The fast-growing food industry is bringing significant number of new products to the market. To protect consumers’ health and rights, it is crucial that food control laboratories are able to ensure reliable quality testing, including product authentication and detection of adulterations. In our study, we applied a fast and eco-friendly method based on shotgun-lipidomic mass spectrometry for the authentication of niche edible oils. Comprehensive lipid profiles of camelina (CA), flax (FL) and hemp (HP) seed oils were obtained. With the aid of principal component analysis (PCA), it was possible to detect and distinguish each of them based on their lipid profiles. Lipidomic markers characteristic ofthe oils were also identified, which can be used as targets and expedite development of new multiplexed testing methods. Edible oils have been used since antiquity for health purposes; however, people did not realize what was responsible for this effect. Current analytical tools allow oils to be broken down into their individual components; thus, we can identify exact constituents affecting various medical conditions. Plant oils comprise mainly triacylglycerols and diacylglycerols (TAGs and DAGs), free fatty acids (FFA), phospholipids, glycolipids, carotenols, polyphenols, tocochromanols, phytosterols, carotenoids, and squalene, as well as antibacterial and anti-inflammatory ingredients . They arcis/trans configuration, the number and localization of unsaturated bonds, and the positions of substitutions on the glycerol backbone –t[2] score plots in all models. Clear separation of CA, FL and HP samples was observed indicating high potential of classification and discriminating power of lipidomic profiles.2X, R2Y and Q2 were, respectively, equal to 0.844, 0.967 and 0.954 for a TAG species dataset; 0.974, 0.967 and 0.951 for a DAG species dataset; 0.976, 0.965 and 0.952 for a DAG subspecies dataset; 0.845, 0.968 and 0.955 for a combined DAG and TAG species dataset; and 0.831, 0.976 and 0.964 for a FA in DAG and TAG dataset. Clear classification and discrimination of the three examined oils  were observed in the score plots. Models indicated discriminating variables (lipidomic markers). Biplots of OPLS-DA models, which display superimposed scores and loadings, are presented in Next, OPLS-DA models were built on the same datasets. OPLS separates the systematic variation in dataset into two parts, one part that is correlated (predictive) to Y (oil type), and one part that is uncorrelated  to Y. In the single-Y case, there is only one predictive component, and all components beyond the first one reflect orthogonal variation. However, with multiple Y-variables, there can be more than one predictive OPLS component. Each OPLS-DA modeling resulted in the model with two predictive components (2+0+0), which is consistent with the PCA-based observations. Model Rsn positions for TAGs and DAGs.Our results demonstrate that rapid and straightforward analysis by mass spectrometry shotgun lipidomics, followed by data processing using chemometric tools, can quickly classify and distinguish CA, FL, and HP oils according to their specific lipid profiles. Shotgun lipidomics is a high-throughput approach enabling the qualitative and quantitative detection of lipid molecular species in a single run, although this method cannot separate compounds to the extent achieved by coupled techniques, e.g., LC/MS or GC/MS. Moreover, it is incapable to determine regioisomers, or enantiomers, neither to provide structural information on double bond and Initial analysis of group profiles for DAG and TAG contents based on the number of double bonds in FAs and the lengths of FA chains indicated that they were significantly different for the three oils, suggesting the possibility of differentiation of oils . HoweverHP, CA and FL oils were clearly differentiated using multivariate analysis. Samples of the same type of oil clearly grouped together in different parts of the PCA space, regardless of the depth level of TAG and DAG characterization. It was found that the oils discrimination can be reached at both the DAG and TAG molecular groups (species), as well as at DAG individual molecule (subspecies) and FA profile in DAG and TAG levels. The two first PCs of the models explained between 83% to 95% of variability in lipids profiles, which can be attributed in each case to between type-of-oil variation. This was confirmed in OPLS-DA analyses upon supervised data modeling, with oil samples assigned to the class , was performed; OPLS-DA models had two predictive components. Unambiguous classification and discrimination of the oils was obtained . The finThe obtained results indicated that the development of analytical strategies for profiling these three oils using a separation technique  may focus only on the DAG class or only on the major components of oils—TAGs—which will grant shorter analysis times and higher laboratory throughput than the oil authenticity control based on comprehensive LC lipid profiling. The acquiring of highly comprehensive lipidomic profiles covering DAG and TAG require high separation selectivity and long chromatographic run times. Currently our undergoing investigations are focused on translating the findings to user-friendly LC-MS based methods.The DAG and TAG molecular groups with the most significant contributions to the differentiation of the three oils are presented in The study focused on the differentiation of three niche cold-pressed oils  using a mass spectrometry shotgun lipidomic technique. It provided quantitative DAG and TAG profiles and their FA profiles. It was demonstrated that the identification of each oil sample at the DAG or TAG molecular group level, the DAG subspecies level, and at the FA composition in DAG and TAG level was possible. In each case, multivariate data analyses lead to univocal classification and differentiation of the oils. Differentiating lipid markers were identified and may be used for the development of targeted methods for oil testing. DAGs 34:2; 36:2–6 and TAGs 56:4–5; 58:4 can be employed as quantitative markers for differentiation of all three tested oils, whereas DAG 32:3 for FL oil, DAG 38:4 for CA oil, TAG 55:3–4 for CA oil, and TAG 56:1 for FL oil may be used as oil specific markers.Targeted approaches including multiple reaction monitoring on liquid chromatography triple quadrupole mass spectrometry systems or a list of targets for easy and fast data interpretation for mass spectrometry shotgun analyses, as more user-friendly techniques, are more feasible for implementation to routine laboratory practice. The main advantage of shotgun technique is the lack of chromatographic separation, which makes the shotgun methods fast, cost-effective, and eco-friendly, so their raising popularity and utility is anticipated. The characterization of oils for the quality control using a shotgun lipidomic analysis is a powerful analytical tool applicable to oil authentication, and the complexity of data processing may be easily overcome with the setting of lists of targets.


HNSCC is the sixth most frequent type of malignant carcinoma with a low prognosis rate. In addition, autophagy is important in cancer development and progression. The purpose of this study is to investigate the potential significance of ARGs in the diagnosis and treatment of HNSCC.  Expression data and clinical information of HNSCC samples were collected from the TCGA database, and a list of ARGs was obtained from the MSigDB. Then, we used R software to perform differential expression analysis and functional enrichment analysis. Further analysis was also performed to find out the survival-related ARGs in HNSCC, and two prognosis-related ARGs, FADD and NKX2-3, were selected to construct a prognosis prediction model. Moreover, some methods were applied to validate the prognosis prediction model. Finally, we used cell lines and clinical tissue samples of HNSCC to analyze the importance of FADD and NKX2-3.  We screened a total of 38 differentially expressed ARGs, and enrichment analysis showed that these genes were mainly involved in autophagy. Then, we selected FADD and NKX2-3 to construct a prognosis model and the risk score calculated by the model was proved to be effective in predicting the survival of HNSCC patients. Additionally, significant differences of the clinicopathological parameters could also be observed in the risk scores and the expression of NKX2-3 and FADD. The expression of FADD and NKX2-3 in cell lines and HNSCC tissue samples also showed the same trends.  ARGs may be a potential biomarker for HNSCC prognosis, and targeted therapies for FADD and NKX2-3 are possible to be a new strategy of HNSCC treatment. Head and neck squamous cell carcinoma (HNSCC) is the sixth most common malignancy of the world. It arises in the epithelium cells of the upper aerodigestive tract and includes the larynx, paranasal sinuses, oral cavity, nasal cavity, and pharynx . GeneticAutophagy is a common biological phenomenon and another name for it is type II programmed cell death. It is a process in order to maintain cellular homeostasis, conducting damaged or defective intracellular components . PreviouTo better investigate the influence of ARGs on the survival of clinical patients, we downloaded original gene expression data for HNSCC from the TCGA database. We then used these gene expression data, together with information we obtained from other public databases, to develop a prognostic prediction model as an indicator of overall survival (OS) for HNSCC. We also identified the genes related to clinical outcomes of HNSCC patients. Finally, we used experiments to confirm the results of our analysis, with the purpose of selecting possible targets that can be used for the clinical diagnosis and treatment of HNSCC patients.The Cancer Genome Atlas (TCGA) database is a complete genome-wide gene expression database used for categorizing and detecting genomic abnormalities in a large population worldwide . We downp value < 0.05. Then, we draw heat map, volcano map, and box plot. Gene Ontology (GO) enrichment analysis and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis were also performed to find the major biological attributes of differential expression ARGs. The visualization of the enrichment maps was performed by R through the “ClusterProfiler” packages [We analyzed the expression data by using Wilcox test methods through package limma in R  to choospackages .p < 0.05, HR > 1). We obtained 2 prognostic ARGs, and then, based on the multivariate Cox regression, we calculated the correlation coefficient of the ARGs. According to the correlation coefficient, the survival-related prediction formulas were performed to build prognostic models. We evaluated the risk score of all HNSCC samples through the prognosis prediction model. To further assess the survival differences, we first divided the HNSCC patients into a high-risk group and a low-risk group, according to the median value of the risk score. Then, Kaplan-Meier (K-M) methods were applied to compare the high-risk and low-risk groups.Univariate and multivariate Cox regression analyses were applied to screen the survival-associated ARGs in HNSCC , HSC-3, HSC-4, and HSC-6  were purchased from the Institute of Chinese Academy of Sciences . We cultured these cells in 1640  medium with 10% fetal bovine serum  in an incubator, which was 37°C and 5% COΔΔCt method was used to analyze the mRNA relative expression. The primer sequences of the ARGs were as follows: FADD: 5′-CGGCCTAGACCTCTTCTCCAT-3′ (forward), 5′-TGAGACTTTGAGCTGACGAGC-3′ (reverse); NKX2-3: 5′-GGAAGACGAGGGCGAGAAAT-3′ (forward), 5′-TCTAGAGACTTCTTCAGCTGGC-3′ (reverse).Total RNA was extracted from HOK, HSC-3, HSC-4, and HSC-6 cell lines by using Trizol (Invitrogen). Subsequently, RNA concentration was measured by an ultraviolet spectrophotometer. We stored the extracted RNA samples at –80°C until use. The complementary deoxyribonucleic acids (cDNAs) were obtained by reverse transcription, and the SYBR Green method was used for PCR detection. GAPDH was used as internal references for mRNA, and the 2-μm sections. The HE and IHC staining for FADD proteins were then carried out in these tissue samples. We diluted the primary antibody FADD  with a ratio of 1 : 50. When finished, we observed the gene expression under the microscope. Finally, we took pictures of it and the magnifications used were 100x.We collected the tissue samples from the First Affiliated Hospital of Guangxi Medical University, which was approved by the Ethics Committee. All the paraffin-embedded sections were cut into 4 t-test and chi-squared test were used to compare the data of two groups. Statistical significance was defined as p < 0.05. All statistical analyses were carried out using the IBM SPSS software (version 25).The independent sample We involved a total of 502 primary HNSCC patients with gene expression data and clinical information in our study. At the same time, 232 ARGs derived from MSigDB were included in our study and there were 38 differentially expressed ARGs, including 28 upregulated  and 10 downregulated ARGs , with thresholds of ∣log2 fold change (FC) | >2. The heat map and volcano plot showed the differentially expressed ARGs, green represented low expression, and red represented high expression Figures . FinallyIn order to better understand the associated mechanisms in the development of HNSCC, we functionally categorized the differentially expressed ARGs. The Gene Ontology (GO) database denotes for numerous gene annotation terms, classified based on their association with biological processes (BP), molecule function (MF), and cellular component (CC). We then used the Kyoto Encyclopedia of Genes and Genomes (KEGG) to identify functional and pathways.Figures Differentially expressed ARGs, which were significantly associated with survival of patients, were screened to analyze ARGs involved in HNSCC progression. As a result, we identified two ARGs, including FADD and NKX2-3, and furthermore, the prognosis prediction model was constructed by these two prognostic ARGs. The prognosis prediction model =  + , and the calculated result was risk score.Figures p = 0.002; p = 0.049; p values of lymph node metastasis were also less than 0.05 in univariate analysis and multivariate analysis, which could be used as independent prognostic indicators as well. In the HNSCC data downloaded from TCGA, only 2 patients had distant metastasis, so we did not include metastasis as a factor in our analysis.Univariate analysis showed that risk score was significantly related to the prognosis of patients  and higher in Stage III&IV than in Stage I&II (p = 0.018). No difference of risk score was observed from age, gender, and grade (The risk score of the prognosis prediction model was higher in T3-4 than in T1-2 (nd grade . Similarnd grade .p < 0.05), and the expression trend of FADD was consistent with the trend we analyzed in HNSCC . Also, approximately 66.7% (14/21) of laryngeal carcinoma tissues and 28.6% (2/7) of laryngeal epithelial tissues were positive for FADD. The results were all statistically different (p < 0.05).To further clarify the potential biological function of ARGs in HNSCC transformation, we next selected FADD, which performed well in cell lines, to characterize the expression changes in clinical samples by IHC. Tissues of oral squamous cell carcinoma and laryngeal carcinoma tissues were used for detection, both of which belong to HNSCC. We also collected normal oral epithelial tissues and laryngeal epithelial tissues as control groups for detection. We first performed HE staining to observe the pathological structure of these tissues . For IHCIn recent decades, the prognosis of HNSCC has been relatively poor, and treatment plans have been based primarily on the TNM stage. In addition, histopathological findings, such as marginal state, perineural infiltration, and lymphovascular invasion, are also used as the basis for treatment planning . PreviouIn our study, we first obtained all ARGs from the public databases, then identified 38 differentially expressed ARGs in HNSCC samples, and finally selected 2 ARGs that related to the prognosis of patients with HNSCC. The prognosis prediction model was developed to predict the survival of HNSCC patients. The results demonstrated that the HNSCC patients with high-risk scores always resulted in poor overall survival. To better predict the survival of patients, we incorporated the risk score, age, gender, tumor grade, tumor stage, tumor size, and lymph node metastasis to construct a nomogram. Our results showed that the risk score has a high prognostic value and it could be used as a diagnostic biomarker. Finally, we analyzed the clinical features of two prognostic ARGs that we used to construct the prognostic model and calculate the risk score. According to our analysis and experimental results, these two genes have significant differences both in cell lines and clinical samples, which means they are closely associated with the occurrence and development of HNSCC. They are able to be used as therapeutic targets for HNSCC. Among these two ARGs, Fas-associated protein with death domain is the full name for FADD. FADD is a key adaptor protein that mediates apoptosis signal transduction . ExcepteIn this study, a prognosis prediction for HNSCC was established and it showed good predictive ability, which provided useful guidance for the prediction of individual patients. In addition, we confirmed the critical role of ARGs, including NKX2-3 and FADD, during the occurrence and development of HNSCC for the first time, which can be used as a diagnostic biomarker and a therapeutic target for HNSCC. However, there are still some limitations in our study. This is a study based on bioinformatics analysis, and the data were acquired from the public database. Thus, we need more independent cohorts to prove the effectiveness of the model we constructed. Additionally, although we did some preliminary validation on the 2 ARGs, their mechanism needs further functional experimental research and more clinical samples to verify. In conclusion, this study provides new strategies for the diagnosis, prognosis prediction, and treatment of patients with HNSCC.


Objectives: Invasive fungal infection (IFI) remains an important cause of mortality in liver transplantation (LT). The objective of this meta-analysis was to identify the risk factors for IFI after LT.Methods: We searched for relevant studies published up to June 2020 from PubMed, Web of Science, Embase, and the Cochrane Library. Odds ratios (ORs) and their corresponding 95% CIs were used to identify significant differences in the risk factors. Heterogeneity between studies was evaluated by the I2 test, and potential publication bias was assessed with Egger's test. The quality of included studies was evaluated with the Newcastle-Ottawa Scale (NOS).Results: A total of 14 studies enrolling 4,284 recipients were included in the meta-analysis. Reoperation , posttransplantation dialysis , bacterial infection , live donor , retransplantation , and fungal colonization  were associated with the risk factors of IFI after LT.Conclusions: Despite some risk factors that have been identified as significant factors for IFI post-LT, which may inform prevention recommendations, rigorous and well-designed studies with adequate sample sizes should be conducted to solve the limitations of this study. Since the first liver transplantation (LT) by Thomas Starzl in 1963, the prognosis was significantly improved. LT can be considered the most effective therapy for nearly all causes of end-stage liver diseases (ESLDs) . IFIs ocCandida species are the most common causes of IFI post-LT, followed by Aspergillus species  statement . The incThe following were the exclusion criteria: (1) duplicate articles; (2) reviews, meeting abstracts, letters, or case reports; (3) no diagnostic or no defined criteria for IFIs; (4) studies were related to the risk factors of IFIs after the organ transplantation but did not report the relevant data on the LT subgroup; (5) studies included data of risk factors for LT infection but did not show the information for IFI.Relevant information was extracted independently by the two reviewers (ML and LYS). A final check was confirmed by another researcher (ZJZ). The extracted data included the first author, publication year, country of origin, study time and design, number of patients and controls, and risk factors for IFIs with odds ratio (OR) and 95% CI from the multivariate analyses.The quality of each included study was independently evaluated by the three reviewers  based on the Newcastle–Ottawa Scale (NOS) . The NOSI2 > 50% or P < 0.1 (I2 < 50% or P > 0.05). Otherwise, the random-effects model was used. Sensitivity analysis was conducted by excluding one study at a time. Publication bias was assessed with Egger's test. P < 0.05 suggested that there was a publication bias in this study. The population attributable risk proportion (PARP) was calculated as follows: PARP = Pe (OR−1)/[Pe (OR−1) + 1]. Pe was defined as the pooled exposure rate of controls that represented the overall population exposure rate.Statistical analysis was performed using Review Manager 5.3 and Stata 12.0. Heterogeneity was considered significant with  P < 0.1 . The fixThe literature search yielded 2,405 results; most studies were excluded because they were duplicate studies or because they were not relevant to our meta-analysis. Then, 84 studies were excluded after the full-text articles were reviewed because they did not match the criteria. Finally, 14 studies involving 4,284 recipients  were included in this meta-analysis , 18–27. The specific characteristics of the studies included in the meta-analysis are presented in The risk factors for IFI post-LT are shown in Population attributable risk proportion was used to represent the proportion of cases in a population that was attributable to the exposed factor. The PARP of risk factors such as reoperation, posttransplant dialysis, bacterial infection, live donor, fungal colonization, and retransplantation is shown in Sensitivity analysis was used to evaluate the potential effect of heterogeneity conducted by eliminating one study in each turn. Sensitivity analyses manifested no significant changing of heterogeneity when one study was eliminated at a time.P < 0.05. Egger's test showed that most risk factors did not have a publication bias (P > 0.05).Egger's test was conducted for statistical investigation to evaluate potential publication bias . The pubInvasive fungal infection is associated with poor outcomes in recipients with posttransplant . TherefoCandida species were the most common causative organism of IFI among recipients of the LT, and Aspergillus species was the second most common.According to the inclusion and exclusion criteria, we identified 14 studies enrolling 4,284 patients. In our meta-analysis, risk factors for IFI after LT included reoperation, posttransplant dialysis, bacterial infection, retransplantation, live donor, and fungal colonization. As summarized in Reoperation and retransplantation, which indicated a more complicated intraoperative and postoperative procedure, were risk factors for IFI. Meta-analysis showed that the risk of IFI in recipients with reoperation was 2.18 times higher than the recipients without reoperation, which was consistent with the results of previous studies , 30. HowRecipients of the live donor were at a higher risk of IFI after LT, which was consistent with the previous studies , 31. In Our study also found that the risk of IFI increased with the posttransplant dialysis that is consistent with the studies of Ohkubo et al. , LavezzoWe used PARP to estimate the percentage of IFI in recipients of LT attributed to one kind of risk factor. We found that the PARP of the bacterial infection and reoperation was high. Thus, we infer that these risk factors were important for IFI post-LT.Fungal colonization was defined as the presence of fungus before LT without clinical symptoms or evidence of infection. We found that the patients with fungal colonization were at a higher risk of IFI. Several studies have shown that antifungal prophylaxis dramatically reduces fungal colonization, mortality caused by a fungal infection, and the overall incidence of fungal infection , 32. FurThere were several limitations to this meta-analysis. First, we only included English language literature from four databases, and there may have been incomplete retrieval. Second, there may have been mistakes in the data conversion because some study data required to be recalculated. Third, because of the limitations of the included date, we did not conduct subgroup analyses and funnel plots. At last, analyses were limited by the sample size included in this meta-analysis, so the combined effect size may have been exaggerated to draw the opposite conclusion.In conclusion, this meta-analysis identified some risk factors for IFI post-LT and might provide a basis for clinical prevention. However, a well-designed prospective cohort study should be conducted to validate our findings.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.ML and LYS designed the study and wrote the first draft of the manuscript. ML and ZJZ verified data extraction, data analysis, and reviewed the manuscript. LYS and ZJZ supervised the data acquisition, data analysis, and interpretation. All the authors read and approved the final manuscript.This research was supported by the Beijing Municipal Science & Technology Commission (No. Z181100001718220).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Diets are simultaneously connected with population health and environment. The EAT-Lancet Commission proposed a sustainable reference diet to improve population health and respect the planetary boundaries. Recently, the Planetary Health Diet Index (PHDI) has been developed to assess the adherence to this reference diet. In the present study, we aimed to evaluate the adherence to the EAT-Lancet diet through the PHDI in a nationwide population-based study carried out in Brazil. We used data from the National Dietary Survey conducted through the Household Budget Survey in 2017–2018, with 46,164 Brazilians aged over 10 years old. Food consumption was evaluated with a 24 h dietary recall. The average PHDI total score in the Brazilian population was 45.9 points (95% CI 45.6:46.1) on a total score that can range from 0 to 150 points. The adherence to EAT-Lancet diet was low among all Brazilian regions. Women, elderly, those overweighed/obese, with higher per capita income and living in the urban area had higher scores in the PHDI. In general, the Brazilian population presented low adherence to a healthy and sustainable dietary pattern and seems far from meeting the EAT-Lancet recommendations. Diets are simultaneously connected with population health and environment. Sustainable diets are key in addressing many of the health, environmental, social, and economic issues in the food system. Promoting sustainable diets through food choices is essential for achieving the sustainable development goals, including zero hunger, set by the United Nations .According to the Food and Agriculture Organization (FAO) and World Health Organization (WHO), sustainable healthy diets are “dietary patterns that promote all dimensions of individuals’ health and wellbeing; have low environmental pressure and impact; are accessible, affordable, safe and equitable; and are culturally acceptable” . They arThe landmark EAT–Lancet Commission report on healthy diets from sustainable food systems called for a “Great Food Transformation” to enable substantial dietary shifts and sustainable food production. They recognize that providing a growing global population with healthy diets from sustainable food systems are an immediate challenge, and proposed a healthy reference diet for human and planetary health, called the “planetary health diet” (PHD) . The EATThe field of modern nutrition has evolved from focusing on single nutrient to food and dietary patterns to explain many effects of diets, since it is recognized that we ate foods, not nutrients . IndicesRecently, we proposed the Planetary Health Diet Index (PHDI), which consists of 16 components that score proportionally and consider all EAT-Lancet food groups as caloric intake ratios ,9. PHDI The Brazilian National Dietary Survey, conducted in a sub-sample of the Household Budget Survey  in 2017–2018, allows estimates of individual food consumption for the entire Brazilian population . An analNDS-HBS 2017–2018 was embedded in the HBS 2017–2018, a nationwide survey carried out by household sampling. HBS collects information on family expenses, living conditions, and consumption habits of Brazilian families. Details about the sampling process and the definition of the master sample can be obtained from official publications of the Brazilian Institute of Geography and Statistics (IBGE) . BrieflyThe individual food consumption data was obtained from the personal food consumption questionnaire. Food consumption was assessed in-person interview, using two 24 h food recalls (R24h) at the respondent’s home, on non-consecutive days. The structured interview followed the Multiple-Pass Method, using a software designed for tables specifically for the research, containing 1832 food items . The infTo verify the adherence to the EAT-Lancet reference diet, we used the PHDI , which wThe PHDI scores were calculated through the procedure described by Cacau et al. . InitialAfter the disaggregation of the ingredients of the processed food items, the ingredients were allocated in their respective PHDI component. The total daily energy intake for the calculation of the PHDI components considered only the food groups recommended by the EAT-Lancet report itself. Each component contribution to total daily energy intake was calculated, as required for PHDI computations, and after that, the percentages of total energy intake were respectively evaluated according to cutoff and/or thresholds points and considering their original scoring system .2) and then classified according to WHO, considering age-group and z-scores for those with <19 years.The reference person in the household answered a questionnaire requiring socioeconomic and demographic data, such as information on age, education, sex of the residents, and family income. The following sociodemographic and economic variables were used as covariates in the statistical analysis: sex, age, per capita income, education, residence area, and geographic regions. Age was categorized in <19, 19–30, 31–45, 46–59, and ≥60 years Education was categorized in years of study: ≤8 years, 9–11 years, and ≥12 years. Per capita income was evaluated in quartiles. The weight and height were self-reported by the respondents of the NDS 2017–2018. Body mass index (BMI) was calculated as weight in kilograms divided by the square of the height in meters  and categorical variables as proportions. The PHDI total score was compared among sex , age group , geographic region , per capita income (in quartiles), years of study, residence area , and BMI. The average PHDI total and components scores according to Brazilian regions were also evaluated, as well their food groups consumption in grams per day (g/d) and in calories per day . We also evaluated the PHDI total score according to per capita income and age-group stratified by sex.2 (including BMI ≥ 30 kg/m2), and for those with <19 years, overweight was classified as above +1 z-score (including above +2 z-score). The regression model was adjusted for age, sex, per capita income, and daily total energy intake.To evaluate the relationship between the PHDI total score with overweight (including obesity), we built logistic regression models. For 19 years and over, overweight was classified as BMI ≥ 25 kg/m® , version 14.2 and considering the sample complexity by using the “survey” command. Statistically significant differences were considered when the 95% CI did not overlap.Data analysis was carried out on STATAIn this population-based study, the average PHDI total score was 45.9 (95% CI 45.6–46.1) points, on a total score that can range from 0 to 150. Higher scores were observed in women compared to men, in those with 31 years or older  compared to those with 30 years or younger (<19 and 19–30 years), in those overweight compared to those with an adequate BMI, in individuals with higher per capita income compared to those with a lower one (1st quartile) and in those living in the urban area, when compared to those living in rural area. Moreover, higher adherence to the planetary health diet proposed by EAT-Lancet Commission occurred among individuals in the Southeast and Middle-West regions, while the lowest was found among those in the Northeast region, as presented in There were differences in PHDI total score according to per capita income and age-group when stratified by sex. Women had significant higher PHDI scores than men in the highest quartile of per capita income and women with 45–59 years have higher scores than men in the same age group , despiteAll Brazilian regions had average adherences scores around one third of the maximum PHDI . It can When evaluating the PHDI components in the entire population, we observed the highest scores for vegetables, vegetable oils and animal fats, and a half score for legumes, fruits, and chicken and substitutes. On the other hand, red meat and dairy components reached around 30% of total components score (10 points). Eggs, tubers, added sugars, nuts and peanuts, whole cereals, and fish had the lowest scores .There were differences in the PHDI components scores among Brazilian regions . For theThe average of total energy intake from PHDI components was 1749.6 (95% CI 1733.9–1765.3) kcal/d, while by region it was as follows: North , Northeast , Southeast , South , and Middle-West . We also evaluated the consumption in grams per day (g/d) and in kcal per day  of the PHDI components in the Brazilian population and across the Brazilian regions . The legNo association was found between the PHDI total scores with overweight  after adjustment for sex, age-group, per capita income, and total energy intake .Our study reports on the adherence to a healthy and sustainable dietary pattern, using an index based on the EAT-Lancet Commission report, the Planetary Health Diet Index (PHDI), in a representative sample in Brazil. In general, the Brazilian population seems to be far from reaching the recommendations of a healthy and sustainable diet as proposed by the EAT-Lancet Commission.The average score achieved in this population was 45.9 (95% CI 45.6:46.1) points, representing about 30% of the maximum score. When applied to another Brazilian population (ELSA-Brazil cohort), a mean score of 60.4 was observed (about 40% of the maximum score) . The parThe index employed was previously validated, performing satisfactorily . It was The low adherence to the recommendations for a healthy and sustainable diet observed in this study can be explained by the low scores verified for most components. Poor dietary intake quality has already been reported in the Brazilian population ,22. VerlBrazil is a country of continental dimensions and home to several biomes , and possesses the largest biodiversity in the world . This avSustainable diets are increasingly being recognized as fundamental to address many of the environmental, social, and economic issues in the food system . The relKnuppel et al.  created Shamah-Levy et al.  in a samOn the contrary, in a previous work, we did not observe an association with overweight (including obesity) in a wealthier Brazilian population belonging to a cohort study . Shamah-In accordance with previous national ,36,37 anOur study is not without limitations. The methods for collecting dietary intake are prone to error. However, dietary intake was collected by a 24 h recall, which is recognized as more accurate than a food frequency questionnaire, and we use the first day, which is considered adequate to describe group means . HoweverThe Brazilian population presents low adherence to a healthy and sustainable dietary pattern, evaluated using an index based on the EAT-Lancet Commission report, the Planetary Health Dietary Index, with all different Brazilian regions presenting about one-third of the potential score. Women, older age group, and higher income have higher scores, although still low. In this scenario, to improve diets that are compliant with EAT-Lancet recommendations, great efforts from different stakeholders and the development of public policies will be necessary.


The recent coronavirus disease 2019 (COVID-19) pandemic pushed almost all institutions to adopt online and virtual education. The uncertainty of this situation produced various questions that perplexed educationists regarding what implications the pandemic would have on educational institutions, especially regarding how the switch to online education would impact the behavior and performance of students. The vast importance of this matter attracted the attention of researchers and served as the motivation for this research, which aims to resolve this confusion by studying the use of mobile learning (ML) among students for educational purposes during the COVID-19 period. This study also examines how this situation has affected student learning behavior (LB) and performance (SP) in the higher education setting. This research is based on collaborative learning theory, sociocultural learning theory, and ML theory. This quantitative research employed the convenient sampling technique to collect data through structured questionnaires distributed to 396 students of higher education institutions who carry a mobile device. This study used descriptive and inferential statistics to make the data more meaningful. Structural equation modeling (SEM) with AMOS software was used for hypothesis testing. The results showed that ML was a significant and positive predictor of SP and LB. Moreover, student LB partially mediated the relationship between ML and SP. The findings suggest that the academic performance of students can be enhanced by building a ML environment that aligns with the LB of students. Nevertheless, content suitable for ML must be developed, and future research should be conducted on this topic. Many countries decided to close their educational institutions to reduce the spread of coronavirus disease 2019 (COVID-19) . Althougvia ML, which promotes collaboration and strengthens their engagement. Also, since mobile devices are easy to carry, it is easy for their owners to stay connected and obtain a broad range of educational and information sources at all times  has been conducted in South Asian countries. Although a few indirect studies on ML have been carried out, it remains unclear how ML enhances LB and SP, especially in the COVID-19 period, during which almost all students have shifted to ML. ML has changed the lifestyles, thinking habits, learning abilities, and LB of learners. ML also provides significant advantages within direct and indirect education modalities , learning self-efficacy (LSE), and learning motivation (LMT). ML influences the motivation, collaboration, information sharing, interactivity, and mobility of learners . Directl1a:H Learning mobility has a positive effect on the learning performance of students.1b:H LSE has a positive effect on the learning performance of students.via rehearsal and self-regulation), excellent learning, and attain the best performance  , person-2:H ML has a positive effect on the LB of students.Learners engage in various activities and perform various LBs in ML settings, and the use of ML (apps) affects LB  through 3:H Student LB has a positive effect on SP.via self-regulation while monitoring their thoughts and acting to achieve set objectives. However, gaining a thorough understanding of this relationship is one of the objectives of this research; therefore, a dimensional study of LB on SP was carried out.Mobile learners achieve social learning through social networks and online communities, engage in peer-to-peer collaborative learning, find answers from the Internet, submit assignments through email, and organize their work using technology, thus performing personalized learning tasks. Learners can share information and collaborate with their peers. LB is comprised of PLB, CLB, and SLB. In PLB, students manage their learning Personalized LB manifests in self-direction, self-empowerment, and preparedness for learning. Meanwhile, cocreating tailored learning is customized to the needs, interests, and strengths of learners while the learners regulate what, how, when, where, and with whom they will learn. The learners also create the content and complete assignments with their peers . While t3a:H Personalized LB has a positive effect on SP.The second dimension, i.e., collaborative learning, is when students intentionally work to accomplish common goals . It is “3b:H Collaborative LB has a positive effect on SP.via social interactions between individuals in social networks  to supply these devices. Therefore, they can use mobile devices for educational purposes only when their fathers are at home with them. Per the objectives of this research, it can be conducted only on university students who were free to use mobile devices for their education at their convenience.This cross-sectional study employed a predictive non-experimental survey design. Data were collected through self-administered questionnaires, with items rated on a 7-point Likert scale. The painstaking efforts were made to collect data from students attending different higher educational institutions to ensure that the sample is truly representative of the study population. The sample of 396 students comprised 51% (202) men and 49% (194) women. Also, 64.9% (257) were full-time students, and 35.1% (139) were part-time students. Of the participants, 64.89% (257) used mobile devices for their online studies, whereas 35.10% (139) used laptops for this purpose. Regarding age, 63.3% (250) aged 18–22 years, 31.8% (126) aged 23–27 years, and 5.05% (20) aged 28 years and above.via adopted scales with confirmed reliability and validity. The LB construct was measured using an adapted Motivated Strategies for Learning Questionnaire (MSLQ) by The survey questionnaire consisted of 45 items, comprising four demographic items, namely, gender, age, studentship category, and mobile device ownership, as all of these were the important antecedents of ML . The resAfter the data were collected, the data preparation process started , during Reliability was also ensured, as all Cronbach’s alpha values were above 0.70. Specifically, the Cronbach’s alpha values are given in Furthermore, Harman’s single-factor test was used to test common method bias; this test exhibited only 29.1% of the whole variance, verifying that common method bias was not an issue. Also, the assumption of multicollinearity was met, as the variance inflation factor (VIF) values ranged from 1.3 to 2.0; thus, none exceeded the acceptable threshold value of 3.0. An SEM technique (applied using AMOS software) was utilized for a two-step data analysis approach recommended by As part of the specification search, CFA was conducted with 10 first-order latent variables and 49 observed variables. A maximum likelihood estimation was used to assess the model. The first-order CFA was carried out to obtain factor loadings (FLs), squared multiple correlation (SMC) range, average variance extracted (AVE), and Cronbach’s alpha values so that any factors that might lead to poor model fit could be removed. All items were checked to determine whether their FL, AVE, or Cronbach’s alpha values were below the accepted values. The FLs of all items were within the acceptable range, so no items were removed .In the second-order CFA, ML, and LB were modeled as higher-order reflective constructs, while SP was modeled as a first-order construct. Furthermore, we used reliability, convergent validity, and discriminant validity as part of a measurement model analysis. The AVE values of all the first-order constructs exceeded the required threshold of 0.50, confirming the convergent validity of the first-order constructs. All FLs were significant and above the recommended thresholds, thus providing evidence of convergent validity. Three methods were used to establish discriminant validity. First, the square root of AVE was compared with the square of inter-construct correlation coefficients. The results showed that the correlation CI values of all the constructs were less than 1.00, meaning that all constructs were considerably different from one another. Thus, these results confirmed that the discriminant validity was achieved .FL ≥ 0.50), further evidencing their discriminant validity  ranged from 0.746 to 0.896, thus exceeding the acceptable values. The AVEs of the individual variables were evaluated to measure validity while measuring convergent validity. The values of the SMCs for all individual items were within the range of 0.766–0.785. Standardized second-order FL  excludedAfter assessing the measurements of model fit, the structural model fit was evaluated to examine the theorized relationships between all endogenous and exogenous variables.The structural model encompasses three variables comprising 11 indicators that were structured based on the theoretical/conceptual model proposed by Hayes. The model contains one exogenous variable (ML), one endogenous variable (SP), and one mediating variable (LB).R2 = 0.65, p < 0.01) of the variance in SP . Hence, H1  is accepted. Similarly, the results showed that ML caused 91% of the change in LB. Therefore, ML had a highly significant and positive relationship with LB, thus supporting H2. Furthermore, the results showed that 67% of the variance in SP was due to LB. Thus, LB was significantly and positively related to SP  had significant and positive relationships with SP, as they explained 22, 25, and 36% of the variance in SP, respectively  had a significant positive association with SP, explaining 25, 21, and 41% of the variance in SP, respectively  revealed that students who have had to learn via ML in the emergency situation caused by the COVID-19 pandemic obtained good outcomes, sometimes improving on their pre-COVID performance. Therefore, it can be said that the ML-based solution to the stoppage of face-to-face education has been viable. Based on the benefits that have been attained from ML in enhancing SP (either directly or indirectly), universities should strive to provide ML so that students can further develop their ML behaviors. The efforts of universities in this direction seem to have been fruitful and should be continued in the form of blended learning when COVID-19 lockdown ends. The findings presented in this study support the notion that implementing ML at higher education institutions allows students to improve their LB from anywhere at any time with anyone, thus validating the theory of learning in the mobile age  and mobile technologies according to the psychology of students. This information highlights that higher education institutions can best fulfill their vital roles when they offer a better ICT and ML setting that empowers educators by helping them become creative and innovative learners who will lead the students to success within the university and beyond.The COVID-19 pandemic has forced educational institutions to shift from offline to online instruction by adopting modern technology. Online teaching and learning were considered the panacea for the crisis caused by school closures after the outbreak of COVID-19. The new circumstances appeared to increase the importance of ML, which has now become an inevitable part of the lives of students. Moreover, this catastrophe has shown us several previously unknown benefits of online teaching and learning. It seems, however, that the traditional methods of teaching and learning have become less effective as new technologies continue to emerge and develop . With thThe inevitability of ML has shown that even in the coming post-COVID period, e-learning should be used alongside traditional methods to foster academic efficiency and effectiveness. In this mobile age, all educational institutions need to consider using different online teaching methods and determining how these methods can be used most effectively. However, the findings of this research pose certain challenges that may hinder ML adoption and that educational institutions need to address through policy revisions. These challenges may be associated with the lack of digital skills of both teachers and learners, the lack of interactivity and motivation of learners, the lack of social and cognitive presence of teachers, the lack of human interaction between teachers and students, and the lack of communication among the students. One more important challenge may be related to current academic evaluation methods, as learning is spreading across multiple new settings. Therefore, the methods used to define and evaluate effective learning need to be reconsidered.This study has some limitations. For one, this study was cross-sectional, and future studies should employ longitudinal or time lag designs to better investigate causal relationships. Moreover, the study population comprised university students only. Other categories of students  should be included in future research. Moreover, different learning outcomes of ML, such as student satisfaction and student engagement, should be investigated. Also, specific dispositional factors such as student/teacher personality, availability of financial resources, working status, and gender should be used as moderators by future researchers to more thoroughly explain this mode of learning. Future research should also be conducted on students in remote or low living areas in developing and underdeveloped countries because these students face many physical and non-physical constraints, including the unavailability of personal mobile devices, electricity shutdowns, the unavailability of the Internet, and poverty.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by the Riphah International University. The patients/participants provided their written informed consent to participate in this study.ZW and AQ contributed in conceptualization of literature review and data analysis. AA and MA contributed in data collection and formal analysis. AQ and XL contributed supervising and validation of the original draft. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Malaria is a great concern for global health and accounts for a large amount of morbidity and mortality, particularly in Africa, with sub-Saharan Africa carrying the greatest burden of the disease. Malaria control tools such as insecticide-treated bed nets, indoor residual spraying, and antimalarial drugs have been relatively successful in reducing the burden of malaria; however, sub-Saharan African countries encounter great challenges, the greatest being antimalarial drug resistance. Chloroquine (CQ) was the first-line drug in the 20th century until it was replaced by sulfadoxine–pyrimethamine (SP) as a consequence of resistance. The extensive use of these antimalarials intensified the spread of resistance throughout sub-Saharan Africa, thus resulting in a loss of efficacy for the treatment of malaria. SP was replaced by artemisinin-based combination therapy (ACT) after the emergence of resistance toward SP; however, the use of ACTs is now threatened by the emergence of resistant parasites. The decreased selective pressure on CQ and SP allowed for the reintroduction of sensitivity toward those antimalarials in regions of sub-Saharan Africa where they were not the primary drug for treatment. Therefore, the emergence and spread of antimalarial drug resistance should be tracked to prevent further spread of the resistant parasites, and the re-emergence of sensitivity should be monitored to detect the possible reappearance of sensitivity in sub-Saharan Africa. Plasmodium falciparum infections and deaths with almost all malaria caused by P. falciparum in this area  gene and the P. falciparum multidrug-resistance gene 1 (pfmdr-1) have been implicated in CQ resistance (CQR) ] and pfdhfr [P. falciparum dihydrofolate reductase (DHPS)]—became widespread throughout Africa , which is needed in the asexual erythrocytic development stage. Although details of its function are not fully known  as the first-line drug for malaria up to the start of this millennium. However, it was replaced with sulfadoxine–pyrimethamine (SP) after CQ was declared ineffective as a result of resistant parasites  but soonce (CQR) . CQR wasce (CQR) . In Soutsistance . Key facsistance . In 1978ning use . Howeverning use , were onning use . Shortlyt Africa . The asst Africa . In Afrit Africa . By 2007t Africa . The eff borders . There h borders . The eme borders , especia borders . P. falcly known , they arly known . Accordily known . A recenocytosis . K13 is sistance ; therefo malaria .P. falciparum strains  to the food vacuole. To do this, it is located along the food vacuole membrane and pushes CQ away off the cytosol   in facilitating in vitro and in vivo CQR has received a lot of interest in research  ; additiowith CQR . Three mis CVIET . Another had an Asp to Tyr mutation, and both mutations were observed in 82% (18 of 24) of the isolates. Both alleles have reported association with CQR. In addition, 75% (18 of 24) of samples each had polymorphisms on both cg2 and pfmdr-l  that confer resistance to PYR and five sites in the DHFR (dhps) gene that confer resistance to SDX. Different combinations of mutations in each gene lead to varied resistance levels of SP ; resistance mutations Asn → Ile at codon 51 and/or Cys → Arg at codon 59 (C59R) and a Ser → Thr mutation at position 108 (S108N) with an Ala → Val change at position 16, synergistically confering PYR resistance in Plasmodium species . High mutated alleles of pfdhfr were reported for codons N51I, C59R, and codon S108N. The pfdhfr  proportion of single, triple, and quadruple mutations was very high in the study population  and the pfdhfr triple mutants were individually associated with SP treatment failure in children aged less than 5 years, with pfdhps and pfdhfr quintuple mutations being highly associated with SP treatment failure in Ibadan, Nigeria  increased from 200% to 300%, and the triple mutant pfdhfr  allele (conferring PYR resistance) increased by 37–63% in Tanzanian population when SP was used as a first-line antimalarial  to be 64%, 82%, and 92% in Chiredzi, Kariba, and Bindura, respectively. On the pfdhfr locus, the presence of triple mutations at codons N51I, C59R, and S108N was approximately 50% across the three locations, therefore indicative of widespread prevalence of molecular markers associated with CQ and PYR resistance in Zimbabwe  haplotypes were widespread throughout sub-Saharan Africa, particularly in Uganda, Mali, Kenya, and Malawi , but thepfdhfr responsible for PYR resistance showed no mutation in codons A16V, C59R, or I164L, while there was 84% mutation at codons N51I and S108N , thus conferring parasite resistance against both CQ and SP. The C59R mutation observed in Mali, Kenya, and Malawi was, however, absent in Sudan in spite of 80% prevalence of pfdhps K540E. Pfdhfr N51I and S108N occurred in more than 80%  at pfdhfr associated with SP resistance is concurrent with those found even outside sub-Saharan Africa  and IRS, which are the mainstay of malaria control. These two strategies have proven useful in the reduction of local malaria transmission by protecting susceptible individuals against infective mosquito bites, thereby leading to a reduction in the level of malaria intensity. When sleeping under the net, the net serves as a means of preventing mosquito contact or bite. Reducing the vector population through this means can indirectly serve as a measure to mitigate the spread of CQ- and SP-resistant with ITN . IRS haswith ITN . When vewith ITN .P. falciparum, it is recommended that two or more drugs must be combined. The combined drugs must have different modes of action. Since artemisinin-based compounds  are fast acting, they are usually combined with other classes of antimalarial with long half-life such as mefloquine, amodiaquine, lumefantrine, and piperaquine (An important strategy continues to be the use of effective antimalarials. However, this is threatened by the extensive resistance observed in the parasite toward the most affordable classes of drugs, thus highlighting the need for novel antimalarials  and ultieraquine . The ACTeraquine . The higeraquine . The arteraquine . By Juneeraquine . Part oferaquine .Among humans, there are a variety of beliefs that can impact our behavior significantly. These beliefs are scarcely changed and can therefore affect adherence to antimalarials such as ACTs, thus highlighting the need for patients’ beliefs to be considered when care is offered . NumerouThe CQ/SP resistance developed partly due to widespread presumptuous use of these medications without prior objective confirmation of the diagnosis. Due to the poverty and economic setting of many malaria endemic countries especially in sub-Saharan Africa, most people self-medicate and thereby inappropriately use CQ/SP . To thisCoartem®Dispersible, adapted to cater to the needs of children affected by P. falciparum malaria and was the first successfully co-developed product launched by the MMV, in which 400 million products were distributed (Generally, counterfeit medication presents a great challenge globally, thus contributing to the burden presented by the development of antimalarial drug resistance. Studies done in Eastern DR Congo showed that majority of the CQ has its active ingredient to be significantly underdosed while the SP was overdosed in terms of the active ingredients . A similtributed . MMV conVarious studies have shown that with replacement of CQ/SP as the first line of treatment and subsequent replacement with ACTs, there was notable decrease in the prevalence of pfcrt K76T present in such communities. This was first demonstrated in Malawi in 2004, with the prevalence of pfcrt K76T reaching an undetectable level .Similar studies have validated this point in China and Zambia, with the outcome of both studies showing a resurgence of CQ sensitivity . ConsideIn sub-Saharan Africa, where the burden of malaria infection is great, one of the core challenges for malaria control is the emergence and spread of antimalarial drug resistance. Although other strategies are employed for malaria control such as ITNs and IRS, which are the foundation of the malaria control agenda, antimalarial drugs are essential to reduce transmission. However, because of their accessibility and affordability, CQ and SP—both first-line drugs in the past—were used excessively, which resulted in the establishment of resistance, which in turn hindered malaria control in sub-Saharan Africa. This prompted the introduction of ACTs, which decreased the pressure on CQ and SP in some regions of sub-Saharan Africa, thus encouraging their reintroduction in those regions. Ongoing antimalarial drug resistance should be closely monitored in sub-Saharan Africa to prevent the establishment and spread of resistance and to detect the return of sensitivity, which could result in the possible reintroduction of specific antimalarials.AR: writing, editing, and collation. LM, OO, and OA: writing and editing. RM: supervision and editing. MA and MO: conceptualization, supervision, editing, and funding.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.


Introduction: Thyroid hormone affects lipid metabolism. Various studies have shown a contradictory relationship between lipid profile (LP) and subclinical hypothyroidism (SCH). Currently, there is a scarcity of regional data on the relationship between LP and SCH.Methods: This longitudinal study was conducted in the internal medicine and cardiology units of a tertiary care hospital in Pakistan from September 2019 to March 2021. A total of 900 participants, of either gender and between the ages of 40 to 70 years, were enrolled in the study. Blood samples were sent to the laboratory to determine lipid and thyroid parameters. Participants were divided into two groups based on the presence of SCH.Results: In our study, 179 (19.8%) participants had SCH. Total cholesterol (TC) and low-density lipoprotein (LDL) was significantly higher in participants with SCH compared to participants without SCH  and , respectively.Conclusion: In conclusion, this study found an increased incidence of dyslipidemias in patients with SCH. It is associated with elevated TC and LDL levels, which are risk factors for cardiovascular disease and mortality. In subclinical hypothyroidism (SCH), thyroid-stimulating hormone (TSH) levels are elevated in the blood, but serum free thyroxine FT4) levels are normal. It is rather prevalent, affecting about 10% of women over the age of 55 . Other c levels aCurrently, there is a scarcity of regional data on the relationship between lipid levels and SCH. To analyze and identify patients at risk of cardiovascular events, it is crucial to understand the link between lipid readings and SCH.This longitudinal study was conducted in the tertiary care hospital's internal medicine and cardiology unit from September 2019 to March 2021. Community-dwelling participants (n = 900) of either gender, between the ages of 40 to 70 years, who were visiting the outpatient department for routine checkups, were enrolled in the study. The entire procedure was explained to the participants and their consent was taken. Participants were enrolled via consecutive convenient non-probability sampling. Ethical review board approval was taken from the institute before the start of the study. Participants with known thyroid dysfunction or participants on statin medication were excluded from the study. Furthermore, subjects on levothyroxine or antithyroid drugs, amiodarone or lithium, were also excluded from the study in addition to patients with terminal illness and patients who underwent recent surgery (within the last four weeks).After enrollment, detailed history of the participant was taken and noted in a self-structured questionnaire. After the history, consent was taken again to withdraw 5-mL blood from the cubital vein via phlebotomy in two different vials. Blood was sent to the laboratory to determine lipid and thyroid parameters. Lipid parameters included TC, LDL-C, HDL-C, and TG levels. Thyroid parameters included TSH, FT4, and free triiodothyronine (FT3). SCH was defined as TSH levels between 5 and 10 mIU/L with normal thyroid hormones . ParticiData analysis was done using the Statistical Package for Social Sciences® software, version 23.0 . Continuous variables such as age, TSH. T3, T4, low-density lipoprotein (LDL), high-density lipoprotein (HDL), TC, and TG were presented as mean and standard deviation. Categorical variables such as gender and the presence of SCH were presented by percentages and frequencies. Mean lipid values for groups with and without SCH were compared using an independent t-test. A p-value of less than 0.05 was considered statistically significant.In our study, 179 (19.8%) participants had SCH. SCH was more common in females and participants with higher body mass index (BMI). TSH was significantly higher in patients with SCH compared to participants without SCH   and , respectively (Table This study compared lipid profiles among individuals with SCH and healthy controls. According to our results, individuals with SCH were more likely to be females and more likely to have a BMI of more than 25 kg/m2. It was associated with hypercholesteremia and higher LDL levels as compared to the healthy controls. There was no significant difference seen in HDL and TG levels.Vierhapper et al. conducted a study on patients with euthyroidism, SCH, and overt hypothyroidism and observed similar LDL-C levels in euthyroid and SCH patients, and increased levels in overt hypothyroidism only . HuestonThe association between cholesterol levels and SCH is of great significance as dyslipidemias are associated with increased risk of hypertension, cardiovascular disease, and stroke incidence ,12. SCH To correct the underlying cause of dyslipidemias in SCH, treatment with thyroxine may be considered; however, the beneficence of its use on LP is still a matter of debate. Several investigations carried out to observe the outcome of thyroxine supplementation in patients with SCH have reported a reduction in the levels of TC and LDL levels -16. MeieTo the best of our knowledge, this is the first study from this region to study the relation between lipid parameters and SCH. However, since the study was conducted in a single institute, care should be taken while inferring the result to the general population. Secondly, since it was a case-control study, a definite association could not be established. A large-scale prospective study is needed to confirm the association between dyslipidemia and SCH.In conclusion, this study found an increased incidence of dyslipidemias in patients with SCH. SCH is associated with elevated TC and LDL levels, which are risk factors for cardiovascular disease and mortality. To reduce the adverse outcomes associated with these findings, adequate monitoring of lipid profile is required along with treatment of the underlying cause in such patients. Thyroxine is one of the proposed interventions, but the evidence of its benefit is controversial.


Despite growing recognition of male-on-male rape and its related myths, research in this area has been held back by the lack of a reliable and comprehensive measure or scale. The present work utilises a large and diverse participant sample over two studies  to validate a new Male Rape Myth Acceptance Scale (MRMAS), measuring myths falling under six principle themes: masculinity, sexuality, pleasure, perpetrators, context, and effect. Analysis suggested a two-factor scale, with ‘Blame’ and ‘Minimisation/Exoneration’ sub-scales. Both the overall scale and sub-scales demonstrate excellent reliability and construct validity, and are thus proposed as tools to enable the proliferation of future research on male rape myth acceptance, both in general and specialist populations, in an attempt to improve the experiences of male rape victims. rape; male rape; rape myth acceptance; validation; scale However, following the legal recognition of male rape in the UK in 1994 . Specifically, widely held beliefs that physiological reactions to physical stimulation and arousal  imply pleasure and enjoyment , are proA specific subset of myths relate to the behaviour and nature of perpetrators, many of which mirror sexuality myths relating to victims. Specifically, as with male victims, assumptions are made that men who rape other men are gay  and are particular contexts, and that this occurrence is typical or inevitable. These include prisons, the military, LGBTQ + venues, and male societies  of rape on men. Specifically, myths articulate that men are not psychologically or physically affected by rape, principally because they are men and can ‘take it’, and that they are not as affected by the incident as women . This is1.3As knowledge of male rape myths has increased, a limited number of studies have emerged exploring their effect on judgments towards male victims and perpetrators, most commonly through attribution of responsibility ratings. For example, several studies demonstrate that gay victims are attributed higher levels of responsibility for their victimisation than heterosexual victims see . MoreoveHowever, whilst some information on the influence of male rape myths is available, the research outlined above remains limited, as the effects of only some male rape myths are explored. Moreover, information regarding the prevalence of male rape myth acceptance within society, and our understanding of the relationship between male rape myth acceptance and judgments given, is currently extremely inadequate. Moreover, levels of MRMA in specialist populations who directly interact with male victims  is also yet to be comprehensively measured. The principal reason for the scarcity of literature in this area is the lack of a reliable and targeted scale measuring said myths.1.4At present, two scales for the measure of male rape myth acceptance exist. The first is a 12-item scale developed by Several issues with this scale present. First, questions relating to incidents involving female perpetrators are included. This is problematic as it can be argued that whilst there are some areas of overlap , many myths about men raped by other men and about men sexually assaulted by women, are distinct and should be measured as such. Take, for example, myths around sexuality which only exist in relation to male-on-male assaults, or myths around perpetrators which by nature must be sex-specific. A further example is the common myth concerning female-perpetrated sexual assault, that ‘men always want sex’ , which wThe second issue is that the range of myths measured is too narrow and does not capture the variety of beliefs regarding male rape. As outlined above, there are (at least) six principal male rape myth ‘themes’; this scale only covers three (with only two items each). The final issue is that measures of scale reliability are unavailable. Cronbach's alpha values are not reported in the original publication  or in moThe second available scale is a 22-item questionnaire, developed as part of a doctoral dissertation programme by 80 potential items) and too homogenous (only undergraduate students were utilised). Fourth, this scale was still developed over 20 years ago, when attitudes towards male victims were likely different to the present day, and, as such, would potentially have been phrased differently. Finally, the publication detailing this scale has not been peer-reviewed , and it can thus be argued that the process for development and determination of reliability of this scale has not been subjected to rigorous academic appraisal. In summation, whilst some measures of male rape myth acceptance do exist, they require improvement in a number of key areas.Melanson's scale improved upon the Struckman-Johnson and Struckman-Johnson measure in two ways. First, several reliability analyses are available, with this scale demonstrating excellent reliability scores As detailed above, since the early 1990s, interest and research in the existence of male rape myths has significantly increased. Such research has detailed the nature of said myths and has begun to examine the influence of such attitudes on reactions and judgments toward male victims. However, at present, research is limited by the lack of a reliable, comprehensive, and targeted tool to measure acceptance of male rape myths, as exists for ‘traditional’ rape myths. The necessity for such a scale is outlined well in Arguably, this need is most exemplified within criminal justice contexts, as increasing our understanding of how specialist populations  interact with male victims is critical in improving victim engagement and satisfaction with justice processes, and case success.The aim of the present research therefore was to produce and validate the first Male Rape Myth Acceptance Scale (MRMAS), measuring myths under six themes: masculinity, sexuality, pleasure, perpetrators, context, and effect. Study 1 details the formulation, analysis, and selection of male rape myth items through a variety of reliability measures including exploratory factor analysis. Study 2 describes validation of a revised 44-item scale, including assessment of validity in relation proximal constructs.22.1Full ethical approval for this study was granted by the University Research and Ethics Committee at the University of West London.2.1.1generation were designed to ensure maximum validity, with decisions taken during item administration and analysis then designed to maximise reliability, which was subsequently prioritised. These choices were made as this study was not designed to explore which myths exist , but rather to develop a robust system of measurement . Thus predictive, rather than content validity was prioritised . Discussions were either theory-led, drawing from existing literature on male rape myths , or more informal, for example by asking others what they thought about male rape . During item generation, careful consideration of the balance between reliability and validity was considered, as outlined in The process outlined above resulted in the first iteration of the Male Rape Myth Acceptance Scale (MRMAS). This constituted 55 items covering six areas of male rape myths, as outlined above, including: Masculinity , Sexuality , Pleasure , Effect , Context , and Perpetrators . Participants answered on a 7-point Likert scale between 1 (Strong Disagree) and 7 (Strongly Agree), as used in other popular rape myth scales . Items were presented in the same order to all participants, and in unidimensional blocks  from two universities in the UK; one in London, and one in the North West (though this was not recorded during participation). Participants’ identified gender was predominantly as a woman (53.1%) or a man (33.7%), with male (6.9%) and female (4.3%) constituting the next highest percentages. Other responses included agender, cisgender, fourth gender and genderqueer . Most participants identified as heterosexual (81.4%), with 8.4% identifying as bisexual, 5.1% as homosexual, and 4.5% preferring not to say. The sample also included a variety of ethnic backgrounds, with White participants constituting 47.1%, Black/Black British providing 21.8%, and Asian/Asian British making up 16.3%. Other and Mixed groups constituted the remaining 14.9%. Participants were recruited through opportunity sampling across the two institution campuses. All participants were offered the chance to be entered into a prize draw to win a £25 Amazon voucher, and psychology students were also awarded two research credits, as part of departmental initiatives to encourage research participation.2.1.3Participants were recruited using two principal methods. Some were recruited through advertisement in lectures at their institution and were provided a link to the study should they wish to take part. Others were approached by a research assistant whilst they were alone and in a quiet space (such as a library) and were asked to either complete the survey on a tablet or take a leaflet to do so in their own time. Participants were made aware of the general context of the study , before being asked if they would like to participate. If they clicked on the link provided, they were presented with an information sheet outlining the study in more detail, before being asked to provide informed consent – which was obtained from all participants. They were then asked to provide basic demographic information, before being presented with brief instructions on how to complete the MRMAS, followed by the questionnaire. Once complete, participants were presented with a debrief explaining the purpose and aims of the study and directing them to appropriate support services should they be needed. Participants could also give their contact information (stored separately to their data) to be entered into the prize draw. This study was approved by the University Research and Ethics Committee (UREC) at the University of West London.2.2Psych package in R .Using SPSS Version 25 descriptive statistics and item-to-total correlations were produced to allow for assessment of sample distribution, and to provide guidance on which items required elimination for Study 2. Exploratory factor analysis was performed using SPSS to assess the latent structure of the scale and further identify items which did not load well, and thus could also be eliminated. The age in R  was usedage in R  to help 2.2.1The MRMAS full scale mean  for individual participants ranged from 1.22 to 5.91 (Range = 4.69), with a sample MRMAS full scale mean of 2.59. A skewness value of 0.77 suggests moderate positive skew in the MRMAS full scale mean. This is unsurprising, as scales of this nature, which ask questions on sensitive or emotive topics such as rape, often produce lower means. A kurtosis value of 0.26 in the MRMAS full scale mean suggests a normal level for a sample of this size . The CroIndividual item descriptive statistics and item-total correlations are shown in 2.2.2All items were subjected to a Principal Axis Factoring exploratory factor analysis (EFA), to assess the underlying structure of the scale, and to identify further candidate items for elimination .A two-factor solution demonstrated near simple structure with most items loading onto one of the two factors. Upon closer inspection, it appears that, whilst some overlap occurs, most of the items loading onto factor one are principally representative of attitudes which a) directly blame the victim, and/or b) a suggest that only certain groups of men  are raped. Items which load onto factor two appear to be primarily representative of attitudes which a) exonerate the perpetrator, and/or b) minimise the incident itself. The grouping of items in this way suggests that, whilst they are all representative of male rape myths, there may be a latent delineation between two distinct subsets of myth; Seven items did not load above .40 onto either factor , suggesting that they were a) answered significantly differently to other items, b) measuring an unrelated concept, or both. These items were therefore identified for elimination for Study 2 and the final scale. In addition, any items loading below .42 onto a factor  were identified for elimination to ensure only securely (not borderline) loading items were taken forward for the study 2 scales(s). Finally the remaining four items identified for elimination through the descriptive statistics and item-total correlations as above  were removed. Again, all such decisions were taken as reliability was prioritised during analysis . This le3A second study was then conducted to provide reliability and validity measurement for the new, refined MRMAS scale, utilising a more representative population. This included measurement of the relationship between the new MRMAS scale, and related, proximal constructs previously shown to have an association with male rape myth acceptance, including both demographic  and attitudinal variables  took part in study 2 as part of two groups. First, undergraduate students  from two universities in the UK; one in London, and one in the North West (though this was not recorded during participation). Second, members of the general population . Information on participants sex, identified gender, sexuality, ethnicity, employment status, and profession are detailed in 3.1.23.1.2.1A revised 41-item version of the Male Rape Myth Acceptance Scale (MRMAS) from Study 1 was administered to participants. These items again assessed beliefs relating to Masculinity Sexuality, Pleasure, Effect, Context, and Perpetrators. Importantly, following analysis from Study 1, this scale now has two identified sub-scales – a 23 item Blame subscale, and an 18 item Minimisation/Exoneration subscale. Participants answered all items on a 7-point Likert scale between 1 (Strongly Disagree) and 7 (Strongly Agree). The reliability estimates for the 41 item model in this sample using Maximum Likelihood estimation with Pearson (Polychoric) correlations and a Promax rotation were Alpha = .97 (.97), Hierarchal omega = .79 (.74), Omega total = .97 (.98). The Cronbach's alpha and hierarchal omega demonstrates reliability for a general factor solution, however the discrepancy in the Hierarchal omega and Omega total coefficients suggests the variance in the 41 items is likely to be attributable to a multiple factor structure or specific item variances. Cronbach's alpha values for the study 1 version of the subscales 1 (Blame) and 2 (Minimisation/Exoneration) were .96 and .91 respectively.An additional measure of male rape myths was also administered. Namely, the six items from 3.1.2.2The Acceptance of Modern Myths About Sexual Aggression (AMMSA) scale  provided3.1.2.3A modified 27-item version of the LGB-KASH  was admi3.2Descriptive statistics, including item means, item distribution statistics and item-to-total correlations were produced. An exploratory factor analysis was also computed to ratify the presence of the two-factor solution identified in Study 1. The aim was to then use Confirmatory factor analyses to compare the general factor, two factor (Blame and Minimisation/Exoneration) and six factor solution  in the Study 2 data to see how each solution fits. Group differences were assessed through the computation of several t-tests. Correlations were also conducted between the MRMAS measures (in models displaying good fit) and other proximal constructs.3.2.1Item means, skewness statistics and item-total correlations for the revised MRMAS are shown in 3.2.2All of the parameters identified in Study 1  were met in this sample also. Using the Scree plot, Parallel Analysis, inspecting cumulative variance explained, and running the VSS test suggested a two-factor extraction was appropriate. The Velicer's MAP test suggested a four factor structure, however upon review of the indices the third and fourth factors added little to the model, so we proceeded with the two factor extraction. Exploratory factor analysis was again conducted using the Principal Axis Factoring (PAF) technique with a promax (oblique) rotation then applied due to the degree of positive skewness observed in item responses. The two factor model explained 50.75% of the variance. A suppression threshold of .42 was chosen to ensure secure factor loadings onto a factor. Factor loadings for each item are presented in A two-factor solution demonstrated near simple structure with most items loading onto one of the two factors. All items  loaded on the same factors as in Study 1, further supporting the selection of a two-factor solution; victim blaming versus exonerating perpetrator/minimisation. Two items did not load onto either factor in this sample (items 3 and 19), while another two did not load at .42 (items 24 and 35). These items were identified for elimination. As the two factor structure has been maintained through a second PAF analysis, all of the 41 item scores were transformed towards greater normality of distribution in preparation for running the CFA models. Square root and Log 10 transformations were conducted separately on the raw item scores due to the trend towards positive skew in the raw item data. The skewness statistics suggest that the Log 10 transformation was more effective at normalising the distribution of the data see . When co3.2.3Lavaan package in R. Robust maximum likelihood estimation was used, as this allows for some violation in the normal distribution assumption when compared to the standard version , which is available through the  version . CompariIn each of the models the error co-variances were set to be estimated between the items falling within each of the six type areas  as there is likely to be commonly shared item variance in the measurement of the items tapping into each of the six previously theory-determined areas that were used to inspire the creation of the items. Several different indices of model fit were estimated, including the chi square/df ratio (<3 = good), Comparative fit index , Tucker-Lewis fit index , Root mean square error of approximation  and the standardised root mean square residual . These guidelines of model fit are based on reviewing literature debating fit indices published by Following on from the confirmatory factor analyses supporting the existence of the general factor  and the two factor solution, descriptive statistics were run on the total scores calculated for all measures in the study (presented in t (345) = 2.054, p = .041), while the general population group displayed significantly higher levels of Minimisation/Exoneration than Blame  = -3.607, p < .001). It is worth noting that the Student group displayed higher levels of both Blame and Minimisation/Exoneration characteristics than the General population group  = .69, p < .001; The MRMAS and the rights sub scale of the LGB-KASH inventory, r (506) = .67, p < .001; with slightly weaker relationships to the LGB-KASH knowledge, r (506) = .56, p < .001; The AMMSA measure of modern myths directed towards male on female rape (r (508) = .55, p < .001; The LGB-KASH hate subscale, r (506) = .53, p < .001; and The LGB-KASH internalised affirmativeness subscale, r (506) = .50, p < .001, were also all significantly, positively correlated. The MRMAS subscales both displayed trends in a similar direction, although there was some divergence in the correlations to LGB-KASH rights, with Blame displaying a much stronger correlation, r (506) = .71, p < .001, than Minimisation/Exoneration, r (506) = .46, p < .001. The same pattern was displayed with correlations to the Struckman-Johnson and Struckman-Johnson Male Rape Scale, with Blame displaying a much stronger correlation, r (514) = .75, p < .001, than Minimisation/Exoneration, r (514) = .43, p < .001. The opposing direction was found for the correlations to the AMMSA with Blame displaying a slightly weaker correlation, r (508) = .47, p < .001, than Minimisation/Exoneration, r (508) = .59, p < .001.Highest correlations were, as anticipated, present for those variables most proximal, and sharing greatest conceptual overlap. In order of strength of relationships, a significant positive correlation was noted between the MRMAS total and Struckman-Johnson and Struckman-Johnson Male Rape Scale (1992), ale rape , r (508)4This study introduces a new measure of male rape myth acceptance, appropriately named the Male Rape Myth Acceptance Scale (MRMAS). As such, this study provides the first highly reliable, peer reviewed, comprehensive measure of male rapes myths specifically. It is argued that development of such a scale will allow for future measurement of male rape myths, across a variety of populations, institutions and settings, as well as allowing for the correlation of such attitudes with judgments towards male victims and reporting. As with ‘traditional’ rape myths, the opportunity to conduct research of this nature on male victims should allow for the development of training, educational programs and interventions targeting negative beliefs about the crime of male-on-male rape, in attempts to improve the experiences of victim-survivors upon disclosure.4.1As mentioned above, the MRMAS achieved excellent levels of reliability across various methods as assessment. Favorable reliability scores were complimented by high levels of correlation with proximal measures  provides an important and highly impactful route to improving the experiences of male victims. For example, the existence of robust ‘traditional’ rape myth acceptance scales has allowed for the measurement of rape myth acceptance within police officers , the assEngagement in such areas of research would allow for the development of informed and targeted training and educational programs on male rape myths, and their impact on responses to victimization . Indeed, traditional rape myth acceptance scales are routinely used to evaluate the success of police training programs on rape investigation . As a consequence, it should be noted that some themes lost more items than others. Specifically, whilst most ‘themes’ have between seven and nine items, pleasure myths are only represented by three items. However, the scale appears to be structured around a two-factor solution, and the number of items in each of these factors remains robust.Second, as observed in the methods section of both studies, many of the items, and the scale overall, appears to suffer from floor effects. This is common in scales which measure emotive or sensitive topics (such as rape), and in scales which are among the first to measure a specific concept , particularly in the UK (where the legislative definition defines rape as perpetrated by only men towards either men or women). This decision is also supported by the fact that the sample in this study was from the UK, and it may have been confusing for participants to answer items about ‘rape’ perpetrated by females. However, it is important to recognize that the measurement of distinct attitudes pertaining to the sexual assault of men by women is an important future research direction. Ergo, the generation of a more general ‘male sexual assault scale’, or the addition of a sub-scale to the scale generated in this study, can both be considered worthy and much needed endeavors.5It has been argued that research on male rape myths is around 20 years behind that on female rape myths . One of Benjamin A. Hine, Anthony D. Murphy: Conceived and designed the experiments; Performed the experiments; Analyzed and interpreted the data; Contributed reagents, materials, analysis tools or data; Wrote the paper.Jamie S. Churchyard: Analyzed and interpreted the data; Wrote the paper.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.The authors do not have permission to share data.The authors declare no conflict of interest.No additional information is available for this paper.