Background: In line with Article 14 of the Framework Convention for Tobacco Control, we have witnessed vast developments in smoking cessation training for healthcare providers, offering help for smokers. However, there is no specific evaluation tool to monitor and evaluate the effectiveness of these programs for future enhancement and sustainability. Objective: To develop and validate a new tool for evaluating smoking cessation training programs for healthcare providers called the Providers’ Smoking Cessation Training Evaluation (ProSCiTE). Methods: The 74-item ProSCiTE tool was developed based on a review of the literature and an expert panel review. The tool was validated in a sample of 403 healthcare providers using a cross-sectional study design from July to December 2016. Content validity was assessed by the Scale-Content Validity Index (S-CVI). The construct validity of the ProSCiTE was analyzed using exploratory factor analysis (EFA) to confirm psychometric properties. Internal consistency reliability was determined using Cronbach’s alpha. Results: The content validity showed that the S-CVI ranged from 0.82 to 1.00 for consistency, representativeness, relevancy, and the clarity of each construct, resulting in 67 items for the questionnaire. The construct validity of the ProSCiTE  with 54.74% total variance) was acceptable . The internal consistency reliability of the four-factor structure was very good, with Cronbach’s alpha values at 0.89, 0.94, 0.95, and 0.90, respectively. Conclusions: This study showed that 67 items of the ProSCiTE demonstrated good content and construct validity, as well as a high internal consistency reliability for the measurement of knowledge, attitudes, self-efficacy, behavior, and barriers to smoking cessation interventions among healthcare providers. Therefore, the ProSCiTE is a valid and reliable research tool with which to evaluate the effectiveness of smoking cessation training programs. A valid and reliable tool is a very important key indicator to evaluate the effectiveness of a program. In order to evaluate the impact of a program, particularly to assess the effects of smoking cessation training on a 5 As  brief intervention, a good and valid tool is essential. Currently, to the best of our knowledge, there is no valid and reliable tool to evaluate healthcare providers’ smoking cessation training through examining their psychometric properties. Only a few questionnaires were found from previous studies worldwide that measured the effectiveness of smoking cessation training. Some studies showed promising results, but most were not specific or not standardized, and they did not measure any content validity or psychometric properties ,5,6,7,8.Therefore, we developed and tested an evaluation tool called “Providers’ Smoking Cessation Training Evaluation”, or in short, ProSCiTE, within our population. This quantitative study provides an empirical dataset based on healthcare providers in Malaysia. The tool is based on the 5 As brief smoking cessation intervention model, which is recommended by the Malaysian Clinical Practice Guidelines on the Treatment of Tobacco Use Disorder  and the Despite clear recommendations and evidence, healthcare providers currently only provide a limited amount of support to their patients on smoking cessation due to several factors that differ across groups of healthcare providers ,21,22,23Healthcare providers, as front-liners in facilitating smoking cessation, are in an ideal position because they have frequent contact with patients. They are also the most trustworthy people to rely on for health purposes and are considered role models by patients ,35. DespTraining plays a crucial part in healthcare services’ development and sustainability. It fortifies healthcare providers to acquire new skills, strengthen their existing skills, increase productivity, as well as advance all healthcare providers to a higher level with similar skills and knowledge. Training programs around the world have been shown to have a significant impact on nicotine dependence treatment initiatives delivered by healthcare providers ,51,52,53Several tools have been examined to measure the effectiveness of training ,54,55,56The present study aimed to develop and validate the ProSCiTE tool for smoking cessation training. The measures hypothesized to be associated with healthcare providers’ practices in terms of smoking cessation are discussed in this article. This study investigates the content validity, construct validity, and reliability of the ProSCiTE. We also identify how these factors interact and potentially predict the implementation of each component of the 5 As smoking cessation model.The ProSCiTE development and validation involved three processes, including ProSCiTE development, content validity by expert panels, as well as construct validity and reliability through a pilot study among a sample of healthcare providers. A flowchart of the validation process is presented in The development of the “ProSCiTE” survey questionnaire was performed through three steps: determining the content domain/construct, sampling from the content (item generation), and instrument formation ,58. The An initial 74 items reflecting five constructs were developed using a conceptual model of how trainings might work, based on a combination of existing studies and the Integrated Change Model (I-Change Model) . We studOur conceptual framework assumes that healthcare providers’ sociodemographic characteristics, healthcare system-related factors, and patient-related factors might influence their level of knowledge, attitude, and self-efficacy. These factors further influence behavioral changes among healthcare providers toward smoking cessation interventions, which finally impacts the outcome of the smoking cessation provision among healthcare providers. Nevertheless, a total of 67 items that reflected the constructs were primarily approved by a local and international panel of experts on tobacco control. However, considering the potential response burden for participation, only constructs and items that had the greatest potential for predictive power and specificity for use in program planning and evaluation were included in this tool. This tool included a demographic background and five constructs: knowledge, attitude, self-efficacy, behavior, and barriers to providing smoking cessation interventions. Details of the initial development of constructs and items are illustrated in The content validation study was carried out over a three-month period from March to May 2016. International and local expert panels in the tobacco control field were invited to participate in the present study. Our interdisciplinary panel of experts was composed of two behavioral science specialists, one public health intervention specialist, two public health specialists, one dental public health specialist, and one consultant on pulmonary and critical care medicine. The experts were purposely selected to provide diverse ideas based on their specializations. They were selected according to the methodology described in Grant et al. considering their relevant training, experience, and qualifications as content experts. A history of publications in referred-to journals, local and national presentations, clinical expertise, and research on phenomena of interest were also regarded as criteria in selecting the content experts . ZamzadeThe expert panels were approached through email or self-distributed materials and were provided with an introductory cover letter, a set of evaluation tools, and an informed consent form. The expert panels were asked to evaluate based on four aspects  for each item of the ProSCiTE. Each item of the questionnaire was ranked on a four-point scale . The expert panels were also asked to provide recommendations to improve the sentence or structure based on difficulties they faced during the evaluation of the tool. The completed evaluation tool was returned to the researcher via the same medium.A cross-sectional study was carried out over a five-month period from July to December 2016. In this phase, only 55 out of 67 items from the content validity results were used in the exploratory factor analysis (EFA). These items concerned four constructs: attitudes, self-efficacy, behavior, and barriers to smoking cessation interventions. The knowledge domain could not be factor-analyzed due to different formats of response. Here, 403 healthcare providers  completed the paper-and-pencil questionnaire during the face-to-face study. The selected healthcare providers attended a smoking cessation training program called “Smoking Cessation Training Organizing, Planning, and Execution (SCOPE)”, as described in our published paper . The datAfter explaining the study objectives and handling over the explanatory statements, the participants signed the informed consent forms. The researchers distributed the ProSCiTE tool among the healthcare providers and collected the tool upon completion. On average, approximately 15 to 30 min were needed to complete the ProSCiTE tool.A determination of reliability was evaluated based on interitem correlation, Cronbach’s α, the internal consistency of the responses for each scale, and the entire instrument. Internal consistency reflects the extent to which questionnaire items are intercorrelated or whether they are consistent in the measurement of the same domain . CharterCorrelation was evaluated based on a Pearson correlation to determine the relationship between each domain. This study was approved by the Ministry of Health of Malaysia (Reference Number: NMRR-16-2144-32353 (IIR)) and the University of Malaya Medical Ethics Committee (Reference Number: UM. TNC2/RC/H&E/UMREC-118).p-value < 0.05. Statistical analyses were performed using IBM SPSS software . All significant results were based on Descriptive analysis was used to measure the demographic characteristics of the healthcare providers. k). The I-CVI for each item was calculated by dividing the number of experts who provided a rank of 3 or 4 by the total number of experts, and the S-CVI or average for each scale was calculated by summing the I-CVI divided by the number of items. According to Polit et al. (2006) [k of 0.4 to 0.59; Good = k of 0.6–0.74, and Excellent = k > 0.74 [The Content Validity Index (CVI) is extensively used in reporting the content validity of newly developed instruments ,70,71,72k > 0.74 .p < 0.05 is considered acceptable. The factor loadings values were evaluated according to Comrey and Lee (1992): >0.32 = Poor, >0.45 = Fair, >0.55 = Good >0.63 = Very Good, and >0.7 = Excellent [Exploratory factor analysis (EFA) using principal factor analysis with varimax rotation was employed to extract the underlying factor structure of the items. The Kaiser–Meyer–Olkin (KMO) test for sampling adequacy and Bartlett’s test of sphericity were examined before proceeding with further analyses. The KMO test reports the amount of variance in the data that can be explained by the factors. Values of 0.5 or lower are unacceptable and values of 0.6 or above are acceptable. Bartlett’s test of sphericity also indicates the suitability of the data for factor analysis . A signixcellent . Howeverxcellent .F approximation [Internal consistency was indexed by Cronbach’s alpha coefficient with 95% confidence intervals using Kistner and Muller’s ximation . The alpximation . A Pearson correlation of each domain with total scores was conducted to examine the relationship between each domain. Low correlation ranges were from 0.1 to 0.3, moderate ranges were from 0.3 to 0.5, and high ranges were >0.5 ,80.Seven expert panels in the tobacco control field participated in this content validation. Almost equal numbers of them were male/female and local/international. All of them had more than 10 years of experience in the tobacco control field .The original version of the ProSCiTE contained 74 items. However, after going through the content validation process with the expert reviewers, we decided to remove seven items from the behavior domain. Thus, the final version of the ProSCiTE contained 67 items. Out of all the healthcare providers who participated in this study, 403 of them completed the survey, yielding a 90.0% response rate. The majority of the healthcare providers were female, Malay, and Muslim. Slightly above one third (35.2%) of the healthcare providers were pharmacists. There was an approximately equal proportion of healthcare providers aged 33 years old and below and above 33 years old. Almost half of them obtained a bachelor’s degree qualification. More than half (61.3%) of the healthcare providers had more than nine years of working experience. The majority (85.1%) of the healthcare providers reported that they were nonsmokers. More than half of the healthcare providers reported having experience in smoking cessation training, and slightly above half were interested in increasing their smoking cessation skills see .p < 0.001). Hence, these values determined the appropriateness and sampling adequacy of the data for factor analysis [The ProSCiTE tool contained 55 items concerning attitudes, self-efficacy, behavior, and barriers to smoking cessation interventions for the factor analysis. In our study, one factor was clearly distinguished from another after the items underwent the extraction sum of squared loadings and then were rotated through varimax rotation with the Kaiser normalization method using SPSS . The peranalysis .Cronbach’s alpha was calculated to examine the internal consistency reliabilities of all the variables. The selections of items for each factor were scrutinized, and the combination of items with the largest α was retained (α should be at least 0.5) . The alpr) between all the construct scores in the total sample of participants. The results indicated that all constructs were positive and significantly correlated with each other, except for the association between barriers. The results demonstrated high item domain scores, particularly between self-efficacy and behavior (0.61), which may suggest that higher self-efficacy contributes to positive behavior in smoking cessation interventions. Moderate correlations were identified between attitudes and behavior (0.34), as well as between attitudes and self-efficacy (0.27).In any research or program evaluation effort, it is important to ensure that the outcomes of interest are clearly defined and that the outcomes are evaluated using valid and reliable measures. Thus, we developed and validated this study using a factor analysis technique for ProSCiTE, which is an evaluation tool for smoking cessation interventions among healthcare providers in Malaysia. The ProSCiTE is also salient in assessing and monitoring if staff training regarding smoking cessation leads to increased smoking cessation-related knowledge, more positive attitudes toward treating smokers, and increased self-efficacy in smoking cessation interventions. Thus, this tool is promising for evaluating the effectiveness of training in future studies that could also assess whether or not healthcare providers deliver evidence-based smoking cessation interventions over time. In this study, the development of the ProSCiTE was based on a broad literature review and existing scales. Validity and reliability were used to validate the ProSCiTE. The validity of a questionnaire is determined by analyzing if the questionnaire measures what it is intended to measure. In testing the validity, two types of validities were examined: content validity and construct validity. Content validity refers to the extent to which the items in a questionnaire are representative of the entire theoretical domain the questionnaire is designed to assess . The ProConstruct validity is important to measure a construct that is not directly observable. Therefore, in this study, attitude, self-efficacy, behavior, and barriers were measured by construct validity. The interpretation of results and inferences could not be drawn if the questionnaire lacked construct validity. In testing construct validity, a pilot study among healthcare providers was conducted to derive the main factors for smoking cessation training outcomes. Thus, an EFA with varimax rotation was performed to reduce the factors. An EFA was chosen due to the fact that this was the first validity test for a newly developed tool: we needed to measure if relationships existed between the variables, and what those were was not known earlier. A reliability test refers to the consistency of the results drawn from the questionnaire, which can be evaluated using its internal consistency, test–retest reliability, and inter-rater reliability. For the reliability test, an internal consistency was performed, which reflects the extent to which questionnaire items are intercorrelated or whether or not they are consistent in the measurement of the same domain using Cronbach’s alpha .The construct validity and reliability tests  indicated that the ProSCiTE has good psychometric properties. The results of the EFA extracted four factors accordingly. All subscales demonstrated excellent internal consistency. This is the first study to develop and validate an evaluation tool for smoking cessation training in order to measure knowledge, attitude, self-efficacy, behavior, and barriers in Malaysia.The main highlight of this research is that the reliability analysis of the four constructs showed excellent internal consistency, as indicated by Cronbach’s alpha. This study reported a Cronbach’s alpha minimum of 0.89 and a maximum of 0.95 for four of the domains. The value of alpha > 0.7 verified that all items in the factor were highly correlated with each other, providing assurance that random errors were minimized in the factor . One simIn addition, our results for the correlation for each construct were comparable to previous studies ,2), exceTo the best of our knowledge, the ProSCiTE is the first published study that has been developed and that has undergone a detailed validation tailored for smoking cessation training. The involvement of selected expert panels based on their expertise in training and tobacco control could strengthen the face and content validity of the ProSCiTE. Although the 67 questions included in the ProSCiTE seem like a large number and might result in a long completion time, the ProSCiTE is able to detect various impacts of a training from multiple aspects. Since most of the currently available measures emphasize particular aspects such as knowledge, attitudes, and practices, the ProSCiTE can assess the impacts that are not detected by existing measures, including the withdrawal symptoms of smokers. Healthcare providers need to understand the withdrawal symptoms of their patients in order for them to prescribe their patients either pharmacological or behavioral treatments, dealing with withdrawal symptoms as well as other issues related to quitting. This would help healthcare providers understand their patients’ level of addiction and detect changes caused by treatment, as well as allow them to choose the best nicotine replacement therapy products.Furthermore, the criteria validity of the ProSCiTE has not been validated due to the fact that there is no published gold standard for the evaluation of smoking cessation trainings for a comparison to ProSCiTE. While the ProSCiTE was under development, several research works were published on the measurement of smoking cessation that focused on knowledge of health consequences, attitudes, self-efficacy, practices, and barriers ,5,6,7,8.This study successfully validated an evaluation tool, ProSCiTE for Malaysian healthcare providers, based on the 5 As of smoking cessation interventions. However, since the ProSCiTE does not contain items that are specifically related to Malaysian culture, it could be used internationally to evaluate the effectiveness of any smoking cessation training program based on the 5 As. The ProSCiTE was developed through adaption from and the adoption of previous literature on cognitive, behavioral, individual, clinical, and organizational factors ,52,83,84Nevertheless, our study had some limitations that should be addressed. First, the major limitations that this tool has are that this tool is mainly directed toward evaluating training perceptions among healthcare providers  receiving basic or level I SCOPE training . Second,In conclusion, assessments of the content, construct, and internal consistency reliability of an evaluation tool are critical to obtain valid and reliable research findings. Our ProSCiTE tool exhibited good content validity, construct validity, and internal consistency reliability. It also offers a starting point for further tool development and a measure for evaluating tobacco-related policy and training programs. The ProSCiTE also measures the delivery of the 5 As intervention as an innovative evaluation tool for researchers, managers, and practitioners. They can utilize this promising newly validated tool to evaluate their smoking cessation-related programs.


DHEA and GH were more significant and negatively correlated with age. The regression equation of DHEA with age produced a coefficient equal to 1.26. In this study, the difference in DHEA between COPD patients and controls was, on average, 30.2 μg/dL, indicating that the biological age of a COPD patient is on average about 24 years older than that of a control subject of the same age. Similarly, the difference in GH between COPD patients and controls was, on average, 0.42 ng/mL, indicating that the biological age of a COPD patient is on average about 13.1 years older than that of a control subject of the same age. (4) Conclusions: The findings of our study strongly suggest the presence of premature biological aging in COPD patients. Their biological age could actually vary from 13 to 23 years older than non-COPD controls according to DHEA and GH variation.(1) Background: Chronic obstructive pulmonary disease (COPD) is defined as an inflammatory disorder that presents an increasingly prevalent health problem. Accelerated aging has been examined as a pathologic mechanism of many chronic diseases like COPD. We examined whether COPD is combined with accelerated aging, studying two hormones, dehydroepiandrosterone (DHEA) and growth hormone (GH), known to be characteristic biological markers of aging. (2) Methods: Data were collected from 119 participants, 70 (58.8%) COPD patients and 49 (41.2%) from a health control group over the period of 2014–2016 in a spirometry program. Information about their medical history, tobacco use, and blood tests was obtained. (3) Results: The average age of the health control patients was 73.5 years (SD = 5.5), and that of the COPD patients was 75.4 years (SD = 6.9). Both groups were similar in age and sex. A greater proportion of smokers were found in the COPD group (87.1%) versus the control group (36.7%). The majority of COPD patients were classified as STAGE II (51.4%) and STAGE III (37.1%) according to GOLD . Levels of DHEA (SD = 17.1) and GH (SD = 0.37) were significantly lower in the COPD group ( Chronic obstructive pulmonary disease (COPD) is an increasingly prevalent disorder of the respiratory system characterized by a progressive decline in lung function and chronic inflammatory response ,2. Its pIn COPD, processes including oxidant/antioxidant, protease/antiprotease, and proliferative/antiproliferative balance, and the control of the inflammatory response become dysfunctional, as in aging ,5. A cloAging is defined as a time-dependent progressive loss of physiological integrity, resulting in impaired function and increased vulnerability to death . A recenThe contribution of aging markers has recently been reviewed in COPD patients . This reThe interconnection of the different markers of aging has not yet been studied in clinical subjects. We hypothesized that these markers, representing various interconnected aspects of the aging process as recently summarized, are altered in a cohort of COPD patients compared to the control group. These markers include dehydroepiandrosterone (DHEA)-S and growth hormone(GH)as a read-out of biological age.The aim of the present study was to examine whether COPD is associated with accelerated aging using two hormones, dehydroepiandrosterone sulfate and growth hormone, representing biological markers of aging.Participants were recruited in 20health centers of primary care in Thessaly, Greece, during a period of 24 months (January 2015 to December 2016). All volunteers were older than 40 years of age, residents near a primary healthcare practice, and were willing to participate in the spirometry program organized by the Respiratory Department of the University Hospital of Larisa. The study sample finally consisted of 70 newly diagnosed ,15 patieThe study was approved by the University of Thessaly Ethics Committee (6051/29-1-2014). All participants gave informed written consent and allowed the use of their personal data for research purposes.2).A study questionnaire was completed from all participants who were submitted to a physical examination. Personal data  were assessed, including somatometric measurements such as body mass index (BMI), medical history of comorbidities , or any Participants who had smoked over 100 cigarettes in their life were considered as smokers, and those who had given up smoking in the last 12 months as ex-smokers. Smoking status was measured by pack–years (PYS), defined as the number of cigarettes smoked per day divided by 20 and multiplied by years of smoking. According to their smoking habits, they were classified as never smokers, ex-smokers, and current smokers .The study questionnaire was followed by tests, used in describing and giving information about the mental and physical status of the patients themselves, such as the COPD assessment test (CAT score), the clinical COPD questionnaire (CCQ), and the 12-Item short-form health survey (SF-12).A morning blood-test sample was taken in order to examine the two hormones of aging, GH  and DHEA1>12% and >200 ml from the baseline was considered reversible [Spirometry was performed with a dry spirometer  according to American Thoracic Society (ATS) recommendations . Physiciversible .All participants were examined by chest physicians who established the diagnosis of COPD. All patients with a previous diagnosis of COPD were again evaluated by physicians  and currBlood test was drawn from participants in the morning time only and blood was drawn into two 10 mL vacutainers. All blood was immediately spun and aliquoted, and the serum was stored at −80 °C until assays were performed. Serum levels of DHEA–sulfate (DHEA-S) and GH were measured in a solid-phase, two-site chemiluminescent immunometric assay according to the manufacturer’s instructions. The analysis system of the serum was the Immulite 2000 immunoassay with a coefficient of variation of less than 5.23%. Theused method was the microparticular enzyme immunoassay (MPEIA).Control and calculation were held before testing.The laboratory assay range (20–80 percentile) for participants aged 15–80 years was 100–290 μg/dL for DHEA, and 3–8 ng/mL for GH, and was dependent on age, with higher values at younger ages .p-values reported are two-tailed. Statistical significance was set at 0.05, and analyses were conducted using SPSS statistical software (version 19.0).Quantitative variables are expressed as mean values (standard deviation (SD)). Qualitative variables are expressed as absolute and relative frequencies. For the comparison of proportions, chi-square and Fisher’s exact tests were used. Pearson’s correlation coefficients (r) were used to test the association of two continuous measures. Student’s t-tests were used for the comparison of continuous variables between two groups, analysis of variance (ANOVA) was used for the comparison of continuous variables between more than two groups, and Bonferroni correction was used in order to control for type I error, where the level of significance was set at 0.05/No of comparisons. Mean differences along with their standard errors (SE) were also reported. Multiple linear regression analysis was used to find independently associated factors with DHEA and DH. Regression coefficients that reflected the change in the value of dependent variables corresponding to the unit change in independent variable β, along with SE, were computed from the results of the linear regression analyses. All The flowchart of the study participants is presented in During the two years of the study, 507 participants attended the spirometry program. Among them, 168 participants (33.13%) were able to correctly perform the spirometry test, 48 were diagnosed with hormone disorder, and only 119 (23.47%) from the whole sample were finally included in the study.The sample consisted of 119 participants, 70 of whom were originally diagnosed with COPD and 49 without COPD (control group), with a mean age of 74.5 years (SD = 6.5).Demographics and clinical characteristics of the two study groups are presented in The groups consisted of rural residents, similar in age, sex, BMI, family history of COPD, when they started smoking, pack–years, presence of hypertension, arrhythmia, diabetes, allergies, depression, and previous surgeries. Both groups were overweight according to their BMI.A greater proportion of smokers was found in the COPD group. COPD patients were newly diagnosed for the first time in a proportion of 70% men, 87.5% current smokers, with 77 PYS (number of cigarettes smoked per day divided by 20 and multiplied by years of smoking) already being in 51.4% STAGE II of classification of COPD.Dyslipidemia (41.4%) and cardiovascular disease (41.4%) were also more frequent in the COPD group. There was no significant difference in the presence of hypertension between groups.COPD patients were more often male, overweight, older, current or ex-heavy smokers. All respiratory symptoms  were more common in COPD patients.p < 0.001 Student’s t-test) and smoker controls .Univariate analysis for DHEA and GH: Levels of DHEA (mean difference: 30.2 (SE = 9.0)), and GH (mean difference: 0.42 (SE = 0.16)) were significantly lower in the COPD group compared with those in the controls ( t-test) . Additiop < 0.001 Student’s t-test). DHEA and GH were positively correlated with FEV1ml (p < 0.001), FEV1% (p < 0.001), and FEV1/FVC (p < 0.001). No gender differences were found for DHEA and GH, but both DHEA and GH were significantly and negatively correlated with age. Further more, DHEA levels were lower in smokers. Both DHEA and GH were significantly and negatively correlated with the COPD assessment test (CAT), the MRC breathlessness scale, and all clinical COPD questionnaire (CCQ) dimensions  and age ,indicating that greater levels of CAT and greater age were associated with lower levels of DHEA. For GH, the significant factors were CAT  and age , indicating that increased levels of CAT and age were associated with lower levels of GH.Multiple regression analysis was conducted with DHEA and GH as the dependent variables. The independent variables that were entered in the model were sex, age, smoking, CAT, and BMI. Concerning DHEA, the factors that were significant in the regression model were CAT  and markers of cellular senescence (p16/21), and anti-aging molecules  and soluble (S) klotho) . InteresAnother aging theory for COPD focuses on the involvement of sirtruin(SIRT1) in the regulation of inflammation and premature senescence, all crucial characteristics of COPD phenotypes. Findings contributed to the hypothesis that COPD could be considered a disease of accelerated aging and underline the potential of SIRT1 as a valid therapeutic target to treat respiratory disorders sharing chronic inflammation .Kazuhiro Ito et al., in their analysis about geroprotectors, concluded that COPD is one of the most prevalent chronic inflammatory diseases in world populations. Loss of the working generation and disabilities associated with COPD should require urgent awareness from governments, physicians, and scientists, and a new treatment strategy should be considered, as current therapies are not useful in stopping the progression of COPD. The role of accelerated aging in COPD progression is now strongly supported by a number of recent studies. Geroprotection or anti-aging therapy is a novel and attractive strategy to treat age-associated inflammatory diseases or to increase the quality of life of elderly patients. For this purpose, geroprotectors are not used to extend the lifespan, but to prevent premature aging of the lungs .In the present study, it was observed that 36% of newly diagnosed patients were already Stage II and 26% Stage III, which is supported by previous studies .In another clinical study, functional performance and cognitive status were compared in COPD patients of different ages. Significant reductions in functional capacity, cognitive assessment, and lower-limb muscle force, as well as increased inflammatory markers, were observed in the older group .Over the last 50 years ,40, therBoth DHEA-S and GH were selected among well-established markers, with evidence supporting a strong association with aging phenotypes. They are cost-effective and practical for use in larger-scale studies, or even in everyday practice implementation.For some biological markers, the relationship with aging appears to be nonlinear; for example, both high and low IGF-1 are related with greater mortality rates. DHEA-S declines with age from the third decade, and low DHEA-S is associated with increased mortality in older subjects with concurrent frailty. Hormone replacement studies suggest use for both testosterone and estrogen and risk physical frailty and bone health ,44.The present study revealed that the use of biological markers commonly used in a range of settings, like DHEA and GH, could provide valuable data in discriminating between healthy and premature aging regarding COPD patients.Concrete evidence is needed to enhance the understanding of the relationships between cortisol, DHEAS, DHEA-S ratio, adipokines , somatostatin with aging, frailty, and mortality .Overall current knowledge in the molecular mechanisms of lung aging is limited. Studies, such as the one by de Vries, are important if we are to understand how molecular aging mechanisms could be minimized to improve the quality of life of patients with obstructive lung diseases such as COPD . Keene eThe present study is limited by its cross-sectional design. Nevertheless, current findings are significant, revealing a new accessible path in approaching premature aging in COPD patients. Prospective studies are needed in the future to verify these findings. Even though507 individuals attended the spirometry program, only 119 participants were finally eligible. It is possible that a greater number would have better determined the observed differences in the two measured hormones. Nevertheless, the actual number of eligible participants was proven to be adequate to reveal significant differences between COPD patients and the control group. The starting age of participants should also be lower in future projects. That would allow for a lower starting chronological and biological age of COPD patients in order to support a prospective design. More age-related biomarkers could also be calculated according to somatometric characteristics, hormones, inflammatory markers, and, on the molecular level, sirtruins, telomeres, and genes.In summary, our findings concluded that COPD patients present reduced DHEA-S and GH levels. Taking into consideration the correlation of these two hormones as biological markers of age, based on the current findings, it is suggested that a COPD patient is 24 years older as far as DHEA is concerned and 13 years older with regard to GH. This is an exceptional finding regarding the extent to which COPD influences premature aging. Furthermore, additional research is needed toreveal accurate aging biomarkers that can easilybe assessed.


Objective: To characterize the gut microbiota in patients with preeclampsia (PE) compared with healthy controls.Methods: We analyzed and compared the microbiota communities in the feces of 48 PE patients with 48 age-, gestational weeks-, and pre-pregnancy body mass index-matched healthy controls using 16S rRNA gene sequencing, and also we tested fecal and plasma lipopolysaccharide (LPS) and plasma trimethylamine-N-oxide (TMAO) concentration levels in the two groups.Results: Compared with the control group, microbial alpha diversity was lower in the PE group, but there was no statistically significant difference between the two groups. At the phylum level, Firmicutes , Bacteroidetes , Proteobacteria , and Actinobacteria , exhibited significant differences between the PE group and the control group. LEfSe analysis found 17 differentially abundant taxa between the two groups. PICRUSt analysis found that in the KEGG pathways, the microbial gene functions related to LPS biosynthesis were higher in the fecal microbiome of the PE group. The fecal and plasma LPS concentrations and plasma TMAO concentrations of PE patients were higher than those of the healthy controls.Conclusion: PE patients had gut microbiota dysbiosis and increased plasma LPS and TMAO levels, which will lead to a better understanding of the relationship between the gut microbiota and PE. Preeclampsia (PE) is a pregnancy-specific, complex and multisystem disorder characterized by hypertension and proteinuria after 20 weeks' gestation, and is one of the major causes of maternal and perinatal morbidity and mortality worldwide, affecting 3–8% of all pregnancies in the world , are well known as highly inflammagenic and could stimulate an innate immune response that aggravates inflammation action further  is one of the most important gut microbiota-derived metabolites and studies have found that elevated circulating TMAO concentration was a strong prognostic marker for adverse cardiac events and chronic kidney diseases -, and pre-pregnancy body mass index (BMI)-matched healthy controls using 16S rRNA gene sequencing. We also compared fecal and plasma LPS and plasma TMAO levels between the two groups, in order to investigate the relationship between fecal microbiota, LPS, TMAO, and PE.This study was conducted at Peking University Third Hospital from January 2018 to December 2018, and was reviewed and approved by the ethics review board of Peking University Third Hospital (2017-256-01). Signed consents were acquired from all subjects on enrolment for the use of their data and samples for scientific purposes.The inclusion criteria for PE patients were women who matched the diagnostic criteria of the American College of Obstetricians and Gynecologists for PE  divided by the square of the height (meters).Fecal samples were collected with Sarstedt feces collection containers , a 76 × 20 mm tube with a screw cap attached scoop, each of which was preloaded with 5 mL RNAlater Stabilization Solution (QIAGEN Inc.). Samples were collected in tubes by the participants and then frozen at −20°C. The samples were transferred to the laboratory on dry ice within 24 h of collection and stored at −80°C until DNA extraction.Total fecal DNA was extracted using CTAB/SDS method  and removing the chimera sequences using UCHIME algorithm , the clean reads were finally obtained. Sequences analysis were performed by Uparse software (Uparse v7.0.1001 http://drive5.com/uparse/). Sequences with ≥97% similarity were assigned to the same OTUs. The Silva Database (https://www.arb-silva.de/) was used based on Mothur algorithm  and beta diversity on weighted UniFrac was performed basing on this output normalized data and they calculated with QIIME (Version1.7.0)   score >3.5 were ultimately considered. Phylogenetic Investigation of Communities by Reconstruction of Unobserved States (PICRUSt)  twice. Total supernatant was filtered with 0.45 μm filter  and then with 0.22 μm filter . Total plasma and fecal protein concentration was analyzed through the Pierce BCA Protein assay kit. Plasma and fecal LPS levels were measured using LPS RIA Kit  according to the manufacturer's protocol. Briefly, add samples, standards, antibodies and Plasma aliquots were stored at −80°C prior to analysis. The plasma TMAO concentrations were tested and quantified using stable isotope dilution liquid chromatography tandem mass spectrometry  was used for the statistical analysis. Mean (standard deviation) was used to express measurement data that obeyed a normal distribution, while the median (interquartile range) was used to express measurement data of skewed distribution. Student's The baseline characteristics of the PE group and the control group were summarized in P < 0.05). Bacteroidetes was the next most abundant  followed by Proteobacterias  and Actinobacteria , with statistically significant differences between the two groups. The remaining bacterial population belonged to the other phyla , which had a relative abundance lower than 1% in the two groups  (p = 0.09) (P = 0.011)   and Simp = 0.09) , with no= 0.011) .LEfSe analysis was applied to investigate the biomarkers among the two groups. We found 17 differentially abundant taxa between the two groups, all of which had a log LDA score>3.5. The relative abundances of the genera Firmicutes, Clostridia, Clostridiales, Ruminococcaceae, Rikenellaceae, Faecalibacterium, Alistipes, and Bacteroides_stercoris were lower in the PE group than those in the healthy control group, while the relative abundances of genera Bacteroidetes, Proteobacteria, Actinobacteria, Bacteroidia, Gammaproteobacteria, Enterobacteriales, Enterobacteriaceae, Bacteroides_coprocola, and Bacteroides_fragilis were higher in the PE group than those in the healthy control group. Results are presented with green and red colors indicating an increase and decrease of abundance in the PE group, respectively .P < 0.05, PICRUSt based on closed-reference OTU was used to predict the abundances of functional categories. In the KEGG pathways, the microbial gene functions related to LPS biosynthesis were much higher in the fecal microbiome of the PE group (P < 0.05). Similarly, the plasma LPS level in the PE group was 0.53 ± 0.13 EU/ml, which was higher than that of the healthy control group (0.39 ± 0.06 EU/ml). And the difference was statistically significant (P < 0.05) , with statistically significant difference between the two groups ( < 0.05) .P < 0.05)  ( < 0.05) .Gut microbiota perform multiple functions and play an important role in systemic immunity and metabolism. Healthy gut microbiota exert a vital influence on the overall health of the host  of the fecal microbiota in PE patients were lower than those of the control group, but without statistically significant difference, which was similar to Liu's study  in patients with PE differed significantly from that of the control group. At the phylum level, the abundances of Bacteroidetes, Proteobacteria, Actinobacteria were higher, while the abundance of Firmicutes was lower in patients with PE. The members of Bacteroidetes have been reported to be associated with immunity and metabolic processes. Bacteroidetes interact with the host by glycoproteins secretion, short fatty acids imbalance, toxins production and molecular mimicry, which are involved in many diseases, such as autoimmune diseases, metabolic syndrome diseases , and neurodegenerative disorders  could induce pro-inflammatory pathways and alter gut barrier-related molecules in small intestinal tissue during translocation into internal organs . In order to understand the potential confounding effect of BMI on the microbiota, we used covariance analysis to adjust pre-pregnancy BMI, but we didn't find significantly changed abundant taxa between the two groups after the adjustment (2. In future studies, in order to address the influence of obesity on the gut microbiome in women with PE, gut microbiome of obese women with and without PE should be compared and analyzed.Overweight and obesity are known risk factors for PE (Bodnar et al., justment , 2, indiA functional analysis using the data obtained from the KEGG showed that LPS biosynthesis pathways were markedly over-represented in the microbiota of PE patients. Bacteroidetes have been shown to be the main contributors of LPS biosynthesis (Hevia et al., In our study, in addition to alterations in gut microbiota composition and increased fecal and plasma LPS levels, we also found that plasma TMAO concentrations were significantly higher in the PE group. TMAO, a gut microbiota-derived metabolite, has been identified as a contributing factor in the development of cardiovascular diseases and renal diseases in previous studies (Tang et al., Firstly, the sample size was relatively limited, and further studies with larger sample number are needed. Secondly, metagenome analysis with more sophisticated analytical capabilities will provide more detailed information to explore gut microbiota dysbiosis in PE patients closely. Thirdly, longitudinal studies which focus on the different gestational weeks of PE will be needed to reflect the relationship between gut microbiota dysbiosis and disease progression. Finally, there was no information from a diet questionnaire on nutrient intake in the study groups, and the study only described the phenomenon of gut microbiota dysbiosis and disordered gut-derived metabolite TMAO in patients with PE, without further investigation of the pathogenesis of microbiota dysbiosis underlining PE.In conclusion, in this study we found PE patients had gut microbiota dysbiosis and increased plasma LPS and TMAO levels, which were related to inflammation and would lead to a better understanding of the relationship between the gut microbiota and PE.Jingwang0702@126.com.The datasets analyzed in this manuscript are not publicly available. Requests to access the datasets should be directed to JW, The studies involving human participants were reviewed and approved by The ethics review board of Perking University Third Hospital. The patients/participants provided their written informed consent to participate in this study.JW, YW, and YZ conceptualized and designed the study. JW, XG, and JY were responsible for the acquisition of data, analysis, interpretation of data, and statistical analysis. JW drafted the manuscript. YW and YZ critically revised the manuscript. YZ obtained the funding and supervised the study.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.


Background and objectives: Obesity is associated with poor vascular function and may lead to future cardiovascular disease (CVD). Obesity is also related to increased inflammation and a low testosterone level. This study was conducted to determine the relationship between inflammation, testosterone level, and vascular function among subjects with an increased body mass index (BMI) and to determine whether both low testosterone and high inflammation have synergistic effects towards vascular dysfunction. Materials and Methods: A total of 303 men aged 40–80 years were recruited from Klang Valley, Malaysia. Their height, weight, blood pressure (BP), lipid, blood glucose level, total testosterone (TT), free testosterone (FT), and C-reactive protein (CRP) were measured. The carotid femoral pulse wave velocity (PWVCF) and augmentation index (AI) were also recorded as markers of vascular function. Results: The mean age of all the subjects was 54.46 ± 9.77 years. Subjects were divided into a low/normal body mass index (BMI) group  and high BMI group . The mean BMI for NG was 22.20 ± 1.94 kg/m2 while for OG was 28.87 ± 3.24 kg/m2 (p < 0.01). The level of TT  and FT  were reduced while the level of CRP  was increased in OG compared to NG. PWVCF  and AI  were significantly increased in OG after adjustment for other CVD risk factors. The subjects that had both a low FT and an increased CRP had higher AI when compared to those with a high CRP and high FT (p < 0.01). Conclusions: The increased BMI was associated with vascular dysfunction, mediated by a low testosterone level and increased inflammation. Furthermore, having both conditions concurrently lead to higher vascular dysfunction. Weight loss, testosterone supplementation, and the anti-inflammatory agent may be beneficial for men to prevent vascular dysfunction. CF), which reflects aortic stiffness, and augmentation index (AI), which reflects the speed of pressure wave that travels from the aorta to the periphery as ventricles contract each cycle [The prevalence of obesity is increasing rapidly in the developing world . In Malach cycle . This prch cycle . Both mach cycle ,7.On the other hand, obesity is associated with a low testosterone level ,9. HowevThe adipose tissue releases a variety of pro-inflammatory and anti-inflammatory mediators . With thCF and AI. The presence of both conditions may worsen the vascular damage. Thus, this study aimed to examine the interrelation between the vascular function, inflammation, and testosterone level in overweight and obese subjects and to assess whether the presence of low testosterone and increased inflammation had synergistic effects on vascular dysfunction. The information generated from this study will be beneficial in identifying the risk factors of vascular dysfunction and potential areas of therapeutic for CVD diseases.Limited human studies were done on the relationship between testosterone and inflammation with PWVThis study was part of the Malaysian Ageing Men Study . The maiSubjects were recruited using a purposive sampling technique from Klang Valley, Malaysia. Information on subject recruitment, including inclusion and exclusion criteria, was distributed by flyers, brochures, and advertisements on major newspapers and radio broadcasts. Health screening and data collection were conducted in selected community centres and religious places around Klang Valley. The inclusion criteria included men aged 40 to 80 years with no history of major cardiovascular events or other chronic debilitating illnesses. Those with cardiovascular risk factors, such as diabetes mellitus, hypertension, and dyslipidaemia were included. Subjects receiving sex hormones therapy, suffering from cancers or undergoing cancer therapy, had a fracture or underwent a major surgery six months prior to the screening date were excluded. Subjects were briefed on the details of this study and provided informed consent before enrollment.The socio-demography and lifestyle details of the subjects were obtained using a questionnaire. Age was based on the birthday record on the identification card and ethnicity was self-declared. A smoker was identified as an individual who was smoking daily at the time of the study . Medical2 (kg/m2). The high BMI was defined as a BMI > 25 kg/m2, which covered both overweight and obese subjects [A stadiometer and digital scale were used to measure the height and weight, respectively . The body mass index (BMI) was obtained by using the formula weight/heightsubjects . Their wsubjects . SubjectCF was measured by the Vicorder® . The procedure was elaborated in a previous study [CF by dividing the DPW with the tt (m/s).The PWVus study . BrieflyThe cuff was also placed on the right arm to record the brachial BP pressure and waveform. The device then estimated the aortic pressure waveform using a brachial to-aortic mathematical transfer function as mentioned in the previous study . The aorBlood samples were taken in the morning after several hours of fasting. The blood was analysed by an accredited commercial laboratory  for the measurement of the total testosterone, albumin, total cholesterol (TC), high density lipoprotein (HDL), low density lipoprotein (LDL), triglyceride (TG), and high-sensitivity CRP (hs-CRP) by using the automated analyser. The details of the measurement had been illustrated previously ,29. The p < 0.05. All of the analysis was performed using the Statistical Package for Social Sciences (SPSS) version 16 .The normality of the data was examined using the Kolmogorov–Smirnov test. A comparison of basic characteristics between the NG and OG subjects was performed using the univariate analysis with adjustment for potential confounders. The associations between the total testosterone (TT), calculated serum free testosterone (FT) and CVD risk factors were determined using the bivariate Person’s correlation. The associations between the hs-CRP and other factors were determined by Spearman’s correlation since hs-CRP was not normally distributed. Differences between categorical parameters were determined using the Chi-square test. To determine the synergistic effects of the FT and hs-CRP towards the vascular function, the subjects were grouped into those with a high FT and low hs-CRP (G1), high FT and high hs-CRP (G2), low FT and low CRP (G3), and low FT and high CRP (G4), and their levels of PWV and AI were compared by using the one-way analysis of variance followed by Tukey’s pairwise comparison test. The cut-off point of the 50th percentile was used for the determination of the high and low level of FT and hs-CRP. The statistical significance was set at p < 0.01 for all). OG also had a significantly higher AI and PWVCF after adjustment for confounders, such as height, race, and HR, and other CVD risk factors . Adjustment was made for other CVD risk factors to highlight the influence of BMI alone on vascular functions. Dyslipidaemia was the most prevalent risk factor among them.CF  and AI .The correlation analysis revealed a significant negative association between free testosterone (FT) and total testosterone (TT) with major risk factors of CVD, such as age, WC, BMI, SBP, and hs-CRP . For FT,CF and AI compared to the subjects with a low/normal BMI. The hs-CRP was higher and the testosterone level was lower among the OG subjects compared to the NG subjects.In this study, we aimed to identify the associations between testosterone, vascular functions, and inflammation among male subjects with a high BMI in Malaysia. We found that they had increased PWVAbdominal obesity was a CVD risk factor in the NG group because their waist circumference was more than 90 cm . SeveralCF and AI after adjustment for other CVD risk factors and other confounders such as age, HR, height, FBG, SBP, TC, smoker, and ethnicity [CF) was increased among overweight and obese subjects [The increased BMI was associated with decreased vascular functions . We founthnicity . Subjectsubjects  when comsubjects . A signisubjects ,37. Obessubjects . The ambsubjects .CF was found among obese premenopausal women in the study by Ounis-Skali et al. (2007) [However, our findings were not aligned with a few previous studies. No difference in the AI and PWV. (2007) . No diff. (2007) . The disCF) was inversely correlated to the total testosterone after adjustment for the confounders  [In this study, the high BMI was associated with a lower testosterone level. This was supported by previous studies ,42,43. T< 0.001) . Treatme< 0.001) ,45. A st< 0.001) . AnotherSeveral mechanisms had been implicated in relation to the testosterone and increased vascular function. In vitro and in vivo experimental studies showed that testosterone caused a vasorelaxation through several mechanisms such as endothelium-independent pathways, the opening of the potassium channel or calcium antagonistic effects . The tesCF and AI were associated with the hs-CRP. The increased inflammation may lead to the increased arterial stiffness by several mechanisms, which has been extensively reviewed by previous authors [The vascular dysfunction among obese subjects may also be due to an increased inflammation. In this study, both the PWV authors ,59. Infl authors . Lifesty authors .The synergistic effect of testosterone and hs-CRP on the vascular function had not been investigated previously. It was found that the combination of low FT and increased hs-CRP were associated with a higher augmentation index when compared to those with only an increased hs-CRP but high FT. This signifies that both factors may have synergistic effects that contributed to the vascular dysfunction and may have a different mechanism independent of each other as stated above. The presence of both factors, the low FT and high hs-CRP, may lead to a higher risk of vascular damage. In this study, FT correlated with the AI and not the TT. This may be due to the fact that FT is the fraction of testosterone that is free to act on cellular targets. TT is all of the testosterone in the blood, including those bound with the sex hormone binding globulin (SHBG) and albumin, which may not be free to act on biological targets. Thus, despite being a convenient clinical measure of the androgenic status, TT may not be the most reliable indicator to predict biological activities of testosterone in the body .Several limitations need to be considered for the interpretation of the data in this study. Firstly, this was a cross-sectional study so causality between vascular functions and variables of interest cannot be firmly established. Secondly, the subjects consisted of Malays and Chinese only, which did not truly represent the multiracial Malaysian population. Thirdly, the level of obesity was determined by the BMI, which was assumed to be correlated with the level of adiposity. However, the level of adiposity is more accurately assessed by the dual-energy x-Ray absorptiometry (DXA) or leptin-adjusted BMI . These tA further longitudinal study should be conducted to verify the associations between vascular functions, testosterone, and inflammation. An interventional study using a testosterone supplementation, anti-inflammation, and weight lost program may be beneficial to determine their effects towards the vascular function in the obese subjects .Men with a high BMI suffer from an impaired vascular function, which is related to the low testosterone level and increased inflammation. The low testosterone level and increased inflammation may be the main mechanism in inducing the impaired vascular function among obese men. Weight loss, testosterone supplementation and anti-inflammatory agents may be beneficial for men to prevent the vascular dysfunction.


PROM of the hip  significantly (p < 0.001 for multiple comparisons) increased after 1 month  and further after 5 months (p < 0.05 each) in contrast (p < 0.05 each) to a control group with state-of-the-art therapy. Similarly, PROM showed a trend towards improvement in dorsal extension of the ankle (p = 0.07). In summary, this is the first report of a novel device with additional benefit to standard therapy for severe PD. These intriguing results warrant the planned prospective randomised controlled trial to prove the concept and mechanism of action of this device.People with physical disabilities (PD) suffer from consequences due to lack of physical activity and consequently, are at increased risk of chronic diseases. We aimed to evaluate the ability of a motorised assistive device for dynamic standing with weight-bearing in addition to standard state-of-the-art therapy to improve clinical outcome in a meta-analysis of available studies. A total of 11 studies were identified from different European countries analysing the effect of the dynamic device Innowalk. Raw data of nine studies were pooled including a total of 31 patients observed between 2009 and 2017. Standardised questionnaires and physical outcomes were examined in this exploratory meta-analysis. We recorded patients’ characteristics, duration, intensity, and location of usage as well as general clinical outcomes and improvement of passive range of motion (PROM). The analysed population consisted in 90% cases of patients younger than 18 years of age. Patients were severely disabled individuals (aged 8 (6–10) years; 58% male; 67% non-ambulatory, 86% cerebral palsy). A total of 94% used the Innowalk in a home-based or day-care setting. For nearly all individuals (94%), improvements were recorded for: walking or weight-bearing transfer ( Physical disabilities (PD) with permanent motor impairments, due to non-progressive brain disorders, that is, cerebral palsy, are characterised by their complex symptoms, diverse underlying aetiology, and consequent disabling disease progression. These heterogeneous entities often result in pathologic muscle activity, imbalance between agonists and antagonists with consequent contractures and deformities . DevelopExercise and muscle activation have positive effects on muscle strength/function/tone, neuromusculoskeletal and movement-related functions, bladder and bowel function, endurance, flexibility, cardiorespiratory fitness, overall wellbeing, activities, and participation in people with PD . CerebraFor these patients, multimodal treatment by a multidisciplinary team is costly, personnel-intensive and high-level scientific evidence is lacking. Especially for the hip, passive assisted motion of the legs with next-to-physiological gait-like motion in axial alignment may have a direct beneficial long-term effect to prevent hip deformities  and thusInstability of the hip is a key feature for these patients. It occurs due to various interacting factors, such as changes of connective tissue, imbalance of the muscle tone between antagonistic muscle groups, reduced exposure to force of gravity, compensatory pathological movement patterns, or changes of the bones and joints adjacent to the hip . SecondaDevices for dynamic standing, such as the EasyStand glider or the Innowalk device promote passive motion of the lower extremities during standing with weight-bearing. Whilst the EasyStand requires coordinated movement of the arms to move the legs, the Innowalk is the only device available that induces walking movements independent of functioning arm movements. In the Easy stand glider, no extension and flexion in the knee is possible, and the knees seem to be in an extended position, whereas, the Innowalk provides a more natural walking movement. The Innowalk has been specifically designed to be used at home or in institutions such as hospitals and exercise facilities. It is intended to be used by severely disabled (non-ambulatory) children and adults with neuromuscular disabilities related to diagnoses such as cerebral palsy, spina bifida, genetic disorders, traumatic, or hypoxic brain injury. Typically, these patients are unable to come into the upright position without adequate own movement capacity and ability to support their own weight. Furthermore, it is often impossible, for individuals with neuromuscular disorders, to reach the recommended minimum of 30 min for adults and 60 min for children, of moderate to vigorous physical activity minimum 5 days a week.This assistive device makes it possible to reach the goal of regular daily physical activity in an upright weight-bearing position with the necessary and safe trunk support, while enabling passive movement of the legs. It has therefore been proposed to contribute to improvement of individual physical limitations . It was We have gathered data from a network of Innowalk users  from thrA comprehensive literature search was performed to identify all eligible studies. Electronic searches of PubMed, Google Scholar, Scopus, MEDLINE, Database of Reviews of Effectiveness, Cochrane Database of Systematic Reviews, CINAHL and ClinicalTrials.gov were performed in April 2018 using the key words ‘dynamic standing’, ‘EasyStand’, and/or ‘Innowalk’. Reference lists from the identified publications and presentations on congresses were used, the manufacturer of Innowalk was contacted and researchers knowledgeable about this intervention were consulted to identify other potential studies. No restrictions on the language of the publication were made. Determination of study status including prespecified quality criteria and data extraction based on pre-defined characteristics was performed by two independent reviewers (J.K. and A.P.). Following revision, decision to include data of a study into this meta-analysis was reached after consensus by three scientists .The case studies have been conducted in Austria, Norway, and Sweden from 2009 to 2017. Written informed consents complying with individual national requirements were provided.CRD42018109076. The process of data extraction from each study included was performed according to standard procedures  of Landesärztekammer Berlin . The study has been registered in the PROSPERO database on 2nd October 2018 and has been assigned the number ocedures .There were two different devices that claimed to use dynamic standing, the EasyStand and the Innowalk.Dynamic standing in the EasyStand requires addition of the so called gliders, in which the feet are fixed. To move the feet, the users have to move the glide handle actively with their arms to convey motion of the legs. This device is suitable for persons with spinal cord injuries rather than brain damage. Three trials using the EasyStand as passive standing frame only were found but none displayed features of dynamic standing . From din = 4 are currently still using the Innowalk; n = 1 died due to complications due to the original diagnosis (brain injury); n = 1 stopped usage after improvement and reaching prespecified goals, no further data were available; in n = 2 lack of time/motivation of the parents to use the Innowalk was the reason for not further responding and further two patients were lost to FU. Raw data from 2 out of 11 studies could not be obtained in a high enough quality to be included  is a motorised, multi-functional assistive device offering the possibility for assisted repetitive walking movements close to normal gait in an upright weight-bearing position . This moThe device is individually adjusted to the size of the user in accordance to sitting height, sitting depth, leg length, and chest support height. Positioning of foot plates is regulated in accordance to PROM in angle, knees, and hips. Hip support is adjusted to the height of trochanter major in standing position. Head support is adjusted while standing. The angle of the seat (between sitting and full standing) is decided in relation to PROM or other deformities. The adaptation of above mentioned points is done at the first try out. Smaller adjustments are performed subsequently once or twice a year, depending on age and growth curve.The speed of the pedal is started with around 10 rounds per minute (rpm) and increased depending on the patients’ individual tolerance to maximally 85 rpm via remote control. This can be adjusted within 4 s. The emergency stop can be used if the remote control is not working, in case of acute pain, discomfort, and epileptic seizure.For security reasons, anti-spasticity control is included and can be adjusted according to the patients’ individual demands. Patients with uncontrolled epilepsy, skin abrasions, clinical relevant infectious disease, severe congenital disorders  should not use the Innowalk for safety reasons.The responsible physiotherapist and the physician decide on the duration of usage that remains under continual evaluation by the person in the device and person assisting the user, due to tiredness, pain or other observational signs of discomfort.We collected data on frequency of Innowalk use per week, length of the usage period (in weeks), and length of sessions (in minutes). Since this information has been given in different formats and raw data could not be extracted in a standardised manner, and furthermore, the actual use had not been documented in a standardised and comprehensible manner, these data could be presented for four out of nine studies .– Selection bias: differences between experimental groups in terms of possible confounding prognostic factors.– Performance bias: differences between groups in how and how long interventions were administered, presence of control group, randomisation or blinding.– Detection bias: mode of determination of outcome by the use of validated and adequate questionnaires or blinding of the respective study’s investigator.– Attrition bias: systematic group differences in the number of persons that quit or drop-outs or exclusion from analyses for any other reasons.– Reporting bias: that is, the presence of differences between the reported (published) findings, and the initially planned and/or non-reported analyses, or whether at all endpoints had been pre-specified, including adverse events.– Other bias: we additionally determined whether there were any other potential risk of biases, such as the absence of separate pre-tests to assess possible baseline differences in GMFCS-E&R between groups.Two reviewers (A.P. and C.S.-L.) independently evaluated the five major domains of biases according to the Cochrane’s risk of bias tool :– SelecTwo reviewers (A.P. and C.S.-L.) independently evaluated the included studies. Rating was performed manually by using the revised Cochrane risk-of-bias tool for randomised trials (RoB 2.0) . Risk oft-test (two-sided) for normally distributed variables. Data are expressed as mean ± SD, unless otherwise stated. Non-normally distributed continuous variables  were compared by the Mann–Whitney U-test for two groups or by the Kruskal–Wallis test with more than two subgroups with a post hoc analysis (Wilcoxon) for two dependent variables. To control for multiple comparisons in PROM of different joint angles and group comparisons (n = 10) the Bonferroni correction was applied to each p-value and the uncorrected p-values are reported in the text, tables, and graphs. Comparison of categorical variables was generated by the χ2  test. SPSS versions 25.0 was used. Statistical significance was accepted at p < 0.005.Continuous variables were tested for normal distribution with the Kolmogorov–Smirnov test. Comparisons between the two groups were analysed by n = 8) to moderate (n = 4) pain. There was only incomplete information on weight or height, so we refrained from analysing and presenting this information.Characteristics of the studies are in p = 0.09).A total of 26 patients used the Innowalk size small and the remaining five used size medium. Location of usage of the dynamic standing device was at home or in day care (94%), rarely in hospital, as can be seen in Data were collected by paediatricians, physiotherapists, or occupational therapists using standardised questionnaires, at time points before, during, and after usage of the Innowalk. The outcome measures of this pooled study were recorded using the Modified Ashworth Scale , the Modn = 4), muscle strength (n = 5), joint mobility (n = 3), general physical activity (n = 4), walking or weight-bearing transfer (n = 4), control/strength of the trunk or head (n = 4), COPM (n = 5), sleep (n = 4), cardiovascular function (n = 8), or bowel function (n = 15), prevention of deformities/contractures (n = 4), or reduction of spasticity (n = 1) or frost bites (n = 1) or improvement of ‘vital function’ (n = 5).In five studies including 16 out of 31 patients, individual goals for treatment outcome had been prospectively defined with up to six different individual goals for either joint or muscle function, cardiovascular or intestinal function or overall improvement. These were in detail: improvement of mobility (n = 13), control/strength of the trunk or head (n = 6), joint mobility (n = 14), sleep (n = 4 out of 6/67%), or muscle strength (n = 17), ‘vital functions’ (n = 16), bowel function (n = 10), attention/orientation (n = 2). The same outcomes were evaluated with similar results across the studies with similar methods of assessment.As seen in p < 0.005 for multiple comparisons) increased after 1 month (FU 1) and 2–5 months (FU 2). The results from the individual studies can be deducted from p = 0.06,) and flexion (p < 0.0001) were restored. Furthermore, abduction (p = 0.0003) and adduction (p < 0.0001) as well as internal rotation (p < 0.0001) were significantly improved after usage of the Innowalk to a near normal PROM. In contrast (each p < 0.005), as demonstrated in p = 0.06, see p < 0.01 for trend) after 2–5 months, as demonstrated in In two studies including a total of nine patients with CP , improven = 2) or lost-to-follow-up (n = 2). Due to the nature of the study, no reports are available on these patients. For the remaining 31 patients of whom quality of data was sufficient to be included in this meta-analysis no adverse events or unacceptable experiences were reported. Adverse events and unacceptable experience with respect to this medical device and with respect to both, paediatric and adult population are: risk for hand injury at the mechanical upright function underneath the seat and column, risk for hand injury at the tilt function of the front frame, redness of the skin in case guide strap is tied to tight to the leg steels, possible redness of the skin and possible allergic reactions where Innowalk comes in contact with the user. The risk of strangulation or other damages could be caused by cables, belts, straps, wires. The risk of foot injury exists in case Innowalk is not used with shoes that fits the Innowalk.From all available data, including those with missing key variables, a total of four patients have to be classified either as drop-outs (n = 3) (n = 6)   to level (n = 6)  accordinThe salient finding of this pooled analysis is that regular usage of the Innowalk assistive device in addition to state-of-the-art therapy in this population with a predominantly paediatric population (90%) significantly improved PROM of all joints of the lower extremities in axis. What’s more, additional significant increase in PROM had been gained in the hip for axes not directly affected by the device. Furthermore, for predefined goals in daily living such as improved weight-bearing transfer or walking, general muscle strength, reduction in need for medication or even prevention of planned surgery beyond the effect of standard therapy. This shows the complexity of benefits obtained with this device.To obtain these data, relevant sites and the internet in general had been searched for groups that had presented data or were conducting ongoing studies with dynamic standing. Generally, two devices were found. Only for one of them—the Innowalk—was data from studies available. Furthermore, the Innowalk manufacturer provided contacts for additional groups of whom they knew that studies were carried out. All but one groups were willing to share their data, whereas one group had key variables missing. Two groups with three ongoing trials obviously could not provide data. This meta-analysis thus summarises all available data world-wide on treatment with this device gathered by scientific groups. The international multicentre approach of this data collection ensures the ascertainment of a sufficient number of cases with a broad spectrum of neuromuscular and functional disorders having been treated. The groups whose data we analysed used similar standardised validated questionnaires and were guided by similar cultural and only minimally diverging national guidelines. Thus, patterns in frequency and intensity of usage, indications, severity of disability deemed elective for usage as well as goals set were similar. Furthermore, these are in line with data from a comparable cohort from Germany derived from real-life prescriptions (manuscript was made available for reviewers).All of the authors have presented their case series, but none of them has so far performed a sufficiently powered analysis. We tried to overcome these limitations by pooling crude data from distinct yet similar studies involving a generally homogeneous population.Our results show the diverse improvements related to passive motion of the joints, muscular tone and general well-being associated with physical exercise, for the first time providing evidence in support for beneficial effects of usage of the Innowalk. PROM of hips, knees, and ankles in axis is increased due to direct motion by the device, whereas increases in hip abduction and hip adduction are related to indirect effects, most likely due to reduction of muscle tone, effects on imbalance of antagonising muscle groups. It is tempting to speculate that central nervous stimulation of near-to-physiological leg movements might have a role to this effect. Evidence exists from other devices for this patient group that gravity force  and furtPassive motion alone to overcome contractures and to lengthen musculature, increase blood flow and move joints in the physiological range might have first beneficial effects . In addiCumulatively, the Innowalk is a promising tool with high potential to further improve current evidence-based treatment for patients with severe PD. It is not only for joint mobility and preserving/animating to gait-like movements, but also to significantly enhance relevant aspects related to quality of life. This analysis has limitations inherent to the pooling of data. Data were collected from different cohorts with small numbers from exploratory studies with different standards of acquiring data, quality of documentation, usage of validated questionnaires, that is, for quality of life, and planning of set-up and conduct. Some of the studies had no prespecified goals and thus cannot be considered as prospective studies in strict terms. Patients with flaccid paralyses due to muscular spina bifida, muscular atrophy, or dystrophy have different requirements from patients with CP. Whether these different patient groups might both be suitable for treatment with the Innowalk, and most likely with divergent indications, will have to be considered in future studies. The qualitative components of the reported studies at the pre-trial stage serves the purposes of developing clinically relevant hypotheses, most useful outcome measures and measuring ranges for evaluating this complex intervention method for a heterogeneous study population. These studies gather and present the best evidence available for the effectiveness of dynamic standing and identify the gaps in evidence.A future prospective randomised and controlled trial with estimated 30 patients according to our power and sample size calculation should be conducted in an international multicentre setting as an add-on to guideline-conform multidisciplinary treatment. A major challenge will be the need to use individually set endpoints measured with agreed upon standardised and validated questionnaires and protocols. The results presented here give an estimate of duration and FU intervals to assess clinically relevant changes. Clearly, a consecutive long-term FU period is necessary to evaluate long-term benefits, for example, bone mineral density, or prevention of hip dysplasia.With high similarities of study outcomes in these albeit small studies and bearing the limitations of this analysis in mind, we believe that these data are suitable to form the basis for the urgently warranted randomised, controlled, multicentre trial. Aim of this trial will be to challenge the hypothesis of a standardised usage of the Innowalk for dynamic standing in addition to standard state-of-the-art treatment physiotherapy.10.7717/peerj.7098/supp-1Supplemental Information 1The checklist items pertain to the content of a systematic review and meta-analysis, which include the title, abstract, methods, results and discussion.Click here for additional data file.10.7717/peerj.7098/supp-2Supplemental Information 2This figure maps out the number of patients identified, included and excluded, and the reasons for exclusions.Click here for additional data file.10.7717/peerj.7098/supp-3Supplemental Information 3The reason for this review has been to efficiently integrate existing information and provide quality data for further decision making.Click here for additional data file.10.7717/peerj.7098/supp-4Supplemental Information 4Raw data that was used for this meta-analysis.Click here for additional data file.10.7717/peerj.7098/supp-5Supplemental Information 5Plus (+) represents low risk of bias; minus (−) represents high risk of bias; question mark (?) represents unclear risk of bias.Click here for additional data file.10.7717/peerj.7098/supp-6Supplemental Information 6n represents number of joints. In the study of Hansen, there were no control patients (n.d. = not defined).FU1 represents follow up visit after 1 month. FU2 represents follow up visit in the period from 2-5 months. Click here for additional data file.


Identifying priority zones for river restoration is important for biodiversity conservation and catchment management. However, limited data due to the difficulty of field collection has led to research to better understand the ecological status within a catchment and develop a targeted planning strategy for river restoration. To address this need, coupling hydrological and machine learning models were constructed to identify priority zones for river restoration based on a dataset of aquatic organisms  and physicochemical indicators that were collected from 130 sites in September 2014 in the Taizi River, northern China. A process-based model soil and water assessment tool (SWAT) was developed to model the temporal-spatial variations in environmental indicators. A support vector machine (SVM) model was applied to explore the relationships between aquatic organisms and environmental indicators. Biological indices among different hydrological periods were simulated by coupling SWAT and SVM models. Results indicated that aquatic biological indices and physicochemical indicators exhibited apparent temporal and spatial patterns, and those patterns were more evident in the upper reaches compared to the lower reaches. The ecological status of the Taizi River was better in the flood season than that in the dry season. Priority zones were identified for different hydrological seasons by setting the target values for ecological restoration based on biota organisms, and the results suggest that hydrological conditions significantly influenced restoration prioritization over other environmental parameters. Our approach could be applied in other seasonal river ecosystems to provide important preferences for river restoration. The ecological status of rivers is tightly related to human society. Human activities referring to industry, agriculture, and construction may affect important ecological functions and processes, such as nutrient cycling and carbon flux in food webs ,2,3, chaPrevious studies mainly focused on the identification of rivers with hydromorphological or physicochemical restoration priority , whereasAquatic biological indices are directly related to physicochemical indicators, which are affected by the driving forces of watersheds, e.g., geography, climate, and human disturbance. To model aquatic physicochemical indicators, process-based hydrological models are becoming a popular approach to study the temporal and spatial dynamics of river ecosystems . The modThe mechanism on how aquatic organisms vary with space and time is complicated because of the synergistic effects of various environmental factors, e.g., hydrologic regimes and water quality. Therefore, it is important to accurately simulate the relationships between aquatic organisms and physicochemical factors . A data-The generation and migration of non-point source pollution in the basin is mainly determined by three major processes: surface rainfall-runoff process, rainfall-runoff erosion process, and leaching of soil by surface, soil, and underground runoff. Subsequently, the pollutants enter the water body, affecting the distribution of physicochemical indicators of the water body . The SWA2, with a length of 413 km. Within the warm temperate sub-humid area, the Taizi River Basin has a continental monsoon climate. The upper reach of the basin is characterized by low hilly landform, whereas most river channels are between the valleys, with relatively less human exploration and more vegetation coverage. Many rare aquatic organisms have been recorded in this region, such as clean-type fishes , and clean large-scale macrobenthos . In contrast, the middle and lower reaches are the plain area, with the terrain of higher southeast and lower northwest. Meandering river channels represent a curved type river. More distributed industries and human disturbance have led to excessive land utilization in lower reaches. In recent years, urbanization results in increasing pressure on the Taizi River Basin, such as water quality deterioration, habitat degradation, and biodiversity loss .,23.21,233-N, COD, BOD5, TP, and TN), according to the Chinese Water Quality Standard Methods [Fish samples were collected by electronic fishing and gill net fishing, and all fish samples were identified, enumerated, and weighed in situ. Rare or unknown species were preserved with 4% formalin for identification in the laboratory. Benthic macroinvertebrates were collected using a Surber net  and D-frame dip net (15 cm radius and 500 μm mesh), and they were identified to the genera level in the laboratory. Benthic algae were collected from all available substrates and habitats at each site, and were identified to the species level in the laboratory. Physicochemical parameters were measured in situ  or determined from water samples in the laboratory , algae species richness (A_S), and algae Berger-Parker index (A_BP). Among these indicators, F_S, F_IBI, and F_BP are related to physical, chemical, biological and zoogeographic factors, and long-term pressures [Eight biological indicators were implemented in the SVM model, i.e., fish species richness (F_S), fish index of biotic integrity (F_IBI), fish Berger-Parker index (F_BP), macroinvertebrate families richness (M_S), biological monitoring working party (M_BMWP), ressures . M_S is ressures . M_BMWP ressures . M_EPT iressures . A_S andressures . These iThe digital elevation map (DEM), land use, soil type, meteorological station data, reservoir data, and agricultural production data  were inp5 was explored in nine different periods. Values of aqueous environment factors were calculated by the SWAT model output file (rch file).In this study, the Taizi River Basin was divided into 130 sub-basins, and the sampling locations were used as the outlets in ArcSWAT ArcGIS extension 2012 Version . Data on hydrological stations, reservoirs, point emissions, and agricultural management information were also loaded for SWAT modelling. Three typical hydrological years were selected to investigate the distribution of aqueous environment factors in each sub-basin, i.e., flood year (2012), average water year (2004), and dry year (2014). The typical months of the dry season (April), the flood season (September), and the average water season (November) were chosen for modelling from the above three years. Therefore, the distribution of five environmental factors of WQ, TP, TN, DO, and BOD2) were adopted as indicators to evaluate the calibration results. NS demonstrated the ratio of the residual variance to the variance of the measured data [2 values, if it is close to 1, it suggests that better modelling results are required. If R2 is ≥0.6, the results can be accepted.It is necessary to calibrate the sensitive parameters from the modelling results, as there are more than 1000 parameters in SWAT, which can greatly improve the efficiency of the model. In this study, the SWAT-CUP toolbox, which is based on a mathematical algorithm shuffled complex evolution (SCE-UA) from the research of the University of Arizona, was used to automatically determine the parameters. SCE-UA is generally considered the most efficient and effective method , and is red data , showing2) was chosen to describe the overall modelling performance.The SVM is a kernel-based learning algorithm, and it is widely used for pattern classification and regression . In this2) for a given variable was subsequently calculated to obtain the effects of the variable on the model performance, and this process was repeated for every variable. At this stage, the biological indices were selected for the simulation of their temporal-spatial dynamics with the aid of the SWAT model.A sensitivity analysis was applied to investigate sensitive environmental parameters that influence the response of biological indices. The one-factor-at-a-time (OAT) method was used as the assessment tool for checking sensitivity of model variables. The SVM models were running by removing a variable at a time with other parameters being constant. The variation in overall model performance  . For the2 values for each different SVM model were shown in 2 > 0.6) except M_BMWP and M_S, which were 0.41 and 0.59, respectively. The result indicated that the indices of fish communities  and algal communities  were better fitted with the environmental variables when compared with the indicators of macroinvertebrate fauna . Therefore, the indices of fish and algal communities were selected to simulate their temporal-spatial dynamics.ROrthocladiinae, Oligochaeta), and a reduced sensitivity to environmental stress in the Taizi River Basin. Further, our results showed that, in the Taizi River, the SVM model could be a reliable prediction tool for fish and algal communities based on selected environmental factors. However, the ability of the model to predict macroinvertebrate communities was limited, indicating the increased number of pollution tolerance species  and physiochemical conditions  were both considered in the SVM, and played a crucial role in the reproduction and predation of fish communities .2 for every input variable in the SVM model. OAT analysis checked the model fitting by removing a variable. If R2 became smaller, it suggests a greater impact on the model fit, and the variable was more sensitive. For algal communities, the smallest R2 for A_BP was 0.94 (TP), and for A_S was 0.90 (TN). For fish communities, R2 for F_BP was 0.93 (BOD5), for F_IBI was 0.62 (DO), and for F_S was 0.93 (BOD5). For macroinvertebrate communities, R2 for M_BMWP was 0.35 (BOD5), for M_EPT was 0.65 (TN), and for M_S was 0.54 (TP). The result suggests that these sensitive environmental indicators were appropriate for the SWAT model.Sensitivity analysis of the SVM model showed that algae and macroinvertebrates were more sensitive to nutrients, whereas fish communities were more sensitive to DO and organic pollutants. It has been documented that nutrients was a limiting factor for algal and macroinvertebrate communities . Low lev2 and NS in calibration periods of each hydrological station were higher than 0.7. R2 in validation periods was higher than 0.6, and NS in validation periods was higher than 0.7.The statistical indices  showed t5 concentrations. Results demonstrated that aqueous environment factors displayed apparent spatial and temporal patterns. Spatially, TP, TN, DO, and BOD5 concentrations exacerbated gradually from upstream to downstream, and they were generally lower in tributaries than the mainstream, which was consistent with human disturbance gradient. Temporally, water quality in the flood season was better than that in the dry season and the average water season  and an algal ecological index  were selected to simulate the temporal-spatial dynamics by coupling SVM and SWAT models. F_S exhibited an obvious deterioration from upstream to downstream, whereas those from the upper and middle reaches were greater than those from the tributaries, and those of the tributaries from upper headstream were greater than those in the middle and lower reaches. Further, F_S displayed the greatest value in the flood year, followed by that in the dry year, whereas those in the average water year were the lowest. Additionally, F_S showed the greatest value in September, while those from November and April were relatively lower  and aquatic biological indices (F_S and A_S). From upstream to downstream, physicochemical indicators displayed a gradual deterioration, whereas the upper and middle reaches of the mainstream showed better status than tributaries. Moreover, results indicated that tributaries from the upper reaches were characterized by greater quality than those from the middle and lower reaches. Further, aquatic organisms and aqueous physicochemical indicators implied the best ecological status in the flood season, and the worst in the dry season. Simulated values of aquatic organism indices were in good agreement with the measured values. Based on aqueous ecological dynamics, the priority zones of river ecological restoration in watersheds were identified. The results demonstrated that the sub-basin of the tributary flowing from Guanyinge Reservoir through Nandianzi Town of Benxi County was the key area of ecological restoration. The remedial priority area varied with hydrological seasons in the middle and lower reaches. More sub-basins required restoration in the dry season and less in the flood season. The approach that is proposed in this study could provide references for the decision-making of the ecological restoration strategy for other river ecosystems.In this study, a method of temporal-spatial dynamic modelling of aquatic ecological status for ecological restoration by coupling SWAT and SVM models was established in the Taizi River, China. Results showed that there were significant temporal-spatial variations in physicochemical factors (TP, TN, DO, and BOD