demand and consumption to fall. This could be achieved by new and stringent regulations, for instance regarding the type of used animal feeds, feeding and manure management practices, and mandatory feeding additives the use of which would result in lower livestock GHG emissions (supplement to ).More generally, market-based solutions such the global introduction of carbon pricing as either carbon taxation, or emission trading  schemes, would be most efficient and effective even if less popular . Such scIn any case, Malthus 2.0, i.e., scientific food pessimism should be avoided . A first


In order to maintain P homeostasis in nutrient restricted conditions, plants have developed mechanisms which enable P acquisition from the soil solution, and an efficient reutilization of P already present in plant cells. Nitric oxide (NO) is a bioactive molecule with a plethora of functions in plants. Its endogenous synthesis depends on internal and environmental factors, and is closely tied with nitrogen (N) metabolism. Furthermore, there is evidence demonstrating that N supply affects P homeostasis and that P deficiency impacts on N assimilation. This review will provide an overview on how NO levels  It is not uncommon for plant roots to be exposed to temporary changes in local P availability. Considering the pivotal roles of this macronutrient in energy dynamics and metabolic regulation, P fluxes coordinately adjust to balance growth and development at the level of the whole plant. In the same way as it occurs with other mineral nutrients, both local signals acting on the cellular level, and long-distance or systemic signaling pathways, communicating internal nutrient status across different tissues and plant organs, must act coordinately to improve nutrient acquisition and internal utilization . The sigReactive oxygen species (ROS) and NO have been recognized as early components in several mineral nutrient signaling events . Even thSensing, signaling and the elaboration of acclimation responses will determine plant survival and performance in conditions of spatial and temporal variability of soil nutrient concentrations. To that end, in this review, we will discuss the current state of knowledge regarding NO functions in plants specifically under P restriction. We will focus on NO levels (and sources) in plants suffering from P deficiency, and its influence over the processes triggered by P starvation, which could modify P acquisition and use efficiency.Plants are often exposed to growth-limiting levels of P during their life cycle. As this is also true in crops, in order to maintain yields in low P soils, chemical P fertilizers obtained from mineral deposits are applied in each crop cycle . Each ye2PO4– and HPO42–, and whereas the dynamic balance of available and non-available P is determined by diverse soil and climate conditions  and denitrification processes  carried out by microorganisms  enzymes use L-arginine, Ooduce NO . In planoduce NO , which hoduce NO . NO prodOstreococcus tauri H, through its diaphorase/dehydrogenase activity, to the molybdoenzyme NOFNiR , which is in fact responsible for NO synthesis from NO2–, even in the presence of NO3–, condition under which NR is unable to do that. In addition, NR participates in the control of NO levels in cell by supplying electrons to the truncated hemoglobin THB1, which has dioxygenase activity (it can dioxygenate NO to produce NO3–). THB1 would then act by removing the very reactive NO and simultaneously inhibiting NR by uncoupling the electron transfer from NAD(P)H to NO3– (redirecting the electrons from FAD to THB1). THB1 then plays a dual role in NO detoxification and in the modulation of NR activity (2– production (such as the factors which favor the activity of NOFNiR and hemoglobins over NR) is required  and NR in plant tissues. us tauri . Howeverus tauri . In thisactivity . Furtherrequired .Over the last few years, research in the field of NO generation in plants has advanced. However, knowledge of the regulation of the multiple proposed pathways, especially under stress conditions, and in particular under mineral nutrient deprivation, is still limited. Different sources may come together, depending on stress conditions, substrate availability, species, and plant’s organs. Knowledge of the sources (and fates) of NO which operate under nutrient deficiency, in addition to the understanding of the specific roles of this molecule, are key tools to unraveling the mechanisms which trigger acclimation responses, where the modulation of endogenous levels of this molecule could be involved.Nitric oxide may exert its biological functions through protein modifications, such as tyrosine nitration or S-nitrosation , or through interaction with metalloproteins  , besidesAlthough in animals the NO/cGMP-signaling (cyclic guanosine monophosphate) pathway has a main role in transmitting NO signal, plants have developed specific NO signaling different from other eukariotic lineages. According to recent studies, typical NO/cGMP signaling module is absent from representative plant species, while S-nitrosation has emerged as major NO-dependent signaling mechanisms in plants . ProteinS-nitrosoglutathione (GSNO) is the most abundant low-molecular-weight nitrosothiol and, in turn, it is considered to be a form of NO storage and long-distance transport (reviewed in – and nitrogen dioxide (NO2), formed as secondary products of NO metabolism in the presence of oxidants, such as superoxide radicals (O2–), hydrogen peroxide (H2O2), and transition metal centers , contributes to the regulation of growth, development, and of biotic and abiotic stresses responses , where P deficiency enhanced NO production in primary and lateral root tips, with a bigger increase in juvenile and mature cluster roots (bottlebrush like structures). In searching for NO sources, root treatment with the mammalian NOS inhibitor (NG-nitro-L-arginine) and the XOR inhibitor  was found to reduce NO concentration in cluster roots, whereas with the NR inhibitor (tungstate), no effect of treatment was observed. Thus NOS-like activity and XOR may be two of the sources involved in NO production under P deficiency in white lupin.Arabidopsis thaliana, however, the NR double mutant  resulted in more sensitivity to P scarcity than WT plants, which indicated an impairment of the mechanisms involved in the acclimation to low P in these mutants. Moreover, P deprivation led to an increased NO production in roots from WT plants but not from nia1,2, which suggested a role for the NR pathway in NO production under P restriction conditions in Arabidopsis  cannot be ruled out, and may also contribute to NO synthesis in conditions of P restriction. Future research will clarify this variable scenario dependent on multiple factors, including plant species, organ, source of N, and the level of P in the cell.Overall, NO seems to have a role in conditions of P scarcity in plants, not only in root response but also in shoot, where early changes are triggered as a consequence of P decrease. The two main ways of NO production in plants, NR and arginine-dependent, seem to be involved in the regulation of NO levels in the cell, but other potential sources  could affect NO generation , long-term P deprivation (20 days) led to several changes in N assimilation: rates of 15NO3– uptake and net translocation of 15N from roots to shoots decreased, resulting in the alteration of NO3– assimilation. Asparagine accumulated to high levels in stems and roots, and arginine accumulated to high levels in leaves was also observed (Citrus limon) and summer squash (Cucurbita pepo), when grown under P deficient conditions  and the level of NO or GSNO reached in each system  was inhibited by S-nitrosation. As this enzyme catalyses the NADH-dependent reduction of GSNO (stable pool of NO) to oxidized glutathione and NH4+, its inhibition could prevent this GSNO degradation and amplify S-nitrosothiols signals , rates of water flow (hydraulic conductance), and membrane permeability; but other feedback control factors could affect NO– uptake . It is wgulation . It has  signals . Further2– or/and arginine) and modulation in the activity of some enzymes, including NR, XOR or NOS-like, can contribute to modify NO levels in planta. Despite NO origin, it may regulate N assimilation and, as a result, its own levels to participate in signaling events to afford P deficiency.In P scarcity conditions, diverse factors such as changes in the availability of substrates  is frequently used as a model plant to study the formation and function of cluster roots under P-deficient conditions  strongly reduced primary root length, whose effect was reversed in the presence of NO scavenger cPTIO . In ArabOther mechanisms involving GA and NO may play a part in primary root inhibition under P restriction. Knowing that P starvation decreases GA biosynthesis in Arabidopsis, and that the addition of exogenous GA acts as a positive regulator for primary root growth , the intEnhanced root hair development is a typical adaptive plant response to P starvation, where increasing root surface area for nutrient uptake is mediated by ethylene . The desOther nutrient’s availability usually affects root hair development, as is the case of Mg deficiency . ArabidoThe upregulation of high-affinity P transporters is a common phenomenon in response to P restriction in order to coordinate nutrient acquisition and distribution . As expeAs mentioned before, P is easily redistributed, especially in plants under P-restriction. This includes the internal redistribution of P pools, the release of P from vacuoles, cell walls, and phospholipids in membranes, while at the whole plant level, P is reallocated to the young actively growing tissues . P-transGmPAP21 enabled plants to achieve around 96% higher fresh weight under P restriction as compared with WT plants, pointing out the role of this enzyme in internal P use efficiency in plants. Results of assays on maize plants (Zea mays) exposed to an NO donor during P restriction suggested NO played a part in the enhanced activity of root APases  (OsPT2) was up-regulated to facilitate the translocation of P from root to shoot, improving growth under P restriction  . An inte (PhPT1) , as it h (PhPT1) . As a retriction , 2017. Ttriction .Since P-restriction produces an increase in NO  and in eAs a large proportion of P in soil is precipitated, chelated with metals, or becomes a constituent of organic compounds, the exudation of organic acids, protons and enzymes by roots contributes to improving plant’s P availability . The “stCitrus grandis), where citrate content in roots increased after treatment with SNP (10 and 500 μM), due to an alteration in transport from leaves, whereas malate content increased (after treatment with 500 μM SNP), probably due to changes in the activity of the enzymes responsible for its synthesis and degradation , and the stimulatory effects of humic acids were inhibited by the addition of NO scavenger PTIO  exhibited enhanced H+-ATPase activity 48 h after incubation with SNP (200 μM), and a reduced activity after treatment with PTIO , were found to exhibit higher capacity of external medium acidification as compared with P-deprived plants  remain to be studied in plants exposed to low P conditions.To date there is little research on NO levels that have been conducted in plants exposed to P scarcity. NO increased after imposition of P-restriction treatments in lupin, Arabidopsis and rice roots, as well as in soybean leaves. NO seems to be implicated in acclimation responses to low P-availability, as it was described for citrate exudation, transcription and activity of a P transporter, P uptake from diluted solutions, external medium acidification and phosphatase activity, as well as modulation of some metabolic pathways. However, other functions of NO (for example, increasing HConsidering that a large amount of research has been developed using NO donors, caution should be taken regarding some observed side effects. In this regard, the use of other NO donors or scavengers in assays should be encouraged to strongly support some of the results. In addition, measurement of NO levels inside the plant as well as in different organs should be promoted to obtain a more integrated view.Different mechanisms could be involved in NO synthesis during P scarcity but NR seems to have a critical role because of the close relationship between N metabolism and NO generation. Once NO concentration rises to a critical value, it may regulate its own specific level to exert a particular function. An interesting interaction of NO with hormones, such as ethylene, GA, and auxins during P deficiency may be proposed in some key acclimation responses. Moreover, future research in this field may confirm and show additional actors to this scenario. Overall, we encourage research in NO participation during P deficiency in order to find new tools to improve agricultural practices, avoiding fertilizers misuse and consequently, environmental damage.AG, FR-A, AB, and MS contributed equally to conceive and write the manuscript. ML prepared the figures and contributed to the writing. All the authors approved it for publication.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.


In a mixed practice environment, increased resilience and nursing foundations for quality of care lowered nurses’ burnout. Our findings suggest that interventions focused on enhancing individual resilience and practice environment and building better nursing foundations for quality of care should be developed and provided to alleviate burnout in clinical nurses working at tertiary hospitals. Nursing and hospital administrators should consider the importance of practice environment and resilience in nurses in developing interventions to decrease burnout.The purpose of this study was to examine practice environment, resilience, and burnout and to identify the impacts of practice environment and resilience on burnout among clinical nurses working at a tertiary hospital. A cross-sectional secondary data analysis was conducted using a convenience sample of 199 nurses. The nurses completed survey questionnaires regarding practice environment, resilience, and burnout. The majority of the nurses were below the age of 30, single, and worked in medical-surgical wards. Approximately, 92% of the nurses reported moderate to high burnout, with a mean practice environment score of 2.54 ± 0.34 and resilience score of 22.01 ± 5.69. Practice environment and resilience were higher in the low level of burnout than in the moderate to high level of burnout. After controlling for demographic and occupational characteristics, resilience and nursing foundations for quality of care were significant predictors of burnout (OR = 0.71,  In 2017, the number of clinical nursing personnel, such as nurses and nursing assistants, in Korea was approximately 6.9 per 1000 people, which was 2.1 lower than the average of 9.0 from other countries of the Organization for Economic Cooperation and Development (OECD). This number (6.9) was an increase from the 4.8 per 1000 Korean clinical nursing workforce in 2012; however, it is still low and below the OECD average ,4, causeThe practice environment not only refers to a simple physical environment but also a concept that includes peer interaction and institutional policy , and it Resilience, which is a personal attribute of a nurse, is an inherent potential ability that enables them to effectively cope with work-related stress or workplace adversity situations ,11. It iThis study aimed to examine practice environment , resilience , and burnout and aimed to identify the impacts of these factors on burnout among clinical nurses working at a tertiary hospital.Summarizing the literature review findings, we propose the following two hypotheses.Hypothesis 1.Favorable practice environment is negatively associated with burnout among nurses working at a tertiary hospital.Hypothesis 2.Higher resilience is negatively associated with burnout among nurses working at a tertiary hospital.n = 199) responded. After the respondents signed up by email or phone, consent forms and surveys were distributed by mail in enclosed, resealable envelopes. Research assistants visited the wards of each participating nurse on a scheduled day to collect the sealed envelopes that had been placed in designated places. We classified a survey questionnaire with more than 80% of the questions answered as completed. Participation was completely voluntary, and participants could withdraw at any time, without discrimination. Participants received stationery goods worth $5 and a thank-you note for their participation. Ethics clearance for the current study was obtained from the University of Victoria, Canada (18-040).This study used the cross-sectional secondary data analysis of a previously published descriptive correlational study on the factors affecting the quality of nursing service among clinical nurses in Korea . In the Practice environment was assessed using the Korean version of the Nursing Work Index ,25. The Resilience was measured using the Korean version of the 10-item Connor Davidson Resilience Scale . The scaBurnout was measured using 10 items from the Professional Quality of Life Scale (PQOL). The PQOL scale consists of two broad categories: compassion satisfaction and compassion fatigue. Compassion fatigue is further divided into burnout and secondary traumatic stress . BurnoutThe following demographic characteristics were among those included in the assessment: age (in years), marital status (single vs. married), and education level (associate degree or bachelor vs. master’s degree and higher). Occupational characteristics included working position (staff nurse vs. head nurse), career length (in years), ward type , and perceived health status (bad vs. good).Data were analyzed using the Statistical Package for Social Science (SPSS) version 26 . Descriptive analysis using means, standard deviations, frequencies, and percentages were computed to explain sample and variables. Independent t-tests, analysis of variance (ANOVA), or chi-squared tests were performed to compare practice environment, resilience, and burnout, according to demographic and occupational characteristics. Finally, a hierarchical logistic regression analysis was performed to explore the impact of practice environment and resilience on burnout, after controlling for demographic and occupational factors. Demographic and occupational characteristics showing differences in burnout were entered into Model 1, followed by practice environment factors , and resilience levels (Model 3).n = 134, 67.3%) and had completed a diploma or bachelor’s degree . Most of them were staff nurses  and have worked for at least three years or more as a nurse . Currently, more than half of the nurses worked at the medical ward  and reported bad health status  . Majority of the participants were single  .n = 183, 92.0%) , while the staffing and resource adequacy subscale had the lowest score (1.99 ± 0.54). The mean resilience score was 22.01 ± 5.69, and most of the participants indicated moderate to high burnout rates  .F = 3.27, p = 0.040; t = −3.66, p < 0.001; t = −2.52, p = 0.013, respectively). Resilience showed significant differences by age group, marital status, education level, working position, career length, and perceived health status. Resilience was significantly higher in nurses aged 40 years and older, those with master’s degree or higher, those with good health status , those who were married, and head nurses  than it was in their respective counterparts. Characteristically, higher resilience levels were reported in participants who had worked for at least three years and longer than in those who had worked for less than three years . Practice environment and resilience showed significant differences by burnout level. In other words, each subscale of practice environment and resilience was higher in the low level of burnout than in the moderate to high levels of burnout .Practice environment showed significant differences by age group, working position, and perceived health status . Specifi2 = 0.349). In Model 2, practice environment was added to Model 1, and nursing foundations for quality of care was identified as a significant factor affecting burnout level, after controlling for the demographic and occupational factors, explaining 51.5% of the variance (Nagelkerke R2 = 0.515). In Model 3, resilience was added to Model 2, and nursing foundations for quality of care, which is a sub-scale of the practice environment, and resilience predicted less likelihood of moderate to high level of burnout, after controlling for the covariates, explaining 65.7% of the variance in burnout level (Nagelkerke R2 = 0.657). The findings showed that 99% and 29% of the nurses were less likely to have moderate to high level of burnout, with every one-point increase in the score of nursing foundations for quality of care  and in the resilience score , respectively. These results supported hypotheses 1 and 2.A series of binary logistic regression analyses was conducted to examine the impact of practice environment and resilience on nurses’ level of burnout (mild vs. moderate to high) after controlling for demographic and occupational characteristics . In ModeIn this study, we sought to explore how practice environment and resilience contribute to burnout after controlling for socio-demographic and occupational characteristics. Our results revealed that resilience and nursing foundations for quality of care, which is a sub-scale of the practice environment, are significant predictors of burnout. The findings suggest that improving nursing foundations for quality of care at the organizational level and resilience at the individual level could decrease burnout in clinical nurses working at the tertiary hospital.In our study, the practice environment was mixed, and only nursing foundations for quality of care in the practice environment was a significant predictor of burnout. Among the five sub-scales of the practice environment, the score of nursing foundations for quality of care as well as the scores of nurse manager ability, leadership, and support of nurses were high. It is thought that qualitative nursing care systems are well equipped and the quality and level of nurse managers are guaranteed. However, the average scores of the two sub-scales were lower than those of the Magnet Hospital scores, which was awarded as Magnet designation hospital by the American Nurses Credentialing Center , implyinNursing foundations for quality of care, which is a sub-scale of the practice environment, and resilience, were statistically significant predictors of burnout. Because nursing foundations for quality of care is associated with increased job satisfaction, intention to stay at the hospital, and quality of care , as nursThe findings of a previous study reported that resilience reduced burnout occurrence . ResilieThe findings indicate that a favorable practice environment and higher resilience were significantly associated with a lower level of burnout. Building a favorable practice environment and resilience is essential for the quality of nursing, especially at tertiary hospitals. Nursing administrators should therefore consider the importance of practice environment and resilience in developing interventions to decrease burnout in hospitals. Policymakers should stimulate nursing and/or hospital administrators to plan and provide strategies to improve practice environment and resilience among nurses.There are some limitations to this study. First, this study was conducted using a convenient sampling method to collect data from only one tertiary hospital; thus, it is difficult to generalize the study findings. Therefore, further studies should be conducted, increasing the number and types of hospitals and including other regions in Korea. Second, this was a cross-sectional study; thus, it is difficult to explain a causal relationship of the findings. Therefore, further studies should be conducted to examine the causal relationship using a longitudinal study design.In examining the factors influencing burnout in nurses working in a tertiary hospital, nursing foundations for quality of care and resilience were identified as significant influencing factors on burnout level. Our findings suggest that interventions focused on enhancing individual resilience and overall practice environment, and building better nursing foundations for quality of care, should be developed and provided to alleviate burnout in clinical nurses working at tertiary hospitals.


Traditionally, models of positive personality traits have referred to moral characteristics. The High Five Model (HFM) is a factor model of individual positive traits based on an inductive psycho-lexical approach. Unlike other models, in the HFM the positive characteristics were freely determined by lay people, beyond any moral tones. The HFM comprises the following factors: erudition, peace, cheerfulness, honesty, and tenacity, known as “the high factors.” This model was shown to positively exceed the capacity of normal personality to predict emotional, social, and psychological well-being. Additionally, this model is negatively associated with non-transmissible diseases, psychopathological symptoms, and psychopathological personality traits. This study aimed to increase the validation of the HFM, by analyzing the relationships among this model and positive mental health, psychopathological symptoms, academic adjustment, and academic performance in university students. Another objective was to study the association between complete mental well-being  and the high factors of the HFM. The sample consisted of 256 university students. Correlations were calculated, and the two-step cluster analysis was used to obtain profiles. The results showed that tenacity and erudition high factors are positively associated with academic achievement and academic adjustment. Finally, each of the high factors was positively associated with complete mental well-being. The HFM has a broad scope, as it is related not only to psychological variables  but also to academic performance  in university students. Theory-driven or data-driven studies on positive characteristics have focused on one type of positive traits, namely moral traits , excluding abilities or non-moral features e.g., . From a The High Five Model (HFM) was recently proposed for identifying individual positive traits from lay people’s perspective . These tM = 37.7, SD = 15.1, range 18–90 years) generated a list of 854 elements that made up the initial corpus of words . The participants were asked to indicate to what extent the items described them . To determine the number of factors, an exploratory factor analysis was run, using parallel analysis based on minimum rank factor analysis. Additionally, the oblique Crawford-Ferguson (CF) Quartimax rotation was used to obtain a cleaner factor structure, which resulted in a set of 57 items, corresponding to five positive factors. The model refinement sample consisted of 484 participants , who indicated to what extent the positive characteristics described them (range 1–7). A new factor analysis was conducted to reduce the number of items and obtain a factor model with at least four items, omega reliability ≥.80 per factor, and good fit to data. Thus, the High Five Inventory (HFI) was composed of 23 items distributed into five subscales of socially shared positive human characteristics  confirmed the good fit of the model to data using robust analyses , as well as the good reliability of each subscale (omegas > .80). Not only did each high factor show positive associations with emotional, psychological, and social well-being from the hedonic and eudemonic traditions  resemble the findings of the studies on the HFM, since moral traits are generally predictors of life satisfaction and different types of psychological well-being e.g., . In addiIt is necessary to consider why personological variables, in this case positive traits, are expected to correlate with academic performance, given that the personality variables were not designed to predict such an outcome . A corolA validation study of the HFM model was conducted among university students attending different undergraduate courses. The complete optimal functioning, the construct we related to the HFM, was assessed in terms of academic performance (academic adjustment and academic achievement), indicators of positive mental health , and absence of psychopathological symptoms. It was assumed that the HFM makes it possible to predict positive results. Therefore, the objectives of this research were 1) to study the associations of the HFM factors with self-reported academic achievement and self-perceived academic adjustment in university students, and 2) to study the associations of the HFM factors with indicators of positive mental health and absence of psychopathological symptoms in university students.SD = 7.38, range 18–56), mostly residents from Buenos Aires city  and Buenos Aires suburbs . A low percentage  resided in other cities of Buenos Aires Province. Almost three-quarters of the participants were working and studying at the time of the study , attending either state-run  or private  universities.The sample consisted of 256 university students , with a mean age of 27.55 years , 22.7% (n = 58) were living with a partner or married, 21% were dating (n = 54), and the remaining 2% (n = 5) were divorced. Most participants reported having a middle  or lower-middle  socioeconomic status (SES), while 20% reported an upper-middle SES .Half of the participants were single  on a Likert-type scale ranging from 1 (Never) to 7 (Always). The higher the score of each HFI subscale, the higher the high factor. The HFI has convergent and divergent validity in relation to The High Five Inventory HFI;  is an inNot at all) to 4 (Extremely). In this study, the GSI was used as an indicator of symptomatology. The SCL-27 dimensions were strongly positively associated with each other  to 5 (Every day). The MHC-SF has shown good internal consistency (>.70) and adequate validities  in studies conducted in adult populations in the United States, China, Italy, Iran, Canada, Poland, and South Africa   is compoh Africa . The Argh Africa . In the Almost never) to 5 (Always). The items of the Argentinean adaptation are grouped into a single factor that denotes satisfaction with their adjustment. The internal consistency for this sample was high (omega = .81).The Academic Adjustment Scale  was desir = .90) between self-reported academic grades and objective academic achievement as reported by universities  were used. A meta-analysis has shown a strong correlation .The battery of instruments was administered by advanced psychology students attending a university located in Buenos Aires city and performing their professional research practice. They were instructed to contact university students residing in Buenos Aires City and the surrounding area, who responded individually. Instruments with missing data were not included (nine protocols were eliminated). The data were analyzed with the statistical package SPSS version 17. Descriptive statistics and correlations among variables were calculated. Four clusters of complete mental well-being were obtained and the relationships among these groups and the high factors were established.Firstly, descriptive statistics of the variables included in the study were calculated .p < .003) and peace  accounted for 7% of the variance in the global severity index of the SCL-27  = 10.86, p < .0001). The high factors tenacity  and erudition  accounted for 5% of academic achievement  = 7.43, p < .0001), and the high factors tenacity  and erudition  16% of academic adjustment  = 24.50, p < .0001).Secondly, successive series of stepwise multiple regression analysis were performed, including the five high factors as independent variables and the other variables of the study. The high factors peace, tenacity, cheerfulness, and erudition accounted for between 16 and 25% of the variance in well-being, depending on the type of well-being . RegardiThe next step was to obtain clusters of complete mental well-being for the complete optimal functioning, understood as the presence of high levels of both hedonic and eudemonic well-being and a low level of psychopathological symptoms. A two-step cluster analysis was performed. This exploratory analysis identifies the natural structures/grouping within a dataset and gives the optimal number of clusters as well as the quality of the fit of the groups . The logn = 102), the group with the largest number of participants. The members of this group had moderate hedonic and eudemonic well-being and a low level of psychopathological symptomatology. This cluster was named Suboptimal Superior Level of Complete Mental Well-being .The first cluster was composed of 39.8% of the cases (n = 68). This group consisted of people with low levels of hedonic and eudemonic well-being and with a low level of psychopathological symptoms. This cluster was labeled Upper Intermediate Level of Complete Mental Well-being .The second cluster was composed of 26.6% of the cases (n = 55). This group reported an average level of hedonic and eudemonic well-being and above average level of psychopathological symptomatology. This cluster was in some way similar to the upper-intermediate level mentioned above and was named Lower Intermediate Level of Complete Mental Well-being .The third cluster grouped 21.5% of the cases (n = 31). This group had very low levels of hedonic and eudemonic well-being and very high levels of psychopathological symptomatology. This cluster grouped individuals with the worst psychological profile and was labeled Inferior Level of Complete Mental Well-being . In general, this cluster analysis showed that the participants could be placed along a continuum of complete mental health, from the positive pole of complete mental health to the negative pole of complete mental health. The positive pole is characterized by the presence of high hedonic and eudemonic well-being and low psychopathological symptomatology, while the negative pole is characterized by the presence of low hedonic and eudemonic well-being and the presence of high psychopathological symptoms.The fourth cluster consisted of 12.1% of the participants  = 0.80, ns) and age  = 0.41, ns).In the clusters of Complete Mental Well-being (CMW), no differences were found by gender  = 5.52, p < .001, η2 = .010). Univariate contrasts and post-hoc analyses were performed afterward. Significant differences were found among all clusters of CMW and the high factors. In most cases, the high factors of the HFM allowed us to differentiate between all the groups, as follows:Associations between CMW groups and the HFM factors were analyzed. A MANOVA was conducted, comparing the five high factors across the CMW groups. Statistically significant differences were observed among the groups of CMW  = 12.61, p < .001, η2 = .13), post-hoc analyses  showed differences between the four groups of CMW. The highest scores on erudition were found in the group with the highest CMW, while the lowest scores on erudition were present in the group with the lowest CMW.For the erudition factor  = 7.58, p < .001, η2 = .08), post-hoc contrast  showed differences between the inferior CMW group and the other three groups. The group with the poorest CMW presented the lowest levels of the cheerfulness factor.For cheerfulness  = 9.81, p < .001, η2 = .11), post-hoc analyses  showed differences between the groups with higher CMW for optimal functioning (superior and upper intermediate CMW) and the groups with lower CMW (lower intermediate and inferior CMW). The highest scores on the honesty factor were reported by individuals with better CMW, while the lowest scores were found among those with poorer CMW.For honesty  = 12.50, p < .001, η2 = .13), the post-hoc contrast  showed differences among the groups with better CMW (superior and upper intermediate CMW) and those with worse levels of CMW (lower intermediate and inferior CMW). The highest scores on the tenacity factor were reported by individuals with better CMW, while the lowest levels of tenacity were found in those with poorer CMW.For tenacity  = 10.99, p < .001, η2 = .12), the post-hoc analyses  revealed differences in this high factor among the superior, intermediate, and inferior groups of CMW. The highest scores on the peace factor were reported by individuals with better CMW and the lowest scores by those with poorer CMW. Therefore the better the CMW, the higher the high factor.For peace  = 0.94, ns) but differences in perceived academic adjustment  = 13.53, p < .01) were found, the greatest differences being among superior, intermediate, and inferior CMW groups . While the highest academic adjustment was observed in the superior CMW group, the lowest levels were found in the inferior CMW group.Finally, no differences in academic achievement  and erudition (the positive trait of knowledge) are two positive factors of personality strongly related to the perception of adjustment to university life. Young adults with high levels of effort, dedication, and persistence, and are intelligent, educated, and resourceful show good academic skills to cope with university life and feel satisfied with their progress in college. Similarly, tenacity and erudition are positively associated with university grades.The personality model of the Big Five posits that human personality is composed of five basic dimensions named neuroticism, extraversion, agreeableness, openness to experience, and conscientiousness . Among tIn short, the results of this study provide additional validity to the HFM as a predictor of CMW for the complete optimal functioning . The five positive traits adequately identified different gradations in the optimal functioning continuum . High scores for the high factors were found in the most adaptive groups while low scores on these factors were found in the least adaptive groups, that is, those with less mental well-being. Therefore, the results of this research provide additional evidence to support previous findings that high factors are indicators not only of mental health but also of lower risks of medical illness in the general population . In thisA possible limitation of our research is that only self-reported academic grades were used for academic achievement. Using objective grades obtained directly from educational institutions might serve as a more reliable source of information. In addition, this study was cross-sectional. A longitudinal study could have provided more conclusive evidence of the causal relationships in which the high factors could be considered independent variables. Besides, because this study aimed to show the links of the high factors with various positive variables, there was no control for the factors of the Big Five model. Further studies could include the Big Five factors as control variables to determine the contribution that the high factors make to the variables studied here, beyond the explanation of the Big Five factors. Future studies should also address the relationship between the HFM and academic dropout, as well as the behavior of high factors during a university academic period. Additionally, the role of the HFM as a predictor of good job performance could be studied.To summarize, the assessment of positive traits derived from a psycho-lexical approach, evaluated through a brief measurement instrument such as the HFI, can predict both complete mental health for optimal functioning and other positive outcomes such as academic performance . The items of the HFI use descriptors of the HFM model that are easy to understand and rapid to respond, taking no more than 5 minutes to fill out. Consequently, the HFI can be considered a reliable, valid, and efficient assessment of positive personality traits and a good alternative to the classic inventories and other personality assessment techniques that consist of a large number of items and/or more complex evaluation.


We explored the relationship between obstructive sleep apnea (OSA) patients’ anthropometric measures and the CPAP treatment response. To that end, we processed three non-overlapping cohorts ( Obstructive sleep apnea (OSA) is a chronic nocturnal disorder characterized by partial or complete episodes of upper airway collapse, which leads to oxygen desaturation and micro-arousals, causing symptoms, such as excessive sleepiness, fatigue and cognitive dysfunction . OSA is Studies show a prevalence of OSA in the general population of about 20%; the OSA diagnosis depends on the apnea–hypopnea index of higher than 5 in at least 1 hour of sleep . The preAs neck thickness is an important indicator of OSA, the measurement of neck circumference (NC) has become standard practice in the current physical examination when there is suspicion of sleep apnea ,11,12,13ex (BMI) . OverallMany critical scientific problems can be modeled and visualized using complex networks . For insOur main inspiration stemmed from the connections between OSA patient phenotypes and the various manifestations of this disease, found with complex network approaches ,23. In tThe study presented in this paper is based on the approval granted by The Ethical Committee of Victor Babeş Hospital, Timişoara, Romania . As such, we develop a two-step approach. First, we apply network analysis on a relevant population of consecutive patients . We performed an overnight polysomnography following guidelines and recommendations . As suchV the node (or vertex) set and E the link (or edge) set. Each patient is represented by a node risk compatibility relationship between the two corresponding patients. The risk compatibility exists if the two connected nodes—representing patients—fall within at least 4 out of 6 identical parameter classes:Gender ,Age group ,Blood pressure BP ,Neck circumference ,Epworth sleepiness score .In this paper, we follow the network medicine approach ,26, whicIn We select these six specific input parameters according to the state of the art OSA research, and their cutoff points are based on the clinical practice of our sleep centers ,29,30, wBased on the enumerated cutoff values, we classify the input parameters into 2 classes (4 classes for age) instead of using them quantitatively in order to be able to define explicit patient compatibility. Accordingly, this means that if two patients are in the same parameter class, they have a risk compatibility; conversely, different classes suggest no risk compatibility. Consequently, our network edge weight calculation between any two patients results in counting the number of compatible input parameter classes. All input parameters have equal weight in the edge calculation, and there is no critical attribute considered in network formation.We used Gephi 0.8.1  to generThe network community detection techniques we used are modularity  and ForcG, k is the total  degree of vertices in G, and In a complex network ty of Ci .A network layout algorithm assigns each vertex lgorithm , which eThis way, the force-directed layouts generate topological clusters, as some specific network regions have higher than average edge densities. Noack  has demoTo obtain the CPAP patient network based on The procedure of finding an optimal threshold is an empirical one, and is based on creating the graph, and then running modularity and Force Atlas 2 to quantify and visualize the obtained graph. We have previously applied a similar approach on OSA patients ; Figure We performed the Shapiro–Wilk test to examine the normal distribution of the variables of interest. As the continuous variables are not normally distributed, we analyze the correlations with Spearman’s rank test. The difference of continuous variables mean ranks was analyzed with the non-parametric Mann–Whitney U test. The results are summarized as median (interquartile range) for continuous variables and as percentages for categorical variables.We used the receiver operating characteristic (ROC) curve to assess the classification ability of neck circumference for the OSA diagnosis . The ROCp value of less than 0.05 is considered statistically significant.We performed the statistical analysis with SPSS version 20.0 for Windows. A Our network community detection approach, applied in conformity with the state-of-the-art methodology ,18,20, rnormal, mild, moderate, severe. We measured AHI before and after the one-night treatment. The sizes of each community are: The CPAP patient network . Then, we quantify the improvement of AHI in terms of severity class, after the over-night treatment.Furthermore, in Male gender is in both response classes, so it cannot be used as a classifier.HBP = 1 is inconsistent across the two response classes.Obese = 1 is in both response classes.TN = 1 (98–100%) is only in the best response class, and TN = 0 (3–38%) is only in the good response class.Sleepiness is inconsistent across the two response classes.We determined that communities As such, a thick neck  is the best parameter for indicating the CPAP treatment response class. Corroborating We further investigate the distribution of NC on a larger supporting dataset of male patients  of patients with OSA ,22,29. HOur study confirms that NC is a reliable OSA indicator that reflects its severity. The positive correlation of NC with AHI (p<0.001) . The recsubjects ,46.Our study also emphasized the classification ability of neck circumference for CPAP responsiveness, in a population cohort of people referred to sleep labs for OSA evaluation and treatment. The network analysis discovered NC as the best marker correlating with CPAP treatment, and our statistical analysis confirmed a certain NC threshold for reliable treatment and prioritization. Moreover, we found that male patients with NC dherence ,48. Othedherence . In our In line with this study, a future development for our statistical analysis could be to describe the optimal OSA risk thresholds that optimize trade-offs between true positives, true negatives, false positives and false negatives, through the use of a total cost function . AdditioFirst, we discuss the size of dataset  cohorts ,53,54.n = 33 [22.75%] in Second, the number of women in the study  to validate our claims.The central question of this study was whether anthropomorphic variables can indicate the CPAP treatment response. Indeed, we reached this conclusion by finding with the help of network analysis that NC is the best qualitative indicator of treatment response. Furthermore, the NC cutoff value for OSA diagnosed patients, is in line with the optimal cutoff value for the CPAP response.Neck circumference is a reliable risk marker for patients suspected of OSA. Moreover, our novel network medicine interdisciplinary approach has uncovered that an NC To obtain an effective OSA prognosis, we can use NC in combination with other parameters or descriptors such as symptoms, age, gender, and BMI. To that end, we applied the determined NC cutoff point on already defined OSA phenotypes ,22 to na


Heat stroke (HS) is an acute physical disorder that is associated with a high risk of organ dysfunction and even death. HS patients are usually treated symptomatically and conservatively; however, there remains a lack of specific and effective drugs in clinical practice. An analysis of publication contributions from institutions, journals and authors in different countries/regions was used to study research progress and trends regarding HS.We extracted all relevant publications on HS between 1989 and 2019 from Web of Science. Using the Statistical Package for Social Science  and the software GraphPad Prism 8, graphs were generated and statistical analyses were performed, while VOSviewer software was employed to visualize the research trends in HS from the perspectives of co-occurring keywords.Medicine & Science in Sports & Exercise published the most papers related to HS, with Lin MT publishing the most papers in this field (112), while the review by Knochel JP received the highest citation frequency at 969. The keyword heat-stress appeared most recently, with an average appearing year of 2015.5. In the clinical research cluster, exertional heat-stroke was determined to be the hotspot, while ambient-temperature and heat waves were the new trends in the epidemiological research cluster.As of April 14, 2020, we identified 1443 publications with a citation frequency of 5216. The United States accounted for the largest number of publications (36.2%) and the highest number of citations , as well as the highest H-index at 74. Although the sum of publications from China ranked second, there was a contradiction between the quantity and quality of publications. Furthermore, Corresponding to this important field, while the contributions of the publications from the United States were significant, the mismatch between the quantity and quality of publications from China must be examined. Moreover, it is hypothesized that clinical and epidemiological studies may become hotspots in the near future.The online version contains supplementary material available at 10.1186/s40779-021-00300-z. Heat stroke (HS), considered one of the most fatal diseases, is commonly depicted by an unbalanced generation and dissipation of heat as a result of exposure to a hot environment or strenuous exercise, and itis clinically characterized by central nervous system (CNS) dysfunction, multiple organ failure and extreme hyperthermia usually> 40.5 °C) . Despite0.5 °C . Bibliometrics is a statistical and quantitative method used to analyze the academic influence and characteristics of scientific output. Combined with creative design and information visualization, bibliometric mapping visually represents bibliometric data , highligThe present study was aimed at comprehensively analyzing the research progress with respect to HS based on Web of Science (WOS). We applied a bibliometric analysis for the purpose of uncovering the research trends related to HS and predicting its possible future hotspots. Although Mao et al.  used bibIt has been unanimously accepted that the Science Citation Index-Expanded (SCI-E) of Thomson Reuters’ WOS is one of the most appropriate databases for conducting bibliometric analysis research. Therefore, a comprehensive online search dated from 1989to2019 was conducted in WOS with publication types limited to original articles and reviews. As all data were obtained from the public database and had nothing to do with any human subject, ethical consent was not applicable.All searches were conducted on a single day, April 14, 2020, to avoid omissions arising from rapid database renewal. The search strategies were presented as follows: TS = ((heat stroke) OR (stroke heat) OR (heat strokes) OR (heat apoplexy) OR (heatstroke) OR (thermoplegia) OR (heat hyperpyrexia) OR (heatstrokes) OR (heat-stroke) OR (non-pyrogenic hyperthermia) OR (heat illness)) AND Language = English. Original articles and reviews with normal peer-review were potentially eligible, while others were excluded accordingly. Detailed processes of enrollment and screening are displayed in Fig. Two authors (TLO and DMX) independently extracted data from all correlative publications, including titles, keywords, publication dates, origin countries and regions, authors, institutions, published journals, sum of citations, H-index, and so on. The data from WOS was inputted into the statistical package for social sciences , Microsoft Excel 2016 , GraphPad Prism 8 , and VOSviewer version 1.6.12  and were subsequently analyzed and presented both quantitatively and qualitatively. Meanwhile, the World Bank website  and the We applied WOS to analyze the characteristics of all incorporated publications. The term relative research interest (RRI) was defined as the number of publications concerning a specific research field divided by publications across all fields per year, while the impact factor (IF) was obtained from information published in the latest version of Journal Citation Reports (JCRs). It has been widely accepted that the H-index functions as a reflection of the scientific research impacts of a scholar or a country and that it indicates that a scholar or country has published H papers and that each of them has been cited in other publications at least H times.VOSviewer is an optimal approach to analyzing the correlation of highly cited publications with productive authors. The viewer can be employed to construct maps of authors and journals based on cocitation data as well as maps of keywords based on cooccurrence data related to HS. Furthermore, VOSviewer can classify keywords into different clusters in accordance with the results of cooccurrence analysis and simultaneously color them by time course. The definition of average appearing year (AAY) was employed to quantify the relative novelty of a keyword. Hence, author cocitation analysis (ACA) was presented as a network visualization map by using VOSviewer (version 1.6.12) techniques , and theIn all, 1443 articles dated from 1989 to 2019 met our inclusion criteria, with the United States ranking first in the number of publications at 523 (36.2%), followed by China at 349 (24.2%) and Japan at 100 .By retrieving the Journal Citation Report from the WOS database, all articles related to HS had been cited 29,160 times since 1989 , with an average citation frequency of 23.78 times per paper. The United States accounted for 49.3% of the total citations, i.e., 14,400 times , and exhibited an H-index of 74. The number of citations from China was 7933 (4677 times without self-citations) with an H-index of 74, and thus ranked second among all involved countries and districts. Medicine & Science in Sports & Exercise  was the highest with 38 records, while the Journal of Applied Physiology  ranked third with 33 publications. Additionally, Critical Care Medicine  reported27 publications and was ranked sixth, and the journal of Intensive Care Medicine  ranked nineteenth, with a total of 17 publications. For other journals with immense academic impact, Nature Biotechnology published a high-quality article in a related field [New England Journal of Medicine (NEJM) published a review [Cell [. The top 20 journals with the most publications are listed in Fig. Approximately one-third of the papers within the relevant scope were published in the top 20 journals based on IF . Specifically, the number of papers published in ed field , and theew [Cell . The topThe Chi Mei Medical Center in Taiwan Province, China had the highest number of publications among institutions worldwide, with 99 papers documented by this affiliation, which accounted for 6.7% of all publications. Within the list of top 20 institutions in this field, nine were Chinese institutions, five were institutions in the United States, three were Israeli institutions, two were Saudi Arabian institutions and one was an Australian institution Fig. b.A total of 381 papers written by the top ten authors accounted for 26.4% of all studies in the related area. Lin MT from the Chi Mei Medical Center published 112 papers related to HS, thus ranking first in the number of publications. Ranking second was Casa DJ, who had 46 papers. As presented in Table We analyzed the keywords extracted from 1443 publications using VOSviewer. As presented in Fig. As presented in Fig. It is worth noting that an analysis of HS is different from an analysis of a tumor or another disease because of the correlation between disease incidence and local climate. Heat illness, i.e., heatstroke, hyperthermia and dehydration, was responsible for 3306 of 14,539 deaths during the heat wave that occurred in France from August 1st to August 20th of 2003 . BecauseNew England Journal of Medicine that has been cited a number of times [With respect to authors, Knochel JP, who pioneered research on HS, was first author of an impressive review published in the of times . In addiNew England Journal of Medicine in 2002 with Knochel JP as the corresponding author provides an exhaustive and comprehensive overview of HS and indicates that future research should focus on three areas, specifically, identifying genetic traits, searching for new biomarkers, and developing new adjuvant treatments to effectively control inflammatory reactions and counteract multiorgan complications [Published articles with the highest citation frequency are associated with correlative academic impacts in a certain field. Detailed information regarding the top ten most frequently cited publications on HS is provided in Table ications . As relaAs for journals with the most publications, the focus of the top three journals was sports medicine, a result that is obviously owing to one of the two clinical types of HS, i.e., exertional heat stroke, which is associated with strenuous physical exercises Fig. a.According to the map based on the bibliographic data from the co-occurrence analysis of all keywords Fig. a, b, theEscherichia coli exerts regulation on heat shock proteins, specifically, HSP-1(heat shock protein-1), which function as stress-responsive activators [With respect to the latest research hotspots, heat-stress from the basic research cluster is the most recent (cluster 1), with an AAY of 2015.5. An increase in core temperature caused by heat stress has two possible pathways for causing multiple organ dysfunction [tivators . Keywordtivators  regardletivators . Hence, tivators , 25. Anotivators , 27. Thetivators . Additiotivators , 30. Fortivators . Thus, iExertional heat-stroke, exercise-induced hyperthermia and exertional heat illness belong to the clinical research cluster. The emergence of the three keywords is in accordance with the existence of controversies among diagnoses, preventions and treatments of HS that arises from a reliance on core temperature for diagnosing and assessing the severity of exertional heat stroke . First, With respect to the epidemiological research cluster, the newest keywords were ambient temperature and heat waves. A study has found that the temperature significantly rises in vehicles even on clear, sunny days, regardless of whether the windows are left open, thus threatening child passenger safety . HS induThe United States and China were the most productive regions for research on HS, and the scientific research strength of each region was directly related to their corresponding GDP (graphic abstract). The focus of keywords gradually shifted from basic research and clinical research to epidemiological research. It was also recommended to focus on promising research hotspots, such as heat stress, tumor-necrosis factor and heat waves. Our study provides profound insights into the research history and current status of HS, which may indicate its future trend.Additional file 1 : Supplemental Table 1. The analytic consequence of 100 keywords with at least 16 occurrence times. Supplemental Fig. 1. The Co-occurrence analysis of USA and China. Supplemental Fig. 2. The Co-authorship analysis of organizations and countries.