Evaluating the success of a public health campaign is critical. It helps policy makers to improve prevention strategies and close existing gaps. For instance, Brazil's “Syphilis No!” campaign reached many people, but how do we analyze its real impact on population awareness? Are epidemiologic variables sufficient? This study examined literature on using of information technology approaches to analyze the impact of public health campaigns. We began the systematic review with 276 papers and narrowed it down to 17, which analyzed campaigns. In addition to epidemiological variables, other types of variables of interest included: level of (i) access to the campaign website, (ii) subject knowledge and awareness, based on questionnaires, (iii) target population's interest, measured from both online search engine and engagement with Social Network Service, and (iv) campaign exposure through advertising, using data from television commercials. Furthermore, we evaluated the impact by considering several dimensions such as: communication, epidemiology, and policy enforcement. Our findings provide researchers with an overview of various dimensions, and variables-of-interest, for measuring public campaign impact, and examples of how and which campaigns have used them. Public communications campaigns (PCC) are strategic to communicating important information to the public . In the PHC aims to promote awareness, increase knowledge, encourage the adoption of desirable attitudes and behaviors, and contribute to individual and collective health decision-making . PHCs arFor example, the “Sífilis Não!” (Syphilis No!) campaign, communicated the importance of syphilis prevention, and recommended rapid syphilis testing or VDRL test, conducted at Basic Health Units (UBS) of the Unified Health System (SUS) in Brazil. The Ministry of Health sponsored the campaign, to fight the syphilis epidemic in the country. Between Nov 2018 and May 2019, a variety of content reached large audiences through various media platforms , as well as outdoor media, such as billboards and posters, and print media, such as magazines and newspapers.Campaign evaluations serve several useful purposes. They help policy makers improve prevention strategies and close existing gaps. Analysis can guide the development of better campaigns, to improve the impact or intensify the message. Understanding the effectiveness of a campaign can help to better direct the use of funds and effort. To assess levels of engagement with a given topic on a platforms such as the Internet, researchers are increasingly using computational approaches. A variety of such techniques and technologies have been used to assess the impact of public health campaigns. Subsequently, a secondary study is beneficial both to understand the current state-of-the-art and to guide future research in this domain.Accordingly, we performed a systematic literature review (SLR) according to Kitchenham and Charters  and PeteMass media campaigns have long been a tool for promoting public health  and therConversely, some studies do not target a specific public, such as: Shi et al.  aims to Dorfman et al.  proposedThis taxonomy was important to characterize a public campaign, but we missed other properties that we believe to be relevant. Such properties, presented in The research methodology for conducting this systematic literature review (SLR) was performed from the guidelines proposed by Kitchenham and Charters  and PeteThe goal of this research is to analyze information technology approaches that assess the impact of public health communications campaigns as a health care promotion strategic method. Thus, we framed the research questions using the PICOC  criteria as suggested by Kitchenham and Charters .Population: public health campaigns.Intervention: the use of technology information to evaluate health campaigns.Comparison: characterization of the measures used to support the evaluation of health campaign.Outcomes: characterization of the produced output, emergent techniques, overlooked areas and open issues.Context: any case where technology information approaches were used to evaluate health campaign.This leads to the following research questions (RQs):RQ1: When and where have the studies been published?RQ2: What are the characteristics  of the campaigns?RQ3: What variables of interest were analyzed to assess the impact of public health campaigns?RQ4: What techniques or tools have been used to support campaign impact analysis?Scopus database was the main source of scientific papers for the current study. We selected this digital library because it contains publications from major journals and conference proceedings, and it is one of the largest curated bibliographic abstract and citation databases of research literature . MoreoveIn May 2020, we conducted a preliminary search with a set of terms related to the research topics based on Population and the Intervention previous defined. The search generated many results. However, few were relevant. We repeated this process until we found a search string with a set of relevant results. To maximize recall, we did not include the comparison, outcomes, and context criteria in the search term. We considered the context criterion in Inclusion Criteria (IC), while the outcomes and the comparison criteria defined our data extraction strategy.*” AND (ii)  AND (iii) .The set of search terms included three aspects: (i) “campaignThe automated search looked for these terms in titles, abstracts, and keywords, in the Computer Science area. To increase the quality of the studies found, they had to be published in a peer- reviewed journal. In addition, a backward snowball search  was perfThe systematic review included studies that met the following two inclusion criteria: (IC1) The study discusses the effectiveness of using information technology approaches to measure public health campaigns; (IC2) The paper evaluates a health care campaign.Regarding the exclusion criteria (EC), studies were excluded if they presented at least one of the following criteria: (EC1) The study is not written in English; (EC2) The study is an older version of other study already considered; (EC3) The study is a short publication (<5 pages) or poster; (EC4) The study is a gray literature ; (EC5) Paper full text is not available for download.Titles and abstracts of papers resulting from the automated search were evaluated, rejecting papers that were obviously not relevant (Stage 1-identification). If eligibility was unclear from the abstract, the study was retained for further evaluation (Stage 2–screening). Subsequently, in Stage 3-eligibility, the full texts were read to confirm the criteria and submitted to Stage 4–included for data extraction.Fifty-one Studies Were Analyzed in Stage 2 and 18 in Stage 3. However, Only five Documents Were Included for Data Extraction. A Complete Analysis of 18 Documents Was Necessary to Understand the Research Context and to Apply the Inclusion and Exclusion Criteria More accurately.Those five documents served as basis for a subsequent analysis, through their own references, using the backward snowball technique. Thus, 225 articles were identified from citation searching (Stage 1), and screened (Stage 2) in order to verify the inclusion and exclusion criteria. In Stage 3, 19 articles were selected for complete reading and, finally, 12 articles met the determined criteria. Accordingly, 17 studies  were selected for data extraction  and source type , to avoid an exhaustive review. Accordingly, some studies–although relevant–may not be included. We mitigated this limitation by scanning the reference list through a backward snowballing technique  of identRegarding data extraction, the process of selection and classification of the studies was done by one researcher and all data extracted was checked by the other, and subsequently rechecked by the first researcher. At the end, we discussed the results and when doubts remained, a third researcher was consulted, to make the final decision.In total, 276 papers were found by the automatic and snowball searches. However, after applying the inclusion/exclusion criteria, 17 papers remained in the set of relevant papers. We believe that these 17 papers present the necessary criteria to answer the research questions.RQ1: When and where have the studies been published? Historically, the first publication was in 2003. Then, in 2008. After 3 years with no results found, publications returned in 2011, where there were annual publications until 2019. The countries carrying out this research were: Australia (n = 6), United States (n = 6), United Kingdom (n = 3), China (n = 1), and Norway (n = 1). Most studies were published in health and communication journals as shown in RQ2: Which topic areas were addressed to the campaign, location, and year? In the 17 selected studies, the topic areas addressed were Anti-Smoking , Children Vaccination , Newborn screening and biobanking programs , Overweight and Obesity , and Sexual Health Care .When the dates were not clearly specified in the article, an internet search was carried out to find approximate values. For example: In S01, influenza season (2013/2014) meant the period from 02/09/2013 to 13/04/2014 (It was dominated by the circulation of influenza A(H1N1) pdm09 virus, in Europe). When the articles specified only the month and year of the campaign, we considered the first (starting) and last (end) day of the month. One study (S07) did not report a period and due to this it was not shown in the RQ3: What variables of interest were analyzed to assess the impact of public health campaigns? The 17 studies evaluated several types of variables, such as: amount of access to the campaign website, awareness and knowledge of the subject through the questionnaires, interest of the population through the online search engine, engagement through the SNS, and advertising exposure data of television commercials.n = 10), social network service (n = 10), Sexually Transmitted Infection (STI) testing (n = 2), television commercials (n = 2), campaign website (n = 1), pharmaceutical products (n = 1), smoke-free restaurant laws (n = 1), sociodemographic data (n = 1), tobacco prices (n = 1). Most studies sought to cross-check the data obtained with socioeconomic and census data. The data source used to obtain the variables can be categorized as follows: questionnaire  assessing user engagement with the campaign subject through SNS, such as Facebook and Twitter ; and ii) assessing public knowledge, attitudes and behavior through questionnaires , before and/or after campaign dissemination.SNS were used to recruit participants to answer the questionnaires , assessing the reach and knowledge of the impacted people. The authors argued that this approach produced good results due to accurate user geolocation and demographic data .In addition, some studies  highlighted that Facebook advertisements significantly helped to increase both the number of people visiting a campaign webpage, and the number of users who could potentially improve their knowledge and health care behavior, because of the campaign.https://www.nielsen.com/ca/en/about-us/). S03 used TV ratings correlated with social media (Twitter) while S06 correlated TV ratings with questionnaire, tobacco prices, population use of pharmaceutical smoking cessation products, and smoke-free restaurant laws. In both cases, the results indicated success in the approaches used to assess the campaign impact.Televised ads were assessed in two anti-tobacco campaigns using broadcasting time and its Nielsen rating , epidemiology (n = 10), and public policy (n = 2).Grouping the variables of interest in dimensions (areas of context) provided better understanding about which dimension was most explored. Our findings show three dimensions: communication  were widely explored in the studies, the main tools were the dashboards of the respective sites . SNS dashboards often provide enough data to verify the engagement of privately hosted websites.http://www.gnip.com). This vendor provides real-time access to 100% of all tweets and meta-data. These analyses and correlations were supported by general linear models used to assess the relationship between demographics data and campaign awareness. Furthermore, Google analytics was used to identify the number of unique users, total visits, page views, unique views, and average visit duration for each page of the campaign website.Nevertheless, analyzing user-generated content on a social network, such as Twitter, and inferring correlations with campaign data requires a detailed evaluation of the content. Accordingly, the studies S03, S09, and S10 obtained data from Twitter through a licensed data provider (https://www.stata.com/) while studies S06, S08, and S17 used Statistical Analysis System–SAS (https://www.sas.com/enca/software/stat.html). NVivo , a qualitative data analysis software, was used by S05 for textual analysis of the questionnaires and by S11 to capture the campaign page content, using a simple counting method to describe user and moderator content, discussion thread patterns, and moderator intervention. S12 used a web-based survey administration and data management application called REDCap (https://www.project-redcap.org/).Regarding software for statistical analysis and using data science to explore, visualize, model and make inferences in the data, studies S12, S13 and S16 used Stata (https://www.ibm.com/support/pages/spss-statistics-220-available-download), a software platform that offers advanced statistical analysis, a vast library of machine learning algorithms, text analysis, open-source extensibility, integration with big data and seamless deployment into applications.In S05, all statistics analyzes were conducted with SPSS Statistics 22  to test all variables defined in the study.This paper assessed how researchers evaluate public health campaigns. Based on the studies found and the answers to the research questions, we observed that the studies sought to assess campaign impact through quantitative and qualitative analysis, using mainly SNS, especially Facebook. The popularity of social platforms such as Facebook–in the United States and worldwide–serves to justify this approach , 41. FacIn addition, SNS are a rich source of data that can provide responses to PHC impact assessments. This may be because data is available to users through the dashboards, where it is possible to observe quantitative values. Detailed data can be easily obtained from some vendors, by paying fees, which facilitates data collection, allowing such methods and tools to do the “heavy lifting” . A potential threat related to this approach is to identify real engagement of users. Some studies reported this issue , which raised the following question: What is the real motivation to engage on campaign interventions pages on social networks? What about the “spiral of the silence”  which suIt is intriguing to consider the paradox of trying to reach a target audience through the SNS to raise awareness about an infectious disease, since some parts of the population cannot be reached through technologies and the Internet. In Brazil, for example, internet use reached 152 million people, representing 81% of the population. This percentage drops to 67% when we looked at the lower social classes . HoweverIn addition, questionnaires targeting impacted users was another effective form of evaluating campaign impact. This approach is useful for measuring target audience awareness, attitudes and behavior, and has been used in eight out of 17 primary studies.In contrast to most of the studies analyzed, article S15 reported that advertisements through paper-based methods, text messaging and social networking sites were not effective. In this study, only 28 rural youth contacted the health care service  over the 11-month period. Twenty young people were reached by nurses , six through the campaign webpage, one through Facebook and one through the student diary. No clients were recruited through other advertising methods. Arguably, the limited publicity could be because the target audience were young people living in rural areas in Victoria, Australia. Therefore, although SNS have a great potential to provide data to analyze the impact of campaigns, attention must be paid to the public and the conditions of access and web-behavior of that public.Despite the widespread use of social networking sites, only one study (S01) sought a second source of data based on user-generated Internet content (Microsoft's Bing search engine). The study aimed to introduce a complementary framework for evaluating the impact of a targeted intervention, such as a vaccination campaign against an infectious disease, through statistical analysis of user-generated content submitted on web platforms (Twitter and Bing search engine). The results from Twitter data demonstrated less sensitivity across similar controls relative to Bing data, suggesting a greater reliability.In general, we observed a gap in assessing the impact of public health campaigns, regarding the use of online data  and others user-generated Internet content. Google Search and Yahoo should be used in addition to Bing search engine to check the increase of news related to the campaign. In addition, a variety of questions should be asked, such as what can the analysis of this content bring? Are campaigns helping to grow spontaneous news on the related topic? When evaluating a population over time, Google Trends is arguably an excellent tool to demonstrate how the population has sought to know about a certain topic –48. HoweMoreover, databases of scientific papers such as Springer Nature, Wiley Blackwell, Taylor and Francis, IEEE, American Physical Science and Elsevier and its indexers such as Scopus, Web of Science (WoS) and Google Scholar could be used to demonstrate the interest of the academy in developing research on the campaign theme in a comparison of time . These variables of interest can show a new dimension, Education.Health campaigns are common worldwide. Nevertheless, few studies have reported concrete campaign data. We would like to encourage future research to better specify analyzed data in their studies showing properties raised by Dorfman et al.  and compNotably, by using variables of interest that were grouped into three dimensions (as discussed in this review), we analyzed the reach of the “Syphilis No!” campaign , assessiThe paper provided an overview of studies that evaluate the impact of public health campaigns. The analysis focused on identifying variables of interest, techniques and tools used. We discussed the results, presented new questions, and discovered unexplored variables of interest.Public health campaigns play a strategic role promoting awareness, increasing knowledge, and encouraging the target population to adopt desirable attitudes and behaviors. As observed, its impact must be measured in several dimensions such as: i) communication , ii) epidemiology , and iii) policy enforcement .This multidimensional analysis provided a complete evaluation of public health campaigns, to understand its scope, find correlations between different variables of interest and expand possibilities for analysis.Accordingly, we hope this work will motivate future researchers to explore other variables of interest and dimensions that are possibly overlooked in assessing the impact of public health campaigns based on multidimensional aspects.The original contributions presented in the study are included in the article/RP, LS, and VK: conceptualization. RP, LS, RV, and VK: methodology. RP, LS, RV, VK, CG, CO, and JL: validation and writing–review and editing. RP and LS: formal analysis. RP: investigation, data curation, and writing–original draft preparation. LS, RV, and VK: supervision. RV: project administration and funding acquisition. All authors contributed to the article and approved the submitted version.Brazilian Ministry of Health–Number's project: 54/2017.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Background: Malignant bone tumors (MBT) are one of the causes of death in elderly patients. The purpose of our study is to establish a nomogram to predict the overall survival (OS) of elderly patients with MBT.Methods: The clinicopathological data of all elderly patients with MBT from 2004 to 2018 were downloaded from the SEER database. They were randomly assigned to the training set (70%) and validation set (30%). Univariate and multivariate Cox regression analysis was used to identify independent risk factors for elderly patients with MBT. A nomogram was built based on these risk factors to predict the 1-, 3-, and 5-year OS of elderly patients with MBT. Then, used the consistency index (C-index), calibration curve, and the area under the receiver operating curve (AUC) to evaluate the accuracy and discrimination of the prediction model was. Decision curve analysis (DCA) was used to assess the clinical potential application value of the nomogram. Based on the scores on the nomogram, patients were divided into high- and low-risk groups. The Kaplan-Meier (K-M) curve was used to test the difference in survival between the two patients.Results: A total of 1,641 patients were included, and they were randomly assigned to the training set  and the validation set (N = 485). The univariate and multivariate analysis of the training set suggested that age, sex, race, primary site, histologic type, grade, stage, M stage, surgery, and tumor size were independent risk factors for elderly patients with MBT. The C-index of the training set and the validation set were 0.779 [0.759–0.799] and 0.801 [0.772–0.830], respectively. The AUC of the training and validation sets also showed similar results. The calibration curves of the training and validation sets indicated that the observed and predicted values were highly consistent. DCA suggested that the nomogram had potential clinical value compared with traditional TNM staging.Conclusion: We had established a new nomogram to predict the 1-, 3-, 5-year OS of elderly patients with MBT. This predictive model can help doctors and patients develop treatment plans and follow-up strategies. The most common malignant bone tumors (MBT) in elderly patients include osteosarcoma, chondrosarcoma, and chord sarcoma. Osteosarcoma is the most common malignant bone tumor in children and adolescents. About 60% of osteosarcoma patients occur under 20 years of age, and ~10% of patients occur over 60 years of age . At the Studies have reported that the main prognostic factors of osteosarcoma include tumor site, size, age, metastasis, metastasis site, chemotherapy, and surgery , 14. TheArtificial intelligence has been widely used in human health care. Hassan et al.  summarizThe nomogram is a numerical model that predicts an outcome event by using estimated values generated based on various variables , 22. TheThe clinicopathological information of all patients over 60 years old with chondrosarcoma, osteosarcoma, and chord sarcoma from 2004 to 2018 was extracted from the SEER database. The extracted information includes age, gender, race, primary sit, histological grade, histological type, tumor size, TNM stage, surgery, radiotherapy, chemotherapy, and follow-up information. The selection criteria are: (1) age ≥ 60 years old; (2) histological classification includes: chondrosarcoma, osteosarcoma, and chord sarcoma. The exclusion criteria are: (1) survival time is less than one month; (2) tumor size is unknown; (3) TNM stage is unknown (4) surgical method is unknown; (5) tumor stage is unknown. The flow chart of patient screening is shown in The age of all patients was divided into five groups, including 60–64, 65–69, 70–74, 75–79, ≥80 years old. The race was divided into three categories: white, black, and others . The tumor grade was divided into four grades: well-differentiated, moderately differentiated, poorly differentiated, and undifferentiated, and some were unknown graded. The tumor stage was divided into three categories, including localized, regional, and distant. Surgical methods included no surgery, partial resection, radical resection, and amputation.All patients were randomly divided into a training set (70%) and a validation set (30%). Univariate and multivariate Cox regression models were used to determine independent risk factors for patients. These risk factors were included in the nomogram to predict the 1-, 3-, and 5-year OS of elderly patients with MBT. The consistency index (C-index) was used to test the discrimination of the nomogram. The area under the receiver operating curve (AUC) was also used to evaluate the training and validation set's accuracy and discrimination. A calibration curve of 1,000 bootstrap weight samples was used to test the accuracy of the prediction model.Decision curve analysis (DCA) of the training set and validation set was used to evaluate the clinical value of the nomogram. A new algorithm assesses the model's weight by calculating the net benefit under the risk threshold . We alsoU-test for analysis. Univariate and multivariate Cox regression models were used to analyze survival risk factors. This study believes that P < 0.05 is statistically significant, and this test is two-sided.All statistical analyses were performed using SPSS version 26.0 and R software version 4.1.0. The median (inter-quartile range) was used to describe the data that did not follow the normal distribution for measurement data. The non-parametric test (U-test) was used to analyze the difference. For count data, used frequency (%) to describe, used chi-square analysis and non-parametric N = 1,156) and the validation set (N = 485). The clinical-pathological data of the patient is shown in A total of 1,641 patients were included, and they were randomly assigned to the training set (We used univariate Cox regression analysis to confirm the risk factors for the prognosis initially. The selected risk factors were then included in the multivariate Cox regression analysis. In the end, we found that age, sex, race, primary site, histologic type, grade, stage, M stage, surgery, and tumor size were independent risk factors for elderly patients with MBT. The independent risk factors screened by univariate and multivariate analysis are shown in A nomogram was constructed based on the identified independent risk factors to predict the 1-, 3-, and 5-year OS of elderly patients with MBT . It can DCA suggested that nomogram had potential clinical value compared with traditional TNM staging . Based ohttps://jietang.shinyapps.io/DynNomapp/. Enter the clinicopathological characteristics of the patient on this web page to get the corresponding survival probability. This calculation is easy to use and friendly to both patients and doctors.We have developed a web calculator based on the nomogram, which can be accessed at Cancer is one of the most common causes of death in elderly patients. The morbidity and mortality of bone tumors are high. A study has reported 3,600 new bone tumor patients in the United States each year and 1,720 deaths from bone tumors . AlthougIn our study, we found that the increase in age will reduce the survival rate of elderly patients. Previous studies have also reported that age is a risk factor for bone tumors , 29. TheIn this study, we found that surgery significantly improved the prognosis of patients, similar to the results of previous studies , 37. In Although our nomogram includes three histological types of MBT, it has been validated that the prediction model has good accuracy and discrimination. The C-index of the training set and the validation set were 0.779 [0.759–0.799] and 0.801 [0.772–0.830], respectively, proving the discriminative ability of the nomogram. The predicted value of the calibration curve is highly consistent with the observed value, which indicates the accuracy of the prediction model. We compared the 1-, 3-, and 5-year DCA of the nomogram with the traditional TNM staging system and proved that the clinical value of the nomogram is higher than that of the traditional TNM staging system. Risk stratification also accurately distinguished high-risk and low-risk patients, and treatment and follow-up strategies should be different for patients in other risk groups. Patients in the high-risk group should choose appropriate treatment and receive closer follow-up.This study is the first to explore risk factors for death in elderly patients with MBT using data from the SEER database. The overall survival rate of elderly patients with MBT was predicted based on risk factors. In other words, when elderly patients with MBT are admitted to hospitals, doctors can accurately inform patients of the 1-, 3- and 5-year survival rates based on these critical prognostic factors and make corresponding treatment decisions and follow-up strategies according to the survival rate of patients. This nomogram is of great significance for elderly patients with MBT.However, our study still has some limitations. First, the SEER database cannot obtain detailed information on some variables such as surgical margins, BMI, smoking, and drinking, so it has a specific impact on prediction accuracy. However, we include essential variables such as tumor stage, size, surgery, and other factors that affect the prognosis of patients so that the results will not cause a devastating deviation. Second, The lack of information on some critical variables will cause errors in the prediction results. For example, the tumor grade of some patients is unknown. However, it can be seen from the nomogram that the lack of tumor grade of some patients did not cause serious bias. Finally, our nomogram has only been validated internally, and external validation is necessary to test the predictive power of the nomogram.A comprehensive nomogram was constructed to predict the 1-, 3-, and 5-year overall survival of elderly patients with MBT. This nomogram has been validated to have good accuracy and reliability and help patients and doctors predict survival prognosis and formulate treatment and follow-up strategies.https://seer.Cancer.gov.Publicly available datasets were analyzed in this study. This data can be found here: The public and anonymous data shared in this study is obtained from the SEER database.JT, JW, and XP: contributed to the conception and design. JW and JT: collected, analyzed the data, drew the figures and tables, and wrote the draft. XP and JT contributed to manuscript writing and revision. All authors approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The attitude scores were significantly higher among the Saudi physicians (p = 0.027) and those with PHC work experience of less than five years (p < 0.001). Regarding the practices, a significant association was found among the age group of less than 30 years (p = 0.019) and Saudi physicians (p = 0.003). There was a significant positive correlation between knowledge (correlation coefficient (r) = 0.739, p < 0.001) and attitude  with the practice scores. It is recommended that targeted continuous medical education, workshops, and seminars are conducted on the prevention and care of DR among primary care physicians. Furthermore, an exploratory multicenter study that involves primary care physicians belonging to all ministries and private sectors is warranted.Primary care physicians play a vital role in preventing the progression of diabetic retinopathy (DR) from the initial stages to the late stages. This questionnaire-based analytical cross-sectional study was carried out to assess the knowledge, attitude, practices, and their correlation among 274 randomly selected primary care physicians in Saudi Arabia. Among the studied population, high knowledge, attitudes, and practice scores were observed in 21.5%, 15%, and 29.2% of the physicians, respectively. The mean knowledge score was significantly higher among the age group of less than 30 years ( The International Diabetes Federation (IDF) reported that the prevalence of diabetes mellitus (DM) in the adult population in the Kingdom of Saudi Arabia (KSA) is 18.3%, and the total cases of DM are estimated to be around 4.3 million among the adult population ,3. DR isGlobally, the prevalence of DR ranges from 18.9% to 40.3% among diabetes patients ,8,9. A sHealth care is delivered in the KSA at four levels, starting from primary health centers and going up to referral hospitals. Primary health care is delivered in the KSA through a chain of primary health centers and this is the first level of contact for the public for all their health-related needs . The priIn the initial stages of DR, patients are usually asymptomatic and rarely notice their vision impairment. Hence, they may not seek clinical attention from physicians, primarily those not specialized in ophthalmology ,15. The The assessment of knowledge, attitude, and practices towards DR among patients and primary care physicians is essential for coordinated efforts to prevent the progression of DR from the initial stages to the late stages. In the KSA, several studies have been performed among the patients to assess their awareness and attitude towards DR ,20. HoweThis analytical cross-sectional study was carried out from June 2021 to October 2021. In the KSA, health care to the public is delivered through four levels: primary health centers, general hospitals, specialty hospitals, and medical cities . There are thirteen administrative regions/provinces in the KSA. The present study was performed among the primary care physicians working at PHCs in four regions of the KSA . According to the Ministry of Health (MOH), KSA, there were 942 primary care physicians registered in these four regions.2 pq/e2. In this formula, p is the expected prevalence, q is 1 − p, and e is the margin of error at 5%. Whilst calculating the sample size, the factors considered were the expected proportion (p) as 50%, a study power of 80%, and a confidence interval at 95%. As previous studies have depicted a wide range of prevalence in this subject, we took p as 50% to obtain the maximum sample size. Considering the above factors with a finite population of 942, the estimated sample size was 274.The sample size was calculated based on the formula zThe present study applied a probability systematic random sampling method to select the required number of study participants. In this method, all primary care physicians were ordered according to their number assigned by the research team and every third physician was invited to participate in the study. In the event of a non-response from the selected physician, the next participant on the list was asked to participate.The research team initiated the data collection process after ethical clearance and other necessary approvals. The data collectors of this research visited the selected physicians at their health centers. After briefing about the study and obtaining informed consent, the participants were requested to fill in the online data collection sheet on the electronic devices of the data collectors . The research team followed the standard COVID-19 prevention protocol administered by the MOH, KSA, during the data collection process. No other member of the research team except the principal investigator had authorization to access the Google form for the present study. The present study only included MOH-registered physicians. Primary care physicians working in other ministries, physicians on vacation, physicians unwilling to participate, and physicians in the private sector were excluded from this study.A Google form was created with a standard and validated questionnaire adapted from open-source pieces of literature . We condn; %) and the continuous data were presented as a mean and standard deviation (SD). Initially, we performed a Kurtosis and Skewness analysis followed by the Kolmogorov-Smirnov (K-S) test to assess the normality assumption of the collected data. The K-S test values were 0.093, 0.111, and 0.084 and the asymptotic significant values (two-tailed) were 0.158, 0.194, and 0.182, respectively, for the knowledge, attitude, and practices scores. We then performed a one-way analysis of variance (ANOVA) and an independent t-test to find the difference between the knowledge, attitude, and barrier scores with the socio-demographic characteristics of the study population. The research team also executed a Pearson’s correlation analysis to find the relationship between the knowledge, attitude, and practices of the primary care physicians towards DR. Furthermore, we performed a multiple linear regression analysis to identify the correlation between the knowledge, attitude, and practices scores after adjustment with other covariables of the present study. A p-value less than 0.05 identified through two-tailed tests was considered to be a statistically significant value.The collected Microsoft Excel data from the Google form was exported to Statistical Packages for Social Sciences (SPSS), version 21, and coded as per the coding sheet of this survey. The categorical variables were presented as the frequency and proportion , attitude (15%), and practice (29.2%) scores. The majority of them had medium/low scores in all three variables .p = 0.031), the female gender (p = 0.012), Saudi physicians (p < 0.001), and PHC work experience of less than 5 years (p = 0.014). The mean attitude scores were significantly higher among the age group of less than 30 years (p = 0.001), Saudi physicians (p = 0.027), and PHC work experience of less than 5 years (p < 0.001). Regarding the practices, a significant association was found between the age group of less than 30 years (p = 0.019) and Saudi physicians (p = 0.003).p < 0.001) and attitude  with the practice scores.The correlation between the knowledge, attitude, and practice was evaluated by using a Pearson’s correlation analysis. p = 0.008) and attitude  with the practice scores , WHO, and IDF with the main focus on raising awareness of diabetes and its complications. The UN declared the theme for World Diabetes Day 2021–2023 as “access to diabetes care”, focusing on the necessity of continuous support and care to manage the diabetes status and avoid complications such as DR . The preThe present study revealed a suboptimal knowledge among primary care physicians about DR. Similar to the results of the present study, a study by Nyonsavye in Kenya also reported that only a low proportion of general practitioners and primary care physicians had a high knowledge of DR . SimilarThe present study further attempted to find the association between the socio-demographic characteristics with the attitude and practice scores. This study found that both the attitude and practice scores towards DR were significantly higher among the younger age group and Saudi nationals. Furthermore, the present study did not reveal an association between male and female genders with the attitude and practice scores. Contrary to the present study findings, a study performed in the Riyadh region of the KSA found no association between age and nationality . InteresThis study found that only a low proportion of the participants had high knowledge, attitude, and practice scores. Similar to our study, Alrashid et al. in the Riyadh region of the KSA also found that a low proportion of participants had high scores in the knowledge category . In addiThe current study found a positive correlation between the knowledge and attitude with the practice, In Nigeria, a survey conducted by Abdulsalam et al. reported no significant correlation between the knowledge, attitude, and practice scores . This stThe strength of the present study was that it was conducted among 274 primary care physicians from four different provinces of the KSA. To date, this study has the highest number of primary care physicians surveyed on this subject in the KSA. The research team collected the data using a structured and validated questionnaire. Additionally, we used a probability systematic sampling method to select the required number of participants. Hence, the study has several strengths of systematic sampling methods. Although the research team performed this study with a standard methodology, certain constraints need to be considered whilst judging the results of this study. Firstly, the present study included only primary care physicians working at MOH primary health centers of four regions. Hence, the findings of this study cannot be generalized to all regions of the KSA or the Middle East. Secondly, this cross-sectional study assessed only the association between the variables and not the causation. Finally, this survey was based on self-reported responses from primary care physicians. Hence, the possibility of recall bias and social desirability bias cannot be ignored.The present study showed that less than one-third of primary care physicians had a high level of knowledge, attitude, and practice with respect to diabetic retinopathy. In this study, we found several associated factors for high knowledge, attitude, and practices. Furthermore, a positive correlation of the knowledge and attitude with the practice score indicated that an increased knowledge and attitude could help with excellent and efficient practices for DR care at an early stage. Hence, it is recommended that focused continuous medical education (CME), workshops, and seminars are conducted on the prevention and care of DR among primary care physicians. These training programs may also be specifically targeted towards the low and medium knowledge category physicians. Furthermore, an exploratory multicenter study that involves all non-ophthalmic physicians of both the government and private sectors is warranted.


The suppressive rate for axial elongation in the VL glasses group was 21.4% for two years.The fact that outdoor light environment is an important suppressive factor against myopia led us to invent violet light-transmitting eyeglasses (VL glasses) which can transmit violet light (VL), 360–400 nm in wavelength, for the suppression of myopia, and can meanwhile block harmful ultraviolet waves from sunlight. The current study is a double-blinded randomized clinical trial to investigate the myopia-suppressive effect of VL glasses compared to conventional eyeglasses (placebo glasses) that do not transmit VL. The subjects were children aged from 6 to 12 years old, the population in which myopia progression is generally accelerated, and the myopia suppressive effect was followed up for two years in a city in Japan. Periodical ophthalmic examinations, interviews, and measurements of reflection and axial length under mydriasis were performed at the initial visit (the baseline) and at 1, 6, 12, 18, and 24 months. The mean change in axial length in the VL glasses group was significantly smaller than in the placebo glasses group when time for near-work was less than 180 min and when the subjects were limited to those who had never used eyeglasses before this trial ( Myopia is reported to progress due to both genetic and environmental factors , but itsWhen myopia progresses and turns into high myopia, the axial length grows and the shape of the eye changes, which may lead to blindness because of sequelae such as myopic maculopathy, glaucoma, and retinal detachment ,4. In a It is crucial to control environmental factors to suppress the progression of myopia. There are some studies regarding environmental factors in relation to myopia progression, such as the Orinda Study , the SinAlthough many researchers have performed investigations to reveal the reason for the effectiveness of outdoor activities on myopia prevention, there are studies focused on a light wavelength that exists in the outdoor environment. The current environment regarding myopia is characterized by ultraviolet-blocking materials such as windows and eyeglasses . Previoup < 0.05) [p < 0.05) [There have been some previous studies concerning VL. Torii et al. demonstrated that VL suppressed axial elongation and myopic shift of the refractive error in a lens-induced myopia model using chicks . The sam < 0.05) . Another < 0.05) .VL exist in the outdoor environments; however, they hardly exist in indoor environments because most of them are blocked by windows . LikewisThus, we invented eyeglasses that transmit VL and block harmful short ultraviolet (UV) light from sunlight. We designed the study to investigate the myopia-suppressive effect of our eyeglasses, violet light-transmitting eyeglasses (VL glasses), for two years, comparing with conventional eyeglasses (placebo glasses) that do not transmit VL.This was a prospective randomized double-blind placebo-controlled trial conducted for 2 years. The study was performed in compliance with the Declaration of Helsinki, Ethical Guidelines for Medical and Health Research Involving Human Subjects, and local regulatory requirements, and was also conducted under the approval of all study institutional review boards (IRB) and ethics committees. This trial was approved by the Certified Review Board of Keio . This trial was also registered by Japan Registry of Clinical Trials with the registration number jRCTs032180418. This randomized control trial followed CONSORT guidelines.The participants were recruited at Hara Eye Clinic, Tochigi, Japan. The analysis of statistics was outsourced to an independent company , without any relationship with JINS HOLDINGS, Inc., Gunma, Japan, the sponsor of this clinical study, and interpretation after the results of the analysis was performed by the department of ophthalmology and laboratory of photobiology, Keio University School of Medicine, Tokyo, Japan.The participants were enrolled from July 2016 to August 2018 and followed-up for 24 months. As for the sample size, previous research results of MyoVision  showed values of 0.78 ± 0.29 mm for axial elongation and −1.65 ± 0.80 D for refractive change for two years while wearing conventional eyeglasses . When coChildren who met all the criteria were included in the study; (1) those who were aged 6–12 of both gender at the moment of consent; (2) those who spent at least 1 h per a day outdoors; (3) those whose cycloplegic refraction in each eye was between −1.50 D and −4.50 D, (4) those who had one or two parent/s with myopia; (5) those who were able to wear eyeglasses habitually and who could fulfill clinical visits in accordance with the study protocol; (6) those who had no ocular diseases besides ametropia; and (7) those who could provide written informed assent from the study subjects (hereinafter referred to as “subject(s)”) themselves and informed consent from their legal guardian(s). Children who met at least one of the following criteria were excluded from the study; (1) those who had worn bifocals or progressive power lenses; (2) those who had worn orthokeratology lenses; (3) those with anisometropia exceeding 1.50 D; (4) those with astigmatism exceeding 1.50 D, (5) those with manifest strabismus; (6) those with a history of refractive surgery; (7) those with a history of keratoconus, herpetic keratitis, or papillary hyperplasia, etc.; (8) those participating in an ongoing similar study; or (9) those who had been judged to be ineligible to participate in the study by the investigators.Randomization followed the EDC system. Static allocation of stratification by (1) age and (2) gender, i.e., random substitution block method, was performed, and schoolchildren were assigned to either a VL glasses group or a placebo glasses group. The principal investigator and the co-investigator/s were not informed about the details of the allocation steps.The intervention group was obliged to wear VL glasses for 24 months, whereas the control group was instructed to wear conventional eyeglasses (placebo glasses) that did not transmit VL . The primary investigator or co-investigator prescribed refraction correcting eyeglasses based on the result of a visual acuity examination under cycloplegia which was conducted at the baseline. Whether the glasses were VL glasses or placebo glasses was not disclosed to the primary or co-investigator at prescription. At the point of regular eye examination, 1, 6, 12, 18, and 24 months after the baseline, over the 24-month research period, new correcting glasses of each type were prescribed to gain 20/20 or more of visual acuity. Barring these points, the same correcting glasses of each type were prescribed only in case of accidental damage or loss of eyeglasses, and the prescriptions were not allowed to be changed. ®III, NIDEK, Tokyo, Japan) with 0.01 D increments. The measurement of objective refraction under cycloplegia was performed one hour after the application of 1% cyclopentolate hydrochloride eyedrops . Axial length was measured with an IOLMaster 500 . Interviews of the participants were performed at every visit. Participants’ age, gender, number of parents with myopia, living environment, and lifestyles such as time for sunlight exposure, near work, sleep, and physical activities were asked. The time for sunlight exposure and near work was calculated with weighted means of 5 weekdays and 2 weekends. Regular eye examination was performed at 1, 6, 12, 18, and 24 months from the baseline to measure the visual acuity of the prescribed eyeglasses, best corrected visual acuity, subjective refraction, objective refraction under cycloplegia, and axial length. Regarding adverse events, surveillance of each participant during the whole period of this study was performed to report in the form of case reports.At the first encounter, details of the study design and the rights of the participants were explained. An eye examination was performed to measure subjective/objective cycloplegic refraction and axial length following written informed consent. The best corrected visual acuity of subjective refraction was measured under cycloplegia to prescribe the eyeglasses. Objective refraction was measured with a closed-field type auto ref/kerato/tono/pachymeter , under cycloplegia for 24 months, respectively.All data were analyzed based on the intention-to-treatment principle. The primary analysis was performed in the per-protocol set (PPS), and robustness of the results was explored through sensitivity analysis in the full analysis set (FAS). The repeated-measure outcomes were analyzed with a linear mixed-effects model for repeated measures (MMRM) that included intervention, dummy variables for time, intervention-by-time interactions as covariates, and the subjects as a random effect. Furthermore, in this model, all measurements obtained from both eyes were used and entered as repeated effects. The covariance structure was a completely general  covariance matrix. The results were reported as the least squares means with 95% confidence interval (CI) at each time-point. The odds ratios (OR) and 95% confidence intervals (CI) were calculated by univariate logistic regression analysis for independent risk factors associated with rapidly progressed myopia, i.e., increase in axial length by 1.2 mm or more, and deterioration of SER by −2.5 D or less at 24 months. Multivariate analysis was performed with adjustment by gender, “already wearing glasses at first visit”, and parental myopia. There are some papers regarding the definition of rapid progression of myopia. Rapid progression of myopia is mostly defined as −1 D or less of decrease in refractive errors per year ,33. In tSubgroup analysis according to factors considered to be related to the outcome  was conducted with the MMRM. The time of near-work was calculated by weighted means of 5 weekdays and 2 weekend days.p-value of <0.05 was considered statistically significant, and all p-values were two-sided without multiplicity adjustment. All statistical analyses were performed using SAS 9.4 Foundation for Microsoft Windows for x64 .A A total of 113 children were enrolled in this trial. Of these, 57 participants were assigned to the placebo glasses group (placebo group) and 56 participants to the VL glasses group (VL group) . During The profiles of the participants are shown in No adverse effects associated with violet light exposure were reported during the 2-year-clinical study. All adverse events reported during the study were not associated with violet light exposure .p = 0.381), and that of the spherical equivalent was similarly small at 0.110 , without significant statistical difference by the mixed effect model with individual variation factors and repetition effects of the bilateral eyes  belonged to the placebo group and 56  to the VL group. Finally, 91 participants—46 in the placebo group and 45 in the VL group—were selected after application of exclusion criteria such as familial issues and protocol deviation from the research protocol. PPS is defined as cases excluding subjects who fell into the exclusion criteria. FAS is defined as all the cases included in this study. For example, PPS does not include those who did not spend more than 1 h outdoors . In totaral eyes . Factors that contributed to deterioration of myopia were investigated by logistic analysis in this study. This approach suggested that risk factors of 1.2 mm or more of axial elongation were young age, having already worn eyeglasses at the baseline, small change in BMI, paternal myopia, and short sleeping duration . Risk fap = 0.006), whereas the mean change in SER in the VL group was small but not significant  using a mixed effect model  in the placebo group and 0.751 mm (95% CI: 0.646–0.855) in the VL group, respectively, when near-work time was less than 180 min. The change in SER was −1.841D (95% CI: −2.056–−1.626) in the placebo group and −1.538D (95% CI: −1.860–−1.316) in the VL group, respectively. The mean change in axial length in the VL group was significantly small  smaller than those in the placebo group at 24 months. (B) The adjusted means of SER changes in the VL group were smaller than those in the placebo group at 24 months, which was not significant (p = 0.055). Orange lines show the VL group and blue lines show the placebo group. Error bars show 95% confidence intervals. ** p < 0.01. AL: axial length; SER: spherical equivalent refraction; VL group: violet light-transmitting eyeglasses group.The results were obtained by linear mixed-effects model analysis. (A) The adjusted means of change in AL in the VL group were significantly (p < 0.01). This is the first randomized controlled study of VL glasses that reflects their potency. However, this study could not attain statistical significance when no limitation regarding near-work time and eyeglasses histories of the subjects was applied. Because VL transmitting eyeglasses do not exert their effect until they transmit VL in an outdoor environment, it was inappropriate to perform analysis while including the cases who did not have enough time for outdoor activity; therefore, PPS was performed. Nevertheless, since there were unexpectedly many unregistered cases, and those of protocol deviation such as shortage of outdoor activity time, VL glasses were merely found to have a tendency to be effective, but they did not reach statistical significance, even by PPS. The subgroup analysis limited to the group with no history of eyeglasses before this study, and with less than 180 min of near-work time, eventually revealed that VL glasses significantly suppressed axial elongation. The suppressive rate of axial elongation in the VL glasses group for two years was 21.4%, which could be considered meaningful to some extent.According to previous reports, VL has an effect on suppressing myopia progression ,26,30. BThe reason why limiting the subjects with no history of wearing eyeglasses led to the result being significant regarding axial elongation was sought. This study also revealed that the speed of myopia progression in the subgroup that had already worn conventional eyeglasses was actually fast; this result is possibly due to genetic background and the development of myopia at the early stage of life . The excAs a prerequisite for a human study, there have been some reports concerning animal experimental models. Exposure to long-wavelength red light developed hyperopic responses in Rhesus monkeys and tree shrews ,35, wherVL is characteristic of the shortest wavelength and adjacent to ultraviolet waves. Because of this fact, it has often been considered whether VL is detrimental to the eyes. In this study, we did not find any adverse events during the two-years period through this study by regular examinations, including ocular surface, cataracts, allergy, and the fundus . When VLTo date, there have been many types of eyeglasses sold to the public. In order to study the pure effectiveness of VL glasses, the subjects were limited to children who had never worn eyeglasses. Moreover, at the baseline, near-work time in the VL group was less than that in the placebo group, as shown in This study includes some limitations. First, it was performed in a rural area in Japan where children spend much time outdoors; sufficient outdoor activities were an essential condition to demonstrate the myopia-suppressive effect of the VL glasses, as VL exists in the outdoor environment but not in the indoor environment. However, the result did not follow our expectations. The mean time for outdoor activities in a day did not reach 1 h; therefore, we could not analyze all the participants to judge the effectiveness of the VL glasses. Second, we established the necessary number of subjects by calculating sample sizes referring to previous research regarding MyoVision eyeglasses . DespiteViolet light-transmitting eyeglasses suppressed axial elongation without any adverse events and their suppressive rate was 21.4%.A patent has been applied for the optical components internationally (Patent No. WO2017/090128) and registered in Japan (JP.6629343), US (US.10866433) and China (CN.108474888) by Tsubota Laboratory, Inc. and JINS HOLDINGS, Inc.


Autobiographical memories (ABMs) produce rich phenomenological experiences. Although few standardized and comprehensive measures of the phenomenology of ABMs have been developed, a web-based assessment of the full range of phenomenological properties is still missing. In the present study, we aimed to fill this gap and tested the psychometric properties of a web-based version of the Assessment of the Phenomenology of Autobiographical Memory (APAM) in a group of young and older adults. Specifically, taking advantage of the flexibility of web-based assessment methodology, we tested the rating consistency of APAM items, asking participants to rate the phenomenology of their ABMs with respect to seven cues, administered in one per day in seven different days. In each session, we also collected ratings of mood and arousal. Using linear mixed modeling (LMM), we could examine whether the phenomenology ratings differed with respect to age group while controlling for sex, age of the memory, arousal, mood, and specificity of the memory. Results revealed an adequate level of consistency of ratings in both young and older adults. Moreover, LMMs revealed a more intense experience of recollection and reliving  and a higher confidence in memory accuracy in older compared to younger adults. The theoretical and practical usefulness of a web-based assessment of the phenomenology of ABMs are discussed. The median proportion of memories elicited by cue words was 0.90 (range 0.76–0.97), and did not differ between participants (X2 (1) = 3.08, p = 0.080, Cramér’s V = 0.08 ).The median number of memories elicited by the seven cue words in single participants was 6 in the older group (range 4–7) and 7 in the young group (range 3–7) and did not differ between groups  = 3.07, p = 0.001, adjusted p = 0.025, r = 0.28 ; higher ICC in young participants). The comparison for item 13 matched the significance threshold  = 2.68, p = 0.004, adjusted p = 0.050, r = 0.27 ; higher ICC in older adults).Descriptive statistics and consistency of ratings are reported in rocedure , a signiWe then addressed aim (iv), i.e., whether each APAM rating, considered as an outcome variable, could be predicted by age group, sex, age of the memory, arousal, mood, and specificity of the memory, which were modeled as fixed effects. To take into account the nesting of observations in participants and in cues, these were specified as random effects in a cross-classified LMM (intercept-only model).t (75.81) = 1.91, p = 0.060, d = 0.25 ). As a further check, we tested whether the proportion of 6 or 7 scores on item 24  differed between groups, and again we did not find evidence of a difference ).However, before specifying the LMMs, we performed some preliminary analyses to test whether the two groups of participants differed with respect to some theoretically relevant variables that might confound the comparisons. Since some studies have shown that differences in the phenomenology of ABMs were more apparent when recalling personally meaningful memories, which are critical in the construction of individuals’ life stories, we considered the answers to item 24 . Had we found differences in the personal relevance of the memory between our groups of participants, any difference in the other APAM item scores could have been explained by this difference. We thus used a cross-classified LMM  that tooX2 (2) = 1.96, p = 0.374, Cramér’s V = 0.06 ).Second, we tested whether there were significant group differences in the specificity of the memory (item 26). We did not find evidence of a substantial difference (t (82.00) = 11.38, p < 0.001, d = 2.53 ; to address the ordinal nature of these data, the values of age of memory were first converted into ranks and then translated into z-scores using the inverse-normal cumulative distribution function, as suggested by Gelman )how it changes.These results are consistent with previous findings, showing that the subjective experience of ABMs tends to become stronger with age, with older adults reporting higher ratings of phenomenology  ,13,14,58In evaluating these results, some limitations, as well as a number of possibilities for future studies, can be identified. The two groups may appear small in absolute size, but it should be considered that the number of data points is seven times higher, as each participant has been tested seven times. Besides, we chose not to try and recruit further participants as this would have likely led to sample from potentially different populations in either group . Heterogeneity of populations is a known biasing factor for correlation-based analyses, and pooling data from different samples to obtain better estimates with more observations is a procedure usually advised against . FurtheThe downside of this, however, was that our participants were all highly educated, and our sample of older adults consisted of active and intellectually stimulated retired people, thereby raising questions about the generalizability of our findings. Future studies with young and older adults representative of the population they are intended to reflect are needed to empirically address this issue.Although the results presented in this study allow a comparison of the web-based administration of APAM with the paper-and-pencil one reported in Vannucci et al. , a more Another promising application of APAM would be adapting the items to provide an assessment of thinking, and not just memories. In this case, APAM would allow a within-subject design to assess and compare the phenomenology of past and future thinking in both young and older adults. In this regard, a recent study by El Haj and Lenoble  with youKeeping with this, another potential extension of this study is the application of online APAM to other populations of special interest for research on ABMs, such as adolescents and clinical patients. Adolescents are technologically savvy and often prefer to answer questions using a web-based platform compared to the standard paper-and-pencil assessment. Recent studies have already shown that adolescents can accurately and reliably fill in web-based questionnaires about their mental and physical well-being under an unsupervised condition e.g., ,67,68).,68.67,68Given its brevity and ease of administration online, the APAM could be also a useful add-on to assessment batteries for psychological problems. Alterations in the phenomenology of ABMs have been consistently reported in depression ,70 and pThe self-administered web-based version of APAM tested in the present study replicated the good psychometric properties of the original paper-and-pencil version. Results revealed an adequate level of consistency of ratings computed across multiple cues and multiple measurement time points in both young and older adults. This pattern of results makes the online version of APAM a versatile instrument suitable for a comprehensive assessment of the phenomenology in a broad range of samples and contexts.


Anopheles gambiae mosquitoes reared from larvae collected from four districts in Sierra Leone during May and June 2018. And the mutations of kdr, rdl, ace-1 genes in An. gambiae were detected using SNaPshot and sequencing. As a result, one sample from Western Area Rural district belonged to Anopheles melas, and 748 An. gambiae were identified. Furthermore, the rdl mutations, kdr west mutations and ace-1 mutation were found. The overall frequency was 35.7%, 0.3%, 97.6% and 4.5% in A296G rdl, A296S rdl, kdrW and ace-1, respectively. The frequencies of A296G rdl mutation (P < 0.001), kdrW mutation (P = 0.001) and ace-1 mutation (P < 0.001) were unevenly distributed in four districts, respectively, while no statistical significance was found in A296S rdl mutation (P = 0.868). In addition, multiple resistance patterns were also found. In conclusion, multiple mutations involved in insecticide resistance in An. gambiae populations in Sierra Leone were detected in the kdrW, A296G rdl and ace-1 alleles in the present study. It is necessary to monitor vector susceptibility levels to insecticides used in this country, and update the insecticide resistance monitoring and management strategy.Vector control interventions including long-lasting insecticidal nets and indoor residual spraying are important for malaria control and elimination. And effectiveness of these interventions depends entirely on the high level of susceptibility of malaria vectors to insecticides. However, the insecticide resistance in majority of mosquito vector species across African countries is a serious threat to the success of vector control efforts with the extensive use of insecticides, while no data on insecticide resistance was reported from Sierra Leone in the past decade. In the present study, the polymerase chain reaction was applied for the identification of species of 757 dry adult female  Malaria is one of the most widespread infectious diseases globally, with a major burden causing the death of more than 400,000 people yearly in the past three years, most of them were reported in the WHO African Region and children aged under five years . Sierra https://anopheles.irmapper.com/).Vector control is an essential component of malaria control and elimination. At present, long-lasting insecticidal nets and indoor residual spraying are still two core interventions for malaria vector control. The effectiveness of these interventions depends entirely on the high level of susceptibility of malaria vectors to the insecticides. However, the insecticide resistance in majority of mosquito vector species across African countries is a serious threat to the success of vector control efforts with the extensive use of insecticides (ace-1 gene encoding the target site of acetylcholinesterase (AChE) for organophosphate and carbamate insecticides (rdl (resistance to dieldrin) gene (kdr) (resistance to DDT and pyrethroids)  are used in the vector control, and only pyrethroids are for use on nets. Moreover, mutations in the cticides , the rdlin) gene , and thethroids) , have beia, etc. , while nMoreover, strategies for insecticide resistance management in vector control must be implemented on the basis of local epidemiological and entomological data. Hence, bioassays using WHO defined diagnostic doses of insecticide, dose response bioassays, biochemical assays to detect activity of enzymes associated with insecticide resistance, and molecular assays to detect known resistance alleles, have been developed to facilitate the implementation of vector control interventions . Among tIn addition, the World Health Organization (WHO) supported the Sierra Leone National Malaria Control Program (NMCP) to develop an Insecticide Resistance Monitoring and Management Program (IRMMP) 2017-2020 to conduct insecticide resistance monitoring in the four pilot districts - Bo, Bombali, Kono and Western Area Rural district, in order to maintain the effectiveness of existing insecticidal vector control interventions, adhering to the existing malaria strategic plan and linking with other specific implementation documents of the NMCP and the Ministry of Health and Sanitation (MOHS), Sierra Leone.ace-1, rdl and kdr were performed to understand the insecticide resistance of the female An. gambiae to the four classes of insecticides recommended by WHO for vector control especially the pyrethroids in Sierra Leone.In this study, molecular detection of mutations in the three genes of Anopheles gambiae mosquitoes were stored in the 1.5 ml Eppendorf tubes with cottons and silico gels (one mosquito per tube). They were reared from larvae, which were collected from natural breeding water bodies in Kayangba community from Bo district, Magbema community from Bombali district, Lebanon community from Kono district, and Bolima community from Western Area Rural district, respectively, during May and June 2018. And these four districts were selected into a four-year insecticide resistance monitoring and management program (2017-2020) which was supported by WHO to the National Malaria Control Program, Sierra Leone. Upon collection, larvae were kept in separate labelled buckets, transported to the insectary and maintained under optimal condition for mosquitoes rearing.Adult female An. gambiae complex. Genomic DNA was extracted from one mosquito respectively using the Qiagen DNA Mini Kit  according to the manufacturer’s instruction. The identification of single specimens of the An. gambiae complex was performed by a PCR  and kdr east (L1014S) mutations, A296G rdl (Ala-Gly) and A296S rdl (A296S) mutations, and G119S ace-1 (Gly-Ser) mutation were designed .SNaPshot extension primers for detection of Data was entered in Microsoft Excel 2010 and analyzed using IBM SPSS Statistic 20. Frequency counts for mutations of insecticide resistance genes in mosquitoes from different districts were compared using Pearson Chi-Square test or Fisher’s exact test performed at 0.05 level of significance.A total of 757 adult anopheline mosquitoes reared from larvae were analyzed in the present study. In detail, 271, 253, 112, and 121 mosquitoes were from Kayangba community, Magbema community, Lebanon community, and Bolima community, respectively.An. gambiae complex by PCR , Magbema (1), and Bolima (6) were detected as negative results of the x by PCR , and oneAn. gambiae were analyzed for presence of the rdl mutations, kdr mutations and G119S ace-1 mutation , kdrW mutation  and ace-1 mutation  were significantly different among four districts, respectively, while no statistical significance was found in A296S rdl mutation . In addition, there were 12 types of allelic combinations totally including the sites that test failed, and a simple homozygous resistant mutation of kdrW (319), or combined homozygous resistant mutation of A296G rdl (174), or combined heterozygous mutation of A296G rdl (154), were the three most common combinations  and An. melas  were characterized in the present study, which is consistent with Sierra Leone’s records on the species distribution of An. gambiae complex  was found totally and most of them were homozygous  were found  was more frequent in samples from Kayangba community than other three communities. And no mutation was detected in A296S rdl in samples from Lebanon and Bolima communities, and very few samples were heterozygous individuals in the other two sites. Furthermore, the mutation in ace-1 was more frequent in samples from Bolima community than other three communities.With regard to the frequency of mutations, a high mutation frequency of t Africa . Moreovea Bissau . MeanwhikdrW alleles and uneven frequencies of A296G rdl and ace-1 in An. gambiae populations in Sierra Leone detected in the present study prompts the need for close vector monitoring of susceptibility levels to insecticides used in this country. It provides important information to the Sierra Leone Malaria Control Programme for development of insecticide resistance monitoring and adjusting the strategy to implement in this country.High frequencies of The original contributions presented in the study are included in the article. Further inquiries can be directed to the corresponding authors.The project was informed to the study sites, and consent was obtained from the local authorities.JY, SS, and NX conceived the study. FY and SS conducted sample collection and preparation. JY and FY performed the laboratory works. JY performed the result analysis. JY, CZ, SS, LW, and NX contributed to the study design. JY, SZ, HL, ZX, and NX contributed to experimental materials. JY drafted and revised the manuscript. All authors contributed to the article and approved the submitted version.This study was supported by the National Science and Technology Major Program of China (No. 2018ZX10101002–002), Technical Reserve Programme for Global Tropical Diseases Prevention and Control (No. 131031104000160004), the Fifth Round of Three-Year Public Health Action Plan of Shanghai (No. GWV-10.1-XK13), and Sierra Leone-China Second Phase of the Fixed Biological Safety Laboratory Technical Cooperation Project.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Objectives: Mental health differences between men and women can be attributed to sex or gender. Due to absence of brief assessments, contributions of gender expressions to the mental health gap between men and women have been understudied. The purpose of this study is to develop and validate a short screening measure of gender expression and test its associations with mental distress.Methods: German representative survey data from 2006  and 2018  were analysed. A short form of the Personality Attributes Questionnaire with 8 items (PAQ-8) was assessed to measure femininity and masculinity. Validity of the PAQ-8 was tested and associations between femininity, masculinity and mental health were examined.Results: PAQ-8 was a valid screening measure to assess gender expression. Compared to 2006, femininity increased in women and decreased in men in 2018. Higher levels of femininity and masculinity were associated with lower distress. Sex was no longer predictive for mental distress when femininity, masculinity, age and equivalised income were considered.Conclusion: Our findings support the use of gender measures, which may be more predictive of mental health than sex. Mental disorders affect a large proportion of the population affecting quality of life and life expectancy . RepreseGender is nowadays considered as a multidimensional concept based on individual, interactional and macro areas of social life . One aspMental disorders have become a key challenge for health care in the 21st century  with a 1gender expression ).Data of two German representative studies with the same recruitment procedure conducted in the years 2006 (sample 1) and 2018 (sample 2) were analyzed. Sample 1 was split in two halves: sample 1a for short scale development, sample 1b for factorial cross-validation of the short scale. The samples were representative in terms of age, sex and educational level for the general German population, collected by an independent agency  in a nation-wide survey. Following a random route procedure on 258 non-overlapping sample point regions, target households were randomly selected within these areas. Subsequently, one of the household members of this address was selected by chance (Kish-Selection-Grid ) and conAll participants received a detailed data privacy statement by the study assistant, informing about the study procedures, data collection, and anonymization of all personal data. The present study posed a low risk to the participants, as procedures such as medical treatments, invasive diagnostics or procedures causing psychological, spiritual or social harm were not included in the present study. Therefore, all participants provided verbal informed consent, which was noted by the trained interviewer before starting with the survey. In the case of minors, participants gave informed assent with informed consent being provided by their caregivers. The completed questionnaires were linked to the socio-demographic data, but did not contain any data to identify the participant. The study and procedure, including the consent procedure, were approved by the institutional ethics review board of the University of Leipzig (Az 132/18-ek). Furthermore, the study adhered to the guidelines of the ICC/ESOMAR International Code of Marketing and Social Research Practice.All following measures were available for both measurement points, except PAQ which was only assessed in 2006.PAQ and PAQ-8. For the present study, the German version , SRMR = 0.03. The two scales (r = 0.44) with 4 items each had an acceptable internal consistency, Cronbach`s α: masculinity-scale: 0.79; femininity-scale: 0.71 and McDonald`s ω: masculinity-scale: 0.76; femininity-scale: 0.71. According to the objective, eight items were suggested to be excluded due to content redundancy and less comprehensible item formulations. An overview of descriptive statistics of the remaining items are displayed in Descriptive statistics of femininity and masculinity levels for 2006 and 2018 are displayed in 2 = 0.03, F  = 0.187, p = 0.830. Femininity was consistently higher in women and masculinity higher in men in both surveys . As the interaction year X sex shows, in 2018 femininity was higher in women and lower in men compared to 2006 . Thus, sex differences increased regarding femininity over time, but not regarding masculinity . There was also no significant association regarding year .r = 0.34, p < 0.001) compared to 2018 . Femininity was negatively associated to mental distress in 2006  and 2018 . Masculinity was also negatively associated to distress , but to a larger degree, particularly in 2018 . While the correlation between sex and masculinity was quite comparable for 2006 and 2018 , the association between femininity and sex increased . These significant results even hold when applied a conservatively estimated adjusted p-value of α/n (0.01/72) = 0.0001 for multiple testing since the largest p-value of the reported correlation coefficients was p = 0.0000000058. Comparable levels were reported referring to age and gender expression for the total sample at both measurement points. The older people were, the lesser femininity and masculinity were reported. This trend was generally higher for women compared to men. With regards to variables of socio-economic status, education showed low positive correlations with both gender identities. However, in 2018, the correlation between femininity and education approximated zero. For equivalised income at both measurement points, higher positive associations with masculinity compared to femininity were revealed in the total sample. Generally, the associations were weaker in 2018 than in 2006, with exception for women in 2006 where both dimensions of gender expression showed similar correlation coefficients with income. Subsequent sex stratified analysis revealed a counteracting pattern change over time: While the association between masculinity and equivalised income decreased nearly halfway among men, an almost twofold increase was observed for women. Furthermore, no significant association between equivalised income and femininity was given anymore for men in 2018 which also applied for the overall sample analysis.In terms of convergent and discriminant validity, While in univariate analyses sex was predictive of distress, which was higher in women for both measurement points, in the multivariate model with gender expression and sex as predictors, sex was not predictive of distress any more see . FemininFollowing the recommendations of public health agencies such as the US funding guidelines of the National Institutes of Health , the CanBoth dimensions of gender expression showed the highest levels in the early to middle adulthood. Regarding time related aspects, the comparison between the two cohorts indicated that femininity scores were in sum higher than masculinity scores in the total sample at all measurement points. No time effect could be observed between 2006 and 2018 at the mean scores level for the German general population. An interaction between time and sex, though with very small effect size, was shown for femininity. Accordingly, sex differences increased over time with women endorsing more and men less feminine traits. An explanation for this could be a strong shift in gender terminology over the last years . FurtherFurthermore, findings pointed out an increase of the gender gap. For instance, the positive association between masculinity and femininity in the German population decreased nearly by half over time for the total sample and in sex-stratified analysis. In general, masculinity was more positively associated with higher equivalised income than femininity, with the exception for women in 2006. While among men the association between masculinity and equivalised income decreased almost by half over time, the association between equivalised income and masculinity increased almost twofold for women. No association between femininity and equivalised income in men and in the overall sample was found in 2018. Contrary findings for masculinity in women and men regarding income may point to changing gender roles in society. While the stereotype of masculinity and money  more likAs in previous studies, both dimensions of gender expressions were negatively associated with distress , 24, e.gBased on the work of Bem , it has Limitations of the study include the lack of non-binary categories and measuring only one aspect of gender, namely gender expression. Masculine and feminine traits are seen as gender stereotypes that support people in defining their self-concept, however many additional characteristics besides traits are linked to gender . InformaGiven differential burdens of mental disorders, sex-specific reporting of mental health research has become a scientific requirement. However, sex has been often confused with gender. Due to a lack of brief assessments, the contribution of gender to the mental health gap between men and women has been understudied. In this study, we developed and validated a short screening measure of gender expression using representative survey data sets of Germany. Our findings support the use of gender measures, which turned out to be more strongly predictive of mental health than sex.


Thyroid dysfunction is linked to an increased risk of cognitive impairment. However, studies on the relationships between thyroid diseases and Alzheimer’s disease (AD) have reported conflicting results. We investigated the associations between several thyroid diseases and AD in a nested case-control study.A total of 1,977 participants with AD were identified by claims data from 2002-2015 among a random sample of half a million people in the Korean National Health Insurance database. We recruited 16,473 age- and sex-matched (1:4 ratio) control participants and applied conditional logistic regression to estimate the relationships between thyroid diseases and AD, with adjustments for potential confounders, such as basic demographics, lifestyle factors, and various medical conditions or comorbidities.The prevalence rates of hypothyroidism , thyroiditis , and hyperthyroidism  were significantly higher in participants with AD than in control participants after adjustment for confounders.In this large national sample, we found significant relationships between several thyroid diseases and AD. Despite of the need for further investigation, these findings could better support to appreciate the pathophysiology of AD. Thyroid hormones are essential for neuronal development and cellular metabolism, and their dysfunction can lead to potentially devastating health consequences that influence numerous organs in patients of all ages . In partAlzheimer’s disease (AD) is the most prevalent form of dementia and a progressive neurodegenerative disease of the CNS that leads to multidomain cognitive impairment, particularly memory dysfunction. According to the 2010 US Census data, the overall prevalence of AD was estimated to be 14.5% and the annual incidence was 2.3% . The data source for this nested-case control study was the Korean National Health Insurance Service (NHIS)-Health Screening Cohort, which included all the original claims data. Specific statements from the Korean NHIS-Health Screening Cohort data have been explained in greater detail in our previous report .Participants who received treatment with levothyroxine for more than 3 months or who had goiter, hypothyroidism, thyroiditis, or hyperthyroidism were evaluated as described previously , and theAD participants were initially enrolled from a population of 514,866 participants with 615,488,428 medical claim codes between 2002 and 2015 . Participants were included as controls if they were not diagnosed with AD from 2002 to 2015 . Participants who were diagnosed with AD in 2002 were omitted from the study to select only participants who had been newly diagnosed with AD (n=168). In other words, the washout period was designated to exclude the participants who were continuously treated after being diagnosed with AD prior to 2002. To limit confounders, we excluded participants who had experienced head trauma  ≥2 times  and those who had been diagnosed with brain tumors (ICD-10 codes: C70-C72) at least two times . AD participants who had no records of baseline body mass index (BMI), fasting blood glucose or total cholesterol and hemoglobin levels were also excluded (n=20). We matched AD participants and control participants at a 1:4 ratio based on participants’ age, sex, income, and region of residence. To shorten the selection bias, the control participants were assigned a random number order. The index date of each case was determined as the time of the first treatment for AD. Because the index date of control participants was defined as the index date of their corresponding AD participants, each matched AD and control participant had an identical index date. Throughout the matching step, 1,977 AD participants and 410,893 control participants were excluded. Eventually, 16,473 AD participants were matched with 65,892 control participants at a 1:4 ratio Figure 1via BMI (kg/m2) was made in accordance with the Asia-Pacific criteria , diastolic blood pressure (DBS), fasting blood glucose, levels of total cholesterol and hemoglobin, and comorbidity score. Age was stratified into ten groups with intervals of 5 years: from 40-44 to 85+ years old group. Income groups were categorized into 5 classes from class 1 (lowest income) to class 5 (highest income), and each class comprised of 5 self-employment health insurance classes and 5 employment health insurance classes. The one health aid class was included in the lowest income class. The region of residence was categorized as urban or rural . Obesitycriteria . Missingcriteria . The ChaThe balance of baseline characteristics between study groups was assessed by reporting standardized differences. To compare thyroid diseases between AD participants and control participants, odds ratios (ORs) and 95% confidence intervals (CIs) were computed by using a conditional logistic regression method. We further adjusted the ORs for possible covariates using an adjusted model. The covariates BMI, smoking, alcohol consumption, SBP CCI scores and thyroid cancer were adjusted for in model 1. Levothyroxine treatment, goiter, hypothyroidism, thyroiditis, and hyperthyroidism were additionally included in model 1 to estimate model 2. This is because levothyroxine treatment, goiter, hypothyroidism, thyroiditis, and hyperthyroidism histories were significantly linked to each other  and income and region of residence . Each subgroup was stratified into four groups, and the estimates were conducted using the unadjusted model, model 1, and model 2.Two-tailed analyses were conducted, and P values less than 0.05 were considered to indicate a statistically significant difference. A standardized difference of ≤0.1 was deemed an ideal balance, and a standardized difference of ≤0.2 was treated as acceptable balance. Statistical analysis was conducted by using SAS ver. 9.4 .The baseline characteristics of the participants in this study are shown in We performed subgroup analyses to assess the effect of thyroid diseases on AD within subgroups stratified by age and sex, as indicated in This study demonstrated the associations between hypothyroidism, thyroiditis, hyperthyroidism, and AD, with OR values of 1.14, 1.22, and 1.13 after adjusting the model for covariates and each thyroid disease or condition. These findings are consistent with epidemiological studies revealing the effect of clinical hypothyroidism and clinical hyperthyroidism on the risk of dementia in large sample sizes –23. GeorAs with many other studies, including the complex interplay between hormonal axes, contradictory evidence is often also found for these associations. In a population-based cohort study of 1,077 elderly people in the Netherlands, the author reported no association between TSH/thyroid hormones and the risk of dementia (HR=1.00) or AD HR=0.97) (7 (9). ThNotably, our findings also demonstrated that there was a significant association with thyroiditis and AD. To date, no study has addressed the link between all-cause thyroiditis and dementia and AD. It has been mainly supposed that an increased risk of cognitive dysfunction could pertain to autoimmune disease rather than thyroiditis per se, since the most common cause of thyroiditis is an autoimmune disease. In addition, an increased risk for dementia and AD was noted in patients with Hashimoto’s thyroiditis/hypothyroidism in a previous study, which has been suggested to be due to thyroid dysfunction , 26. AltProposed neuropathologic mechanisms contributing to the association of thyroid dysfunction with AD have been established in the probable roles of endogenous thyroid hormones and thyrotropin-releasing hormone (TRH). The first potential mechanism is amyloid plaque accumulation. This is due to increased amyloid precursor protein gene expression by low CNS thyroid hormone levels, as thyroid hormones are involved in the regulation of amyloid beta and amyloid beta precursor genes . The secThe strengths of the present study involved the numerous participants who were recruited from a representative, nationwide population sample and the detailed information regarding the various covariates adjusted as confounding factors in the analyses. Thus, we were able to adjust for plausible confounding factors and perform stratified subgroup analyses to identify potentially relevant interactions. Although the diagnosis of AD was based on ICD-10 coding, the coding of AD from NHIS data had good accuracy and validity, as described in our previous literature File S2.Although we could not confirm a causal relationship due to the cross-sectional design, our results imply that efforts to properly manage thyroid diseases may be beneficial in the prevention of AD.The current results demonstrated that clinical hypothyroidism, thyroiditis, and hyperthyroidism were significantly associated with AD, although the biological mechanisms remain unclear. Furthermore, our findings imply that there may be a role for the treatment of these thyroid diseases in prevention of the development or progression of AD. Further research is warranted to elucidate causality and the directions of these associations.https://nhiss.nhis.or.kr/bd/ay/bdaya001iv.do.The data analyzed in this study is subject to the following licenses/restrictions: The current article used a national sample cohort and does not involve data that can be available. Requests to access these datasets should be directed to This study was approved by the ethics committee of Hallym University (2020-07-022). Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.JK and HL participated in the interpretation of the data and drafted and revised the manuscript. YK, MK, J-HK, CM, and DY participated in data collection and data interpretation. HC designed the study, participated in data collection and data interpretation, and revised the manuscript. All authors contributed to the article and approved the submitted version.This work was supported in part by a research grant (NRF-2021R1C1C1004986) from the National Research Foundation (NRF) of Korea.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.