To date, there has been no universal and validated tool for measuring safety culture in Korea. The Hospital Survey on Patient Safety Culture (HSOPSC), version 2.0 was released by the Agency for Healthcare Research and Quality in 2019, but it had not yet been translated and assessed for use in Korea. The aim of this study was to assess the content validity and other psychometric properties of the Korean-language version of the HSOPSC 2.0.Instrument adaptation was performed using a committee-based translation, cognitive interviews, and expert panel reviews. Confirmatory factor analysis was conducted on data obtained through an online survey from 526 registered nurses who worked on medical-surgical units in three teaching hospitals in South Korea.One item was dropped during the translation and adaption phase of the study as being a poor fit for the Korean healthcare context, resulting in excellent content validity. Confirmatory factor analysis supported the factorial structure of the K-HSOPSC 2.0. Correlations with an overall measure of patient safety provided further evidence of construct validity. Additionally, in comparing the results of this current study to those from U.S. research using the HSOPSC 2.0, it was found that Korean nurses assigned less positive scores to all dimensions of patient safety culture.Our findings provide evidence of the content validity, reliability, and construct validity of the K-HOSPSC 2.0 for measuring patient safety culture in South Korean hospitals.Hospital administrators can use this tool to assess safety culture and identify areas for improvement to enhance patient safety and quality of care.The online version contains supplementary material available at 10.1186/s12912-020-00523-w. Patient safety, a central principle and a determinant of healthcare quality, remains an international priority in healthcare systems. Although efforts have been made over the last two decades to improve patient safety and quality of care, a significant number of patients are still harmed while receiving health care services. One identified reason for such unsafe patient care is a weak safety culture . Safety Several tools have been developed for measuring safety culture in healthcare organizations. Among them, the Hospital Survey on Patient Safety Culture (HSOPSC) developed by the Agency for Healthcare Research and Quality (AHRQ) in 2004 is the most widely used instrument internationally .Healthcare organizations in Korea have made attempts to assess safety culture, but there has been no universal, validated tool for this purpose. Although translations of the original HSOPSC 1.0 or its modified versions have been commonly used to measure patient safety culture in Korea , the autThe AHRQ recommends that the HSOPSC 2.0 be used instead of the original version  and thusA two-phase study was conducted to translate and evaluate the K-HSOPSC 2.0. In phase 1, the instrument was translated into Korean and then each item was assessed for clarity, and cultural relevance and appropriateness . The internal consistency and construct validity of the instrument was examined in phase 2.overall perceptions of patient safety and teamwork across units, with four items each, were deleted in version 2.0. Many of the remaining items were reworded, particularly those that were difficult to translate. Two pilot tests were conducted during the revision process. An initial pilot test in 44 hospitals in the United States (U.S.) in 2017 led to further modifications and a second pilot test in 25 hospitals in 2019; this version became the HSOPSC 2.0 and was released to the public in 2019 . As. As25]. validity .Table 4p < 0.05), indicating sufficient independence among the subscales. The strongest correlation was between supervisor, manager, or clinical leader support for patient safety and communication openness (r = 0.45) and the lowest correlation was for staffing and work pace and supervisor, manager, or clinical leader support for patient safety (r = 0.19) as well as communication openness (r = 0.19). No exceptionally high correlations were noted. Also, the 10 subscales were positively correlated with patient safety grade, with correlations ranging from 0.19 to 0.37, providing further evidence of the construct validity of the instrument.The Pearson correlation coefficients among the 10 subscales ranged from 0.19 to 0.45 , “this unit relies too much on temporary, float, or PRN staff,” from , “this uernstein , other mernstein , 26. Thupatient safety grade, which provides further evidence of the construct validity of the K-HSOPSC 2.0 [The results of the CFA for the 31 items of the translated instrument supported the 10-factor structure of the HOSPSC 2.0. Each item contributed to its expected subscale, providing evidence of construct validity. In addition, as hypothesized, all subscales were associated with OPSC 2.0 .staffing and work pace received the lowest mean score with only 13% of respondents in this study reporting that their work unit had adequate staffing, compared with 56% in the U.S. These findings are similar to the findings from previous Korean research. Nurse staffing has long been a problem in the Korean healthcare systems. Cho and colleagues [Response to error received the second lowest rating, consistent with other Korean studies [In comparing our results to those from the U.S. study , we founlleagues  found thlleagues , a signilleagues . South Klleagues  found th studies , 31. Onlstaffing and work pace and response to error are problematic as adequate staffing and a nonpunitive response to errors are important for improving patient safety and quality of care [The low ratings for  of care , 32. Thu of care . To crea of care .The findings of this study support the use of the K-HOSPSC 2.0 for investigating patient safety culture in Korean hospitals. This tool can assist hospital administrators and nurse managers to identify areas for improvement to enhance patient safety and quality of care. Using this tool, hospital administrators and nursing managers will be able to benchmark their results against that of other units, hospitals, and countries; to date, such comparisons have been limited due to the lack of reliable and valid instrument for measuring patient safety culture in Korea . The preAlthough our study provides evidence of the reliability and construct validity of the K-HSOPSC 2.0 for measuring patient safety culture in Korean hospitals, some limitations should be noted. First, the respondents in this study worked in three tertiary general hospitals, all of which are affiliated with medical schools. In addition, all respondents were direct care staff nurses working in medical/surgical units, and the majority were female. Thus, the results might not represent all Korean nurses and cannot be generalized to other healthcare professionals. Therefore, the psychometric properties of this instrument should be examined in a broader validation context in future research. Second, stability over time was not assessed as a second administration of the instrument was not considered feasible by the hospital managers at this time, in the midst of the coronavirus pandemic. Third, to our best knowledge, there have not yet been any published papers that examine the psychometric properties of the HSOPSC 2.0, and thus we were not able to compare our results to other published studies of the instrument. Finally, we acknowledge that the use of a committee-based approach to cross-cultural translation remains somewhat controversial, although its use has been supported by other research literature , 35.To our knowledge, this is the first study to investigate the psychometric properties of the HSOPSC 2.0 in the Korean healthcare context. Our findings provide preliminary evidence of the internal consistency, content validity, and construct validity of the translated and adapted instrument, based on data from direct care nurses working on medical-surgical units in Korean hospitals. In particular, our CFA results support the use of the 31-item, 10-factor K-HSOPSC 2.0. However, more research is needed to investigate its psychometric properties within a broader validation context.Additional file 1: Supplemental Figure. Standardized parameter estimates for the factor structure of the K-HSOPSC 2.0.


Background: Pain and body perception are essentially two subjective mutually influencing experiences. However, in the field of musculoskeletal disorders and rheumatic diseases we lack of a comprehensive knowledge about the relationship between body perception dysfunctions and pain or disability. We systematically mapped the literature published about the topics of: (a) somatoperception; (b) body ownership; and (c) perception of space, analysing the relationship with pain and disability. The results were organized around the two main topics of the assessment and treatment of perceptual dysfunctions.Methods: This scoping review followed the six-stage methodology suggested by Arksey and O'Malley. Ten electronic databases and grey literature were systematically searched. The PRISMA Extension for Scoping Reviews was used for reporting results. Two reviewers with different background, independently performed study screening and selection, and one author performed data extraction, that was checked by a second reviewer.Results: Thirty-seven studies fulfilled the eligibility criteria. The majority of studies (68%) concerned the assessment methodology, and the remaining 32% investigated the effects of therapeutic interventions. Research designs, methodologies adopted, and settings varied considerably across studies. Evidence of distorted body experience were found mainly for explicit somatoperception, especially in studies adopting self-administered questionnaire and subjective measures, highlighting in some cases the presence of sub-groups with different perceptual features. Almost half of the intervention studies (42%) provided therapeutic approaches combining more than one perceptual task, or sensory-motor tasks together with perceptual strategies, thus it was difficult to estimate the relative effectiveness of each single therapeutic component.Conclusions: To our knowledge, this is the first attempt to systematically map and summarize this research area in the field of musculoskeletal disorders and rheumatic diseases. Although methodological limitations limit the validity of the evidence obtained, some strategies of assessment tested and therapeutic strategies proposed represent useful starting points for future research. This review highlights preliminary evidence, strengths, and limitations of the literature published about the research questions, identifying key points that remain opened to be addressed, and make suggestions for future research studies. Body representation, as well as pain perception and treatment, can be better understood if an enlarged perspective including body and space perception is considered. However, our body interaction with the surrounding world is also made by more rich and complex experiences, as the estimation of body size and shape, or the perception of body parts localization in external space (somatoperception)  , and is under our own control (agency) ; (b) the perception of the space around us in which we are immersed (space perception—SpP); and (c) the integration of the two body experiences in order to produce a coherent sense of self (body ownership—BO). Up to now we have only a partial knowledge of the operational mechanisms guiding SoP because a large number of studies conducted in the fields of experimental psychology and neurophysiology have mainly studied the basic mechanisms of somatosensations while we know much less about the higher-order mechanisms involved in SoP  and implicit (unconscious) body experience, as in the case of illusion phenomena  are a group of diseases commonly affecting bones, muscles and joints  have been found in experimentally-induced pain ; (b) body ownership; and (c) space perception.In order to have a comprehensive and structured knowledge of how body experience has been investigated in MDRDs, we systematically reviewed the literature published about the implicit and explicit mechanisms of: (a) The primary goal of this study was to map and examine the quantity and the nature of the scientific literature concerning the implicit and explicit own's body and space perception, organizing the findings around three main topics:the adopted strategies of assessment for perceptual dysfunctions;the impact of perceptual disorders in MDRDs compared to other disorders  and in sub-groups of MDRDs;the interventions proposed to approach perceptual disorders associated to MDRDs.Figures 3–8.The scoping methodology has been adopted because represents the most appropriate method to overview the literature about an emergent research area that is still fragmented, complex, wide, poorly understood or not deeply investigated before  between May 2018 until September 2018 on 10 electronic databases and grey literature  and full texts screening (AV and MP). Any disagreement was resolved by discussion between reviewers or, in case of persistent disagreement, a third reviewer (MT) was introduced to reach a consensus. The reviewing process is detailed on the PRISMA flow chart .Both for the screening of titles/abstracts and for the selection of full-texts the raters performed a series of pilot tests as a calibration exercise to improve the reliability of judgments and agreement between evaluators  using the recommendations of the Cochrane Collaboration Back Review Group , followed by implicit SoP , and SpP , while the BO made up only the 2% (1/38) of the sample.Only 4/24 (17%) of the included assessment studies investigated implicit SoP. Adamczyk et al. ,b prelimpersonal communication with authors).Only one study , however this score was not correlated with clinical data.The Letter recognition task (or graphesthesia) involves the recognition of letters drawn on the skin. This task was tested only in the study of Wand et al. : CLBP paThe majority of selected assessment studies evaluated the explicit SoP: five studies adopted the Body Image Drawing (BID) task Moseley, , eight sn = 42), matched with 17 healthy controls, Nishigami et al.  mean difference between patients and controls in German population adjusted for age, gender and body mass index . However, this was lower than that found by Wand et al. (p < 0.001). In all included studies investigating CLBP there was a significant correlation between FreBAQ score with, pain   than lower-disability group (13 ± 8 vs. 8 ± 6 points).d et al. , 2016 ond et al. , in postd et al. , and kned et al. . Three sd et al. . Fifty od et al.  and 11.7d et al.  in patied et al.  on a 0–3d et al.  also repd et al.  of 11 pop = 0.02) more disturbances in explicit SoP in the moderate disability sub-groups of patients (median score: 8/36 points) than in pain free controls (median score: 2/36 points). They also found more perceptual dysfunctions in moderate-disability sub-groups respect to low-disability patients (median score: 6.5/36 points) and pain free controls (median score: 2/36 points), however there was no statistical significance . Wand et al. (p = 0.005) more perceptual dysfunctions than those pain-free (median score: 3.5/36 vs. 1/36), and authors found a significant correlation (p = 0.027) of FreBAQ score with pain intensity (r = 0.378), despite it was not correlated with self-reported disability (p = 0.143).Beales et al.  administd et al.  instead p = 0.001) more perceptual dysfunctions in patients than in controls (median difference: 9 points), and a significant correlation (p < 0.002) between pain in motion (rho = 0.37) and disability (rho = −0.41), but not with pain duration .Finally, Nishigami et al.  adopted Neglect-like symptoms questionnaire Two studies using the NLSQ developed by Galer and Jensen . The mean NLSQ score decreased from 77.7 to 42.2 points ; however, the standard deviation was high due to a large inter-subject variation. The motor neglect sub-scale (MNss) was associated in multiple regression analysis with pain both at 3  and 6 weeks , where β represents points on MNss per unit of pain intensity, and with the improvement of range of motion at 6 weeks , with β describing changes in MNss score per range of motion degrees. Magni et al. (p < 0.001); however, the magnitude of the difference was very low .d Jensen  and Fretd Jensen  in CRPS.d Jensen  found thi et al.  reportedp < 0.05) higher both in proprioceptive drift sub-scale and in 4 out 5 items of the agency scale.The study of Martínez et al.  is the op < 0.05) between patients with idiopathic CNP and both whiplash affected patients for SVV error (mean difference: 0.37°), and healthy controls (mean difference: 0.5°). This difference was referred to the Variable Error (VE), indicating the variability of the performance. Also the Root Mean Square Error (RMSE), representing the overall accuracy in achieving the true vertical, resulted significantly different (p = 0.01) between idiopathic neck pain patients and the other two groups . Unexpectedly, difference between patients with Whiplash Associated Disorders (WAD) and healthy controls was not significant in all error measurements evaluated, despite a higher level of disability in this sub-group respect to that with idiopathic neck pain. Docherty et al. (p < 0.05) between CNP patients and healthy controls, they nevertheless fell into the range considered normal (<0.5°). A significant greater error (p < 0.001) in patients than in healthy controls was also found when using a variant with the frame tilted clockwise or counter-clockwise by 18°, but even in this case the median difference was small (<2°). Notably, 16% of patients with CNP scored higher than normal error in both the SVV and SVO, and they reported significantly (p < 0.016) higher disability at the Neck Disability Index respect to other patients with errors falling within the reference range of normality. The same small difference between groups  in SVV was found by  in .Four out twelve intervention studies were conducted in an experimental setting  less post-treatment , regardless of the order of treatment administration (p = 0.182), but the magnitude of change was not clinically relevant. Pain reduction was higher (p = 0.011) for the group where the acupuncture was associated with the sensory discrimination training, however the effect size was not clinically relevant . Louw et al. (p = 0.05), but without significant difference between the two devices.Three studies , but differences between two groups, despite statistically significant (p < 0.001), were never clinically relevant. The same trend was found also by Paolucci et al. (p > 0.05), and both procedures improves pain and disability respect to baseline values (p < 0.001), with variable clinical relevance . Although an improvement in pain level and disability was globally reported for SuPeR approach, the effect size was variable and not always clinically significant at follow-up periods. Wand et al. (p < 0.001). Finally, Ryan et al. (p>0.05), respect to placebo group .Three studies  but not of the neutral hand (p>0.05), reduced the perceived intensity of applied acute painful stimuli, both in patients and in controls, but changes were all under the clinical significance. Preston and Newport , rather than SoP, and the results found may have been consequently biased by these conceptual and practical mismatches.Except for Morone et al.  and VetrFinally, calculation of effect sizes' confidence intervals were not possible in four studies  attests that, since the first investigation of Moseley , overallWe found a wide and heterogeneous literature published in the field of MDRDs about SoP, SpP and BO. It predominantly concerned about the assessment , respect to the intervention strategies . Some preliminary evidence of distorted body experience in MDRDs emerged, mainly in the area of the explicit SoP for spinal pain assessed through the BID task Moseley, , questioWe found only three studies investigating the implicit SoP in MDRDs  compared to other methodologies, while conflicting results were found for studies assessing the implicit SoP. However, in this last case, the small number of studies , could indicate a dysfunction in multisensory integration underlying SoP function, but it is not clear the relationship with clinical relevant variables, and thus the potential role played in pathophysiology of chronic pain. To the best of our knowledge, only one study was published assessing the RHI in CRPS patients  may be reluctant, if not directly questioned , in parallel to the clinical variables commonly used for clinical studies, as some authors have started to do with CRPS patients , during perceptual tasks execution, without limiting the investigation to the functionality of the primary sensory area, as primarily performed in MDRDs field since now.The available studies on assessment and treatment described here need to be replicated in larger and higher-methodological quality studies with appropriate control groups, in order to confirm preliminary results emerged, and to determine whether perceptual disorders represent clinical consistent findings. At the same time, we encourage the production of diagnostic case studies/case series and the publication of preliminary validation studies aimed to describe new assessment and treatment methodology in MDRDs as already made in CRPS  explicit and implicit dysfunctions found in CLBP and CNP may constitute a cause, a consequence or an epiphenomenon respect to pain perception?; (b) the sub-groups highlighted in CLBP and CNP are consistently present even in other kind of MDRDs and also in the implicit domain of SoP; and (c) considering that in healthy subjects, a degree of distorted implicit somatoperception has been found in recent neuropsychological studies with respect to an intact explicit mechanism Longo, , we haveIn order to answer to these questions, we conclude by suggesting three future research lines:Longitudinal studies providing pain and multiple body perception outcome measures, along an enough large period of observation, may constitute an appropriate answer to the first point;Implicit and explicit methodology of assessment should be administered in parallel to patients in order to test the potential divergences between conscious and unconscious mechanisms of body perception within and between MDRDs: this suggestion answer both to the second and the third critical points highlighted;Moreover, the adoption of case-cohort studies with control groups of healthy subjects, further answer to the third point.Overall, in consideration of the amount of literature already published since now we sustain and propose that the theoretical concept to split between implicit and explicit mechanisms of SoP may constitute an important starting point for future research agenda.As suggested by extensive literature in neuropsychological field, pain perception appears to interact with a range of factors, among which implicit and explicit SoP, SpP and BO. For this reason, for future research agenda we encourage researchers to combine experimental lines on body experience with those studying chronic pain in MDRDs.In consideration of findings emerged and the quality of studies found, at the state of art, the conduction of a future systematic review is appropriate only to synthesize the psychometric properties of the FreBAQ.AV contributed to conception of the study, managed the database, extracted data from studies, and wrote the first draft of the manuscript. AV and DR contributed to the design and performed the first search strategy. DR and AG performed peer-review of electronic search strategies. EC, DL, and MP performed calibration phases, screening, and selection steps. DP and AV performed pilot-trials of data extraction. DP performed crosschecking of data extraction. DP and GR performed data analysis. GR, ML, and MT performed data interpretation. AG, GR, ML, and MT wrote sections of the manuscript. All authors contributed to manuscript revisions, read and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Broussonetia papyrifera plants grown in agricultural soil had higher IC, d, IWHC, WTR, water content values and lower IZ, IXc values than those grown in moderately rocky desertified soil. The leaf IC, d, IWHC, WTR and water content values of herbaceous plants were higher than those of woody plants. Solanum tuberosum L. had higher leaf IC, d, IWHC and WTR values, but exhibited lower IZ, IXc, IWUE and IWHT values than Capsicum annuum L. This study highlighted that a plant’s electrical parameters based on bioenergetics clearly indicate its physiological process—e.g., the intracellular water metabolism.Almost all of a plant’s life activities involve electrochemical reactions. Plant electrical parameters respond quickly to environmental changes and are closely related to physiological activities. In this study, the theoretical intrinsic relationships between clamping force and leaf impedance (Z) or capacitive reactance (Xc) and capacitance (C) were revealed as 3-parameter exponential decay and linear models based on bioenergetics, respectively, for the first time. Leaf electrical characteristics including intrinsic impedance (IZ), capacitive reactance (IXc), capacitance (IC) and specific effective thickness (d) were successfully detected using the above-mentioned relationships and were used to manifest plant metabolic activity. The intracellular water-holding capacity (IWHC), water-use efficiency (IWUE), water-holding time (IWHT) and water transfer rate (WTR) of plant leaves were defined on the basis of IZ, IXc, IC and d, and applied to reflect the intracellular water metabolism. The results demonstrated that the leaves of  Almost all life activities in plants involve charge separation, electron movement, and proton and dielectric transport . The eleAbiotic or biotic stimuli, including drought, salt, cold, diseases and insect pests, can rapidly trigger plant electrical activities ,6,8,10. Most (95–99%) of the water in plant leaves dissipates through transpiration, but a small amount 1–5%) is retained in leaf cells to support plant growth –5% is re,25. ManyIn this study, the intrinsic mechanisms and physical models relating clamping force and the Z, Xc, and C values of plant leaves were revealed for the first time. The leaf Z and C values of various plants were measured under different clamping forces using an LCR tester, which is a device for determining inductance (L), capacitance (C) and impedance (R). Moreover, the leaf Xc values were calculated from the leaf C. Subsequently, the intrinsic impedance (IZ), capacitive reactance (IXc), capacitance (IC) and specific effective thickness (d) of the intrinsic electrical parameters in the plant leaves were successfully obtained using the respective mechanism equations. The intracellular water-holding capacity (IWHC), water-use efficiency (IWUE), water-holding time (IWHT) and water-transfer rate (WTR), all key intracellular water metabolism indices in plant leaves, were defined based on the intrinsic electrical parameters, and applied to reflect the intracellular water metabolism. This study aimed to reveal the intrinsic mechanical relationships between exogenous stimuli and leaf Z, Xc, and C, as well as to provide a novel technique for rapidly monitoring the physiological states of plants.Almost all life activities in plants are closely related to electrical processes . The celIn this study, the ions, ion groups, and electrical dipoles in a plant leaf were used as electrolytes, and a parallel-plate capacitor sensor was formed by placing the leaf between the two plates of the parallel-plate capacitor. The leaf Z, Xc, and C values varied with the electrolyte concentration in the leaf, and the variation in the electrolyte concentration was caused by the water status of the leaf cells . Differe0: the standard electromotive force (V), R0: the gas constant (8.314570 J K−1 mol−1), T: the thermodynamic temperature (K), Qi: the concentration of electrolytes responding to Z inside the cell membrane (mol L−1), Qo: the concentration of electrolytes responding to Z outside the cell membrane (mol L−1), F0: Faraday constant ,and nz: the number of transferred electrolytes (mol).The concentrations of electrolytes responding to Z inside and outside the cell membrane determine the plant leaf Z. External stimuli change the membrane permeability of electrolytes and affect their concentrations inside and outside the cell membrane. Under different clamping forces, the membrane permeability of electrolytes responding to Z in the plant cell membrane changes. According to bioenergetics, the Nernst equation can be used to quantitatively describe the potential of ions, ion groups and electric dipoles inside and outside the cell membrane ,22. Thus3). Further, 2). F can be calculated by the gravity formula:The internal energy of the electromotive force can be converted into pressure work, with a direct relationship, PV = a E:o and Qi is certain. Qi is directly proportional to the conductivity of electrolytes that respond to Z, and the conductivity is the reciprocal of Z. Hence, 0: the ratio coefficient of the conversion between Qi and Z and Q is Qo + Qi. Therefore, Formula (2) can be transformed into Formula (4):For mesophyll cells, the sum of QFormula (4) can be rewritten as:Formula (6) takes the exponents of both sides:Further,As d0, R0, T, nz, F0, Q and J0 of Formula (8) are constants. Let 1=1=0, k1 and b1 are the model parameters.For the same leaf tested in the same environment, the d, a, EWhen F = 0, the intrinsic impedance (IZ) of the plant leaves can be obtained:0, k2, and b2 are the model parameters.With the same Z, the intrinsic mechanical relationships of leaf Xc and F are revealed :(12)Xc=pWhen F = 0, the intrinsic capacitive reactance (IXc) of the plant leaves can be calculated as:Subsequently, the intrinsic capacitance (IC) of the plant leaves can also be obtained:3). P can be calculated by the pressure intensity formula:2).According to the first law of thermodynamics, the work done by the clamping force obeys the Gibbs free energy equation:Mesophyll cells can be regarded as concentric sphere capacitors for which the capacitor energy isAccording to energy conservation theory, a capacitor’s energy is equal to the work converted by the Gibbs free energy, i.e., W =It is assumed that d represents the specific effective thickness of the plant leaves; therefore, dLet 0 and h are the model parameters.Formula (20) is a linear model, where xAs 1R: the outer sphere radius (m) and 2R: the inner sphere radius (m). For a plant cell, 2R1R is the thickness of the cell membrane. 1R ≈ 2R, The cell is a spherical structure, and its growth is closely related to an increase in volume. The C of plant leaf cells can be calculated using a formula for concentric spherical capacitors:The cell volume is positively correlated with the volume of the vacuole, and the main component of the vacuole and cytoplasm is water. In other words, the water-holding capacity of cells is directly proportional to The specific effective thickness (d) of plant leaves represents cell growth, and the water-holding capacity supports plant cell growth. Therefore, the intracellular water-use efficiency (IWUE) of leaves is represented by Formula (25):Z: U/Z, where IZ: the physiological current (A), U: the test voltage (V), and Z: the physiological impedance (Ω). At the same time, the current is equal to the product of the capacitance and the differential of voltage in time, as shown in Formula (26):According to Ohm’s law, IAfter the integral transformation, the current time is the product of the capacitance and impedance. Therefore, the intracellular water-holding time (IWHT) of plant leaves is represented by Formula (27):Furthermore, the dynamic water transfer rate (WTR) of plant leaves is calculated by Formula (28):Broussonetia papyrifera leaf grown in agricultural soil with the clamping force. The results showed that the leaf Z, Xc, and C values correlated well with the clamping force. Subsequently, the fitting equation coefficients for both the clamping force and the leaf Z, Xc and C in B. papyrifera plants grown in agricultural and moderately rocky desertified soils were calculated separately  were all over 0.9900 (B. papyrifera growth conditions were obtained using the corresponding parameters of the fitting equations (parately . Moreover 0.9900 . The watquations .B. papyrifera plants grown in the two habitats were significantly different (p < 0.05). The leaf IC, d, IWHC, WTR and water content values of the B. papyrifera plants grown in the agricultural soil were significantly (p < 0.05) higher than those of the B. papyrifera plants grown in moderately rocky desertified soil, and had lower (p < 0.05) IZ and IXc values. The results showed that the water status of the leaves of B. papyrifera plants grown in the better soil was good; the plant become vigorous, and the leaf IC, d, IWHC and WTR values were higher. Due to the poor water status of the leaves of B. papyrifera plants grown in moderately rocky desertified soil, the water supply time (IWHT) of the leaf organs was maintained by decreasing the WTR, resulting in a high IWHT. However, the leaf IWUEs of B. papyrifera in the two habitats were not significantly different, which demonstrated that there was little difference in the intracellular water-use efficiency of leaves in the same plant.As shown in p < 0.05) higher than those of the woody plants grown in the moderately rocky desertified soil. The results showed that the intracellular water metabolism and growth of herbaceous plants were more vigorous than those of woody plants, with lower IZ and IXc values, and higher IC, d, IWHC and WTR values. However, the leaf IWHTs of different plants were not significantly different. Moreover, the leaf IWUE of Senecio scandens was significantly (p < 0.05) higher than that of the other five plants, and there was also a significantly (p < 0.05) difference between the leaf IWUE of Ipomoea batatas and the IWUE of the remaining four plants.The water-use parameters and water content values of the six tested plants are illustrated in S. tuberosum were significantly (p < 0.05) higher than those of C. annuum, while S. tuberosum had lower (p < 0.05) IZ and IXc values. This result indicated that the good water conditions in the S. tuberosum leaves ensured a high WTR, growth rate, IC and d, and a low IZ and IXc values. Moreover, the water supply time (IWHT) of C. annuum leaves was increased by decreasing the WTR. However, the leaf IWUE of S. tuberosum was significantly (p < 0.05) lower than that of C. annuum. These results demonstrated that the leaf IWUE is closely related to the IWHT and that a long IWHT ensures the efficient utilization of intracellular water.As shown in Almost all life activities in plants are accompanied by charge separation, electron movement and proton and dielectric transport. In mesophyll cells, cells and organelles are both surrounded by the cell membrane, which is largely composed of lipids, proteins and sugars . The phoThe Nernst equation is an equation used to quantitatively describe the electrical potential formed by ions between systems A and B, and can also theoretically be used to quantitatively describe the diffusion gradient of electrolytes inside and outside the cell membrane ,22. UsinB. papyrifera grown in agricultural soil were significantly higher than those of B. papyrifera grown in moderately rocky desertified soil, and had lower IZ and IXc values. The leaf thickness in plants is highly variable as dependent mainly on plant species, the water state of leaf and maybe also on mineral nutrition [B. papyrifera grown under good water conditions had high IWHC and water contents, which supported the higher d or leaf thickness of B. papyrifera grown in agricultural soil. The herbaceous plants had higher IC and d, and lower IZ and IXc values than those of woody plants, and S. tuberosum leaves also had higher IC and d, and lower IZ and IXc values than those of C. annuum. These results well explain the phenomenon of life in plants—that is, when the intracellular water in plant leaves is sufficient and the concentration of electrolytes is low, plant cells have high IC and d, and low IZ and IXc.In this study, the IZ, IXc, IC and d values of the intrinsic electrical indices in plant leaves were successfully detected for the first time using the intrinsic mechanical relationships between the clamping force and leaf Z, Xc and C. The results demonstrated that the leaf IC and d values of utrition ,29. The B. papyrifera grown under good water conditions had high IWHC, WTR and water contents. The water supply time (IWHT) of the leaves under poor water conditions was increased by decreasing the WTR, and the IWUE was slightly different between leaves of the same plant species. This proposed plant adaptation mechanism under adverse environments is consistent with a previous study [S. scandens was likely related to its high leaf biomass. In this study, S. tuberosum had higher leaf IWHC and WTR and lower IWUE and IWHT than C. annuum, and these results are consistent with the biological fact that the biomass of S. tuberosum is higher than that of C. annuum [Plants grown in karst areas often suffer from various degrees of karst ecological stresses  . The resus study . Herbaceus study ,33. The . annuum ,35.Previous studies have shown that direct changes in plant electrical parameters such as Z and C can directly reflect changes in plant water ,18,36,37Broussonetia papyrifera plants were grown in two habitats, agricultural soil and moderately rocky desertified soil in Puding county, Guizhou Province . Amygdalus persica L., Rhus chinensis Mill. and Ginkgo biloba L. were grown in moderately rocky desertified soil in Puding, and Ipomoea batatas (L.) Lam., Senecio scandens Buch.-Ham. ex D. Don and Boehmeria penduliflora Wedd. ex Long were grown in agricultural soil in Puding. Capsicum annuum L. and Solanum tuberosum L. were grown in potted agricultural soil at the Guizhou Vocational College of Agriculture in Qingzhen county, Guizhou Province . The average annual temperature, sunshine hours and precipitation in Puding and Qingzhen counties were 15.1 and 14.1 °C, 1164.9 and 1128.2 h and 1378.2 and 1180.9 mm, respectively. The growth age, habitat information, measurement conditions and sampling weather of all tested plants are shown in The leaf C and Z values were measured using a LCR tester , with a frequency and voltage of 3.0 kHz and 1.5 V, respectively, as used by Zhang et al. , with moAdditionally, the leaf water contents were analyzed via the drying method, and the fresh weight of the leaves were measured before soaking.The data were analyzed using SPSS 18.0 . A one-way analysis of variance followed by Duncan’s test was performed.For the first time, the present work revealed the theoretical intrinsic relationships and fitting equations between clamping forces and leaf Z, Xc and C based on bioenergetics. The intrinsic electrical parameters  of plant leaves were also detected for the first time using these equations. Subsequently, the IWHC, IWUE, IWHT and WTR of the intracellular water-use indices in the plant leaves were defined based on the plants’ intrinsic electrical parameters, and the metabolism physiology of intracellular water was evaluated in various plants. These indices accurately revealed the life strategies and diversity of intracellular water metabolism in plant leaves and could potentially be applied to the acquisition of plant intracellular water information. This study highlighted that the intrinsic electrical parameters of plants have promising potential as a novel technique for the rapid monitoring of plants’ physiological states.


A comprehensive approach to the identification of the relationship between behaviors limiting nutrition mistakes, nutrition knowledge, and physical activity in the context of the family environment has not yet been widely explored. We aim to identify patterns of avoiding nutrition mistakes in high school students from Warsaw, Poland, and to assess their associations with nutrition knowledge (NK), physical activity (PA), body mass index (BMI), demographic, and family environment characteristics. A cross-sectional study involving 616 high school students, aged 16–19, was conducted. The data were collected by distributing questionnaires. The k-means method was used for cluster analysis, and logistic regression was used to assess the adherence to identified patterns. We identified three patterns: Prudent Ones (45%), Inconsequent (39%), and Rebels (16%). About 70% of adolescents had insufficient NK. The adherence to the Rebels pattern was lower by 85 % in girls, by 68% in students with younger siblings, and was about 4.0-times higher in children of mothers with primary education, 2.4 times higher in students with insufficient NK, and 1.9-times higher in students living in a family with more than 4 persons. The groups of adolescents with feature characteristics of the Rebels and Inconsequent are possible targets for intervention and require further in-depth research to explain their lack of attempts to avoid nutrition mistakes. The results clearly indicate the necessity of including metropolitan teenage boys in effective nutritional education for the rationalization of their dietary behavior. Adequate nutrition in adolescence is important for both present and future well-being because this period is important for preventing the consequences of nutritional deficiencies and excesses ,2. The dNutritional behaviors are shaped from childhood and are often modified during adolescence. They depend on a variety of factors, including sex, sociodemographic conditions, the family environment, and peers. Nutritional behaviors have a direct impact on the physical development, health, and identity of adolescents ,13. BehaTherefore, the aim of this study is to identify patterns of avoiding nutrition mistakes and to assess their association with sex, BMI, characteristics of the family environment, physical activity in leisure time, and nutrition knowledge among high school students from Warsaw.The cross-sectional study was conducted on high school students between Autumn 2014 and Spring 2015 . From 93N = 1082) were distributed in classes. The following inclusion criteria were used: the age of 16–19 years, living in Warsaw, a Polish metropolis . The following exclusion criteria were applied: diseases requiring special diets, chronic diseases, e.g., diabetes or asthma, use of medicines, and incorrectly completed questionnaires. All participants were informed about the necessary details and agreed to participate in the study. In the case of minors, written consent of the parent or guardian was obtained. A total of 981 students met the criteria (549 girls and 432 boys), but only a total of 652 students responded to the survey. Completed and returned questionnaires (N = 652) were verified by research staff, and incorrectly or incompletely filled questionnaires were excluded (N = 36). The final sample was comprised of 616 students . In each school, paper–pen questionnaires (The selected questions from The Beliefs and Eating Habits Questionnaire (KomPAN), developed and validated by the Commission of Behavioral Determinants of Nutrition from the Polish Academy of Sciences  , were usTo assess the limitation of not-recommended product consumption  and the limitation of unhealthy behaviors , four statements were used: (i) I do not limit myself; (ii) I am looking for a healthier alternative; (iii) I try to eat/drink this very rarely; (iv) I do not eat/drink/practice this. Due to the lack of existing measures, these items were tested in a pilot study on a group of 30 adolescents who did not take part in the main research. Thus, the statement “I do not eat/drink this” was added. The following categories and numerical codes were used for Statement (i)—not limiting (1); for Statements (ii) and (iii)—limiting (2); for Statement (iv)—not eating (3).The data on both the frequency and limitation described above were used to identify patterns of avoiding nutrition mistakes. It was assumed that the most healthy eating pattern would be the one with less frequency, a willingness to not eat or to limit nonrecommended products, and a willingness to limit unhealthy eating behavior. The most unhealthy pattern was assumed to be eating with greater frequency and a willingness to consume nonrecommended products.2 is categorized as thinness; BMI = 18.5 to 24.9 kg/m2 is categorized as normal weight; BMI ≥ 25 kg/m2 is categorized as overweight and obesity [Data on sex, age, weight, height, and family environment characteristics such as household size, siblings , parental education , accommodation , and household structure  were collected. Body mass index (BMI) was calculated using self-reported weight (kg) and height (m). For students aged 16–18 years, the following age-sex-specific BMI cut-offs and categories were applied: BMI < 18.5 kg/m obesity .To assess nutrition knowledge, 8 questions from the test, developed and validated by the group of Polish experts, were selected . These qThe question about physical activity (PA) in leisure time is from The Beliefs and Eating Habits Questionnaire (KomPAN) . The folCategorical variables are presented as a sample percentage (%). Patterns of avoiding nutrition mistakes were derived using cluster analysis. The input variables were 22 data points of the frequency of consumption of not-recommended products, the frequency of unhealthy behaviors, and the limitation of consumption of not-recommended products and unhealthy behaviors. The k-means clustering algorithm, based on the Euclidean distances, was used. Three clusters were selected. The description of the cluster includes the following features: sex, age, BMI, family environment, level of physical activity in leisure time, and nutrition knowledge level. For the codes of numeric values, which refer to the frequency of consumption of not-recommended products, unhealthy nutritional behaviors, and behaviors limiting nutrition mistakes, mean and standard deviations were calculated, and an analysis of variance for comparing means of separate groups was used. p < 0.05 was considered significant. Analyses were performed using IBM® SPSS® Statistics software . Logistic regression modeling was applied to assess the adherence to identified patterns by demographic factors, nutrition knowledge, physical activity, and family characteristics. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated. The ORs were adjusted for sex, BMI, characteristics of family environment, nutrition knowledge, and physical activity, excluding the modeled variable from the confounders set, respectively. The significance of ORs was assessed by Wald’s statistics. For all tests, The majority of the subjects were girls (76%), students aged 16–17 years. The body mass index in the vast majority of participants indicated a normal weight. Almost 20% of students were thin, and only 8% had excessive body weight. Almost 70% of students had insufficient nutrition knowledge. Most of the participants in the study group lived in households with no more than four people (77%), in flats (61%), with both parents (69%). .In the study group, three clusters were identified, whose sociodemographic characteristics, PA level in leisure time, and nutrition knowledge are shown in Patterns of avoiding nutrition mistakes, derived using cluster analysis, were the following:I know and I limit)—the most healthy eating pattern. This group includes subjects who, significantly, seldom consumed not-recommended products and snacks and most often limited or did not eat not-recommended products (Cluster 1. (Prudent Ones: products . I know something and I limit sometimes); this group includes students who most often added sugar and salt but limited most not-recommended products and unhealthy behaviors (Cluster 2. (Inconsequent: ehaviors . I do not know and I do not limit)—the most unhealthy eating pattern. This group includes students with the highest frequency of consumption, who do not limit not-recommended products and snacking and rarely consume breakfast (Cluster 3. (Rebels: reakfast . p < 0.001) and students with moderate PA in leisure time ; p = 0.018) had over six- and two-times higher adherence to the Prudent Ones pattern (p < 0.001) and by 57% in students with insufficient nutrition knowledge ; p < 0.001).Girls ;  pattern . The adhp = 0.045 and aOR = 2.26, 95% CI (1.35–3.78), p = 0.002, respectively) and three-times higher in students with both younger and older siblings ; p < 0.001), 1.6 times higher in children of mothers with secondary education ; p = 0.016), and 1.5 times higher in students with insufficient nutrition knowledge ; p = 0.033).The adherence to the Inconsequent pattern  was aboup < 0.001) and by 68% in students with younger siblings ; p = 0.015). There was almost four-times higher adherence in children of mothers with primary education ; p = 0.001), 1.85-times higher adherence in students living in families larger than 4 persons ; p = 0.047), and 2.35 times higher adherence in students with insufficient nutrition knowledge ; p = 0.003).The adherence to the Rebels pattern  was lowep = 0.017), while it was 49% lower in students with older siblings ; p = 0.004); however, those associations became nonsignificant after the adjustment ; justment .Among the three patterns of avoiding nutrition mistakes among high school students from a Polish metropolis, two opposite patterns were identified: the Prudent Ones pattern, with limited unhealthy behaviors (45%), and the Rebels pattern, with no limits to unhealthy behaviors (16%). As we hypothesized, the avoidance of nutrition mistakes was associated with sex, nutrition knowledge, physical activity, and family environment. Higher adherence to the Prudent Ones pattern was found in girls and students with moderate physical activity, while adherence was lower in students with siblings and students with insufficient nutrition knowledge. The adherence to the most unhealthy pattern (Rebels) was found in students with families larger than 4 persons, children of mothers with primary education, and students with insufficient nutrition knowledge. Having siblings and insufficient nutrition knowledge increased the chance of adherence to the Inconsequent pattern. An unexpected finding of the study was the lack of association of the identified patterns with BMI.Our results indicated that sex was a significant determinant of the adherence to the identified patterns, and metropolitan girls were more likely to avoid nutrition mistakes. This confirms a strong association of the female gender with the most healthy pattern and the male gender with the most unhealthy pattern. This is consistent with previous results indicating that sex significantly determines the choice of food and eating behavior. Young women more often avoid high-fat foods, eat fruits and vegetables, and report the greater importance of healthy eating, so dietary choices depend on the perception of femininity and masculinity . Women oLiving in a household with more than 4 people was associated with higher adherence to the Rebels patern. This relationship is difficult to explain directly. There are models of home eating environments based on sociocognitive and socioeconomic theories that suggest that the influence of the family, including parenting practices and other aspects of home, will shape the adoption of healthy eating behavior ,27. The We found an association between patterns of avoiding nutrition mistakes and having siblings. Having siblings was strongly associated with higher adherence (by 97–98%) to the Inconsequent pattern, characterized by less frequent attempts to limit the consumption of sweets, sugar, and salt. The number and profile of siblings may be related to compliance with specific nutritional patterns or health-related markers, both positive and negative ,30. A SpOur study also confirmed that the adherence to patterns other than the Prudent Ones pattern was associated with the lower education of mothers. It is consistent with van Ansem et al.’s results , which iDespite the presence of elements of nutrition sciences during school education, the majority of students were characterized by insufficient nutrition knowledge. This indicates the lack of effectiveness of the health program in improving the lifestyle of adolescents. Our study shows that high school students with insufficient nutrition knowledge have higher adherence to unhealthy patterns (Rebels or Inconsequent) and lower adherence to the most healthy pattern (Prudent Ones). Despite the fact that some authors have shown that nutrition knowledge has a weak correlation with actual food choices , successIn our study, patterns of avoiding nutrition mistakes were not associated with BMI. The explanation for the lack of such a relationship can be found in the specificity of the studied group, which mostly declared high physical activity. Additionally, the percentage of high school students who were thin was two-times more than those with excess body weight (17% vs. 8%). Furthermore, in our study, 20% of the girls and 10% of the boys were classified as thin. Thinness is more common among adolescent girls and young women in European countries such as the Czech Republic, Sweden, Greece, and France than among boys. Additionally, the prevalence of thinness among Polish children is higher than in other European countries or Australia and the USA. This tendency may be related to sociocultural conditions, the fashion for a slim figure created in the media, and greater weight control in adolescent girls. The authors also point to the role of psychological factors such as self-esteem, body image, and emotional state .Our results show that Polish high school students from the metropolitan area made typical nutrition mistakes such as unrestricted eating of sweets, fast food, and fried meat, drinking sweetened beverages and energy and alcohol drinks, and also adding salt or sugar, snacking, and eating at night. Such behaviors are characteristic for this age group and are associated significantly with the adolescents’ peer behaviors ,45,46,47Our study had a number of strengths and limitations that should be mentioned. This study is novel due to its comprehensive approach, taking into account lifestyle behaviors, the level of nutrition knowledge, as well as family environment characteristics. A major strength is the relatively large sample of metropolitan adolescents. The study area is a metropolis, the capital city of Poland, so the results of this study may be a good basis for further research in high school students from big cities. This is due to the fact that after the completion of primary school, almost half of the graduates continue their education in high schools, of which over 28% are located in the 18 largest Polish cities . IdeallyThis study was also limited by the cross-sectional design, which precludes the investigation of casual relationships. However, it provides data to more complex study designs or to create interventions targeted at improving health-related behaviors.Our research revealed that avoidance and no-avoidance nutrition mistakes were associated with sociodemographics, PA in leisure time, and nutrition knowledge but not with BMI. Among the three identified nutrition-mistakes avoidance patterns, two opposite patterns were identified: the Prudent Ones pattern, with limited unhealthy behaviors, and the Rebels pattern, with no limitation to unhealthy behaviors.Female gender, no siblings, nutrition knowledge, and greater PA in leisure time increased the adherence to the Prudent Ones pattern, which can be described as “know and avoid nutrition mistakes”. Having siblings, mother’s secondary education, and insufficient nutrition knowledge increased the adherence to the Inconsequent pattern, who “know something about healthy eating and sometimes avoid unhealthy behaviors”. Male gender, living in large families, insufficient nutrition knowledge, and mother’s primary education increased the adherence to the Rebels pattern, who “do not know and do not avoid unhealthy behaviors”.From a public health perspective, implementing interventions that increase nutrition knowledge and physical activity in high school students are important for improving prohealth dietary habits. The groups of high school students with the feature characteristics of the Rebels and Inconsequent are possible targets for intervention. Further in-depth research is needed to explain their lack of attempts to avoid unhealthy behaviors.


HELLP syndrome may increase adverse pregnancy outcomes, though the incidence of it is not high. At present, the impact of HELLP syndrome on P-AKI (acute kidney injury during pregnancy) and maternal and infant outcomes is controversial. Thus, we conducted a meta-analysis to find out more about the relationship between HELLP syndrome and P-AKI and pregnancy outcomes.We systematically searched PubMed, Embassy and Cochrane Databases for cohort studies and RCT to assess the effect of HELLP syndrome on P-AKI and maternal and infant outcomes. Study-specific risk estimates were combined by using fixed-effect or random-effect models.This meta-analysis included 11 cohort studies with a total of 6333 Participants, including 355 cases of pregnant women with HELLP syndrome and 5979 cases that without. HELLP syndrome was associated with relatively higher risk of P-AKI , fetal mortality  and Maternal death .HELLP syndrome is associated with relatively higher risk of P-AKI, fetal mortality and maternal death. At present, high blood pressure caused by pregnancy is still an important public health problem in the world. Up to 500,000 pregnant women die every year due to complications related to preeclampsia . HELLP sIn patients with HELLP syndrome, acute kidney injury is a common cause of maternal and fetal death. For pregnant women,acute kidney injury can lead to anuria, heart failure, and severe pulmonary edema . These cWe collected studies on patients with hypertension during pregnancy, and performed a meta-analysis on those with or without HELLP syndrome. We used meta-analysis to assess the association between HELLP syndrome and acute kidney injury to help clinicians make better decisions. To our knowledge, this is the first meta-analysis of HELLP syndrome and Acute kidney injury during pregnancy (P-AKI). Our research has been registered with PROSPERO, the code is CRD42018112333.Based on PRISMA standards and procedures, we used the following method for meta-analysis . We searThe content mainly includes: 1. Basic information included in the research: the author’s name, year of publication, country.2. The basic characteristics of the study subjects: Definition of acute kidney injury, Definition of HELLP syndrome, sample size, Pregnancy outcomes and quantity score.3. The main data of clinical outcomes, and confounding factors which need to be adjusted. Two researchers (LQ and LGJ) screened the literature independently, extracted the data and cross-checked. In case of a disagreement, we would resolved by discussion or submitted it to the third researcher (ZSQ) to make a final decision. We assessed the authenticity and quality of the included studies using Newcastle-Ottawa scales (NOS) , and 6 pMeta-analysis was performed with State software version 12.0. The effect index of dichotomous data was the risk ratio (OR), and the effect index of the continuous data was the mean difference (MD), and there was also a 95% confidence interval (95% CI) . We usedThe literature search yielded 546 articles, with 11 studies identified according to the inclusion criteria  higher likelihood in pregnant women with HELLP syndrome [P = 0.429 Fig. Eight studies reported 79 cases of AKI in 556 Pregnant women with HELLP syndrome and 58 cases of AKI in 1158 pregnant women without HELLP syndrome, producing a 4.87 fold  higher likelihood in pregnant women with HELLP syndrome [P = 0.616 Fig. P = 0.005) higher likelihood in pregnant women with HELLP syndrome, with Very low evidence of heterogeneity   evaluation indicated that the incidence rate of AKI had low-quality evidence Table . There m38) Fig. .Fig. 6BHELLP syndrome is considered to be an important risk factor that increases the mortality of pregnant women and fetuses . The occTo the best of our knowledge, this is the first meta-analysis to explore the effect of HELLP syndrome on P-AKI and pregnancy outcomes. It suggests that pregnant women with HELLP syndrome was associated with higher risk of AKI (4.87 fold), stillbirth (3.70 fold), and maternal death (1.56 fold). The effect of HELLP syndrome on neonatal mortality was not statistically significant in this study, but our data on this subject was less, an in-depth study with more data is necessary. In our study, the stillbirth rate of pregnant women with HELLP syndrome was 49.5%, which was higher than that reported in Serdar study (7.4–34%) . PrematuTraditionally, HELLP syndrome is considered to be a variant of preeclampsia, but it is, in fact, a specific disease, since 20% of pregnant women with HELLP syndrome do not have a history of hypertension or proteinuria , 26. TheThe strength of this systematic review and meta-analysis lies in the instruction significance for clinical questions, as a large volume of data was included and a rigorous methodology used. However, there are some limitations to our study. The first is that the sample size of some included studies is small, which would lead to bias; Second, since individual studies have different definitions of AKI and HELLP syndrome, some patients with AKI and HELLP syndrome may be missed. It is currently believed that the diagnosis criteria of HELLP syndrome proposed by Sibai et al. is stricter and more popular . In the HELLP syndrome is associated with relatively higher risk of P-AKI, fetal mortality and maternal death. Although some conclusions require more research to support, this study resolves the dispute.


Aqueduct of Sylvius (AoS) cerebrospinal fluid flow can be quantified using phase-contrast (PC) Magnetic Resonance Imaging. The software used for AoS segmentation might affect the PC-derived measures. We analyzed AoS PC data of 30 people with multiple sclerosis and 19 normal controls using three software packages, and estimated cross-sectional area (CSA), average and highest AoS velocity (Vmean and Vmax), flow rate and volume. Our aims were to assess the repeatability and reproducibility of each PC-derived measure obtained with the various software packages, including in terms of group differentiation. All the variables had good repeatability, except the average Vmean, flow rate and volume obtained with one software package. Substantial to perfect agreement was seen when evaluating the overlap between the AoS segmentations obtained with different software packages. No variable was significantly different between software packages, with the exception of Vmean diastolic peak and CSA. Vmax diastolic peak differentiated groups, regardless of the software package. In conclusion, a clinical study should preliminarily evaluate the repeatability in order to interpret its findings. Vmax seemed to be a repeatable and reproducible measure, since the pixel with its value is usually located in the center of the AoS, and is thus unlikely be affected by ROI size. The cerebrospinal fluid (CSF) has various fundamental vital functions: it acts as a buffer, protecting the brain during head trauma, supports the brain weight, and helps maintaining stable central nervous system temperature . With itCSF flow can be noninvasively quantified using cardiac-gated cine phase contrast (PC) Magnetic Resonance Imaging (MRI) . 2D-PC, Despite being used for a long time and in numerous clinical cases, the AoS CSF flow measures derived from PC-MRI have various sources of variability that should be taken into account when a clinical study is designed. The main sources of variability are summarized in the following.First, the magnetic field strength affects the image quality, because higher field strength has a better signal-to-noise ratio (SNR). The SNR effect on flow estimates has been previously investigated . Even thSecond, different sequence parameters might cause different absolute flow values. Since the spatial resolution impacts the partial volume effect between brain parenchyma and AoS CSF, the effect of different resolutions was assessed by previous studies with simulations , and in Third, different approaches have been used in the literature for drawing the regions of interest (ROI) corresponding to the AoS and to the static tissue. With regard to the latter, the effect of different positioning has been previously investigated , and simThe various methods of AoS contour drawing used in the literature can be manual ,19,23,24Against this background, we performed a methodological study using three different commercially available software packages for PC-MRI flow quantification. They allow drawing of the AoS ROI with different semiautomatic methods, and to compute various AoS CSF flow parameters. The preliminary aim was to assess the repeatability of each software package. Then, we aimed to evaluate the reproducibility of each measure of interest, testing if the various measures were different depending on the software, and finally if the software choice could influence the differentiation between pwMS and NC.The subjects included in this study were pwMS and NC, randomly chosen from a previously published clinical study of cardiovascular, environmental and genetic factors in pwMS . The incThe pwMS were clinically evaluated by an experienced neurologist and were characterized by the Expanded Disability Status Scale (EDSS) scores . Other rAll the MRI exams were performed with a 3T GE Signa Excite HD 12 Twin Speed 8-channel scanner  and an 8-channel head and neck coil. 2) in order to have at least four pixels covering the AoS diameter, for good flow quantification, as suggested in [The AoS CSF was evaluated using a single slice cine 2D PC sequence, with a pulse oximeter-gated procedure for obtaining 32 points of the cardiac cycle with a velocity encoding of 20 cm/s. The PC sequence had the following parameters: echo time (TE) = 7.9 ms, repetition time (TR) = 40 ms, flip angle = 20°, slice thickness = 4 mm, matrix = 256 × 256, FOV = 10.0 cm. We chose such an axial resolution ; (2) Segment version 2.2 R6887  [The PC cine images were processed in a blind manner, after their quality was evaluated and confirmed. Three different software programs were used for the processing: (1) Java Image Manipulation tool—Jim version 8.0, Xinapse Systems, Leicester, UK er 2020) , freely er 2020) ; (3) sig20 , freeThe time frame with the highest flow, i.e., with the highest contrast of CSF from the surrounding parenchyma, was visually selected B.The images were magnified C so thatThe velocity, corrected for the phase offset, was computed for each pixel inside the AoS ROI and for each frame of the cardiac cycle D using e2) of the AoS; (2) mean velocity (Vmean) in cm/s (The following measures were computed for each time frame of the cardiac cycle: (1) the cross-sectional area .The normality distribution of the data was determined by Kolmogorov-Smirnov test.2 test, Student’s t-test) and non-parametric (Mann-Whitney U-test) comparisons tests, where appropriate.The demographic differences between MS and NCs were derived by parametric .A and B correspond to the masks of the segmented AoS, obtained using two software packages, and A ∩ B is the number of common voxels between them. The masks were obtained using Jim and SPIN graphical user interfaces for the respective segmentations, while an ad hoc script was used in order to read the ROI coordinates obtained using Segment, and filling the contour. The strength of the overlap according to the DSC was classified as almost perfect between 0.81 and 1; substantial between 0.61 and 0.8; moderate between 0.41 and 0.6; fair between 0.21 and 0.4; and slight between 0 and 0.2 [The DSC was computed using a MATLAB script, as follows:  and 0.2 . Given tGeneral linear models (GLM) were used in order to evaluate whether software and group (MS and NC) have an effect on each variable of interest, covarying for age and sex. Specifically, for each GLM, the measure of interest was the independent variable, while the software, group, age and sex were the independent variables, taking male as the reference for sex, and SPIN as the reference for software. Age and sex were taken into account, because it was recently shown that they influence many PC-derived measures in healthy subjects .Another GLM covaried for age and sex, and the repeated measures analysis of variance (RM-ANOVA/mixed model) were used in order to test pairwise differences between software packages. For both the analyses, Bonferroni-corrected pair-wise post hoc comparisons were reported. Finally, separately for each software package, we tested if any of the PC-derived measures were statistically different between pwMS and HC, using a GLM covaried for age and sex. Bonferroni-corrected pair-wise post hoc comparisons were assessed.p-values and multiple comparison corrected q-values <0.05 were considered statistically significant.The The PC-MRI of 30 pwMS and 19 NC were evaluated. The demographic and clinical characteristics of the two groups of subjects are shown in t-test p = 0.261) and sex  matched. The MS population had an average disease duration of 17.5 years and the median EDSS was 2.5. The MS population consisted of 17 RRMS and 13 PMS patients. Nine (30.0%) MS patients were on interferon-β, eight (26.7%) on glatiramer acetate, seven (23.3%) on natalizumab, and six (20.0%) did not use any disease modifying treatment (DMT).The pwMS and NCs were age ; DSCJim_SPIN = 0.877(0.727–0.968); DSCSegment_SPIN = 0.867(0.742–0.963). The median DSC was almost perfect for each comparison, with exception of two subjects for Jim vs. Segment comparison, and five agreement subjects for the Jim vs. SPIN and Segment vs. SPIN comparisons.Comparing the spatial overlap between software packages A and B, the median(range) of the DSC (DSC A–B) was as follows. DSCThe effects of age, sex software , and group (MS or NC) on each variable of interest are reported in p-value = 0.099) and average (p = 0.050), with larger values for males compared to females . With regard to the demographic variables, age significantly affected the CSA, Vmax peaks, FR systolic peak, negative and positive volumes. The greater the age was, the larger these variables were (Beta > 0 for the positive variables and Beta < for the negative variables). Sex significantly affected all the PC-derived measures, with the exception of the Vmean diastolic peak  yield a Reynolds number  far below the threshold for turbulent flow, as similarly found in [It is also important to note that the pixel with the highest velocity is in the central region of the AoS, so it is very likely to find it inside any AoS ROI, if laminar flow is assumed. This is our case, because our values of maximum velocity (highest Vmax peak: less than 19 cm/s) and CSA (always below 6.6 mmfound in . Thus, ifound in , and it Understanding the dependence of Vmean, Vmax and flow rate by ROI positioning and size allows to interpret the results of our repeatability and reproducibility tests. Although fully automatic segmentation methods were not used, we adopted commercially available software with various semiautomatic region drawing approaches, obtaining promising results and highlighting aspects that warrant caution. In particular, we had good and excellent repeatability for CSA, systolic and diastolic Vmax, Vmean, flow rate and volume with all the software. Even though the CSA was significantly different between Jim and Segment, further DSC investigation obtained with all the software packages showed substantial to almost perfect agreement. However, we also acknowledge that only acceptable ICC was obtained with Jim when considering the average of Vmean, and that the Vmean diastolic peak was significantly different between Jim and SPIN. This is easily explainable as being due to the variability in the manual selection of the border pixel that allows to initialize the semiautomatic segmentation. Indeed, Vmean is influenced by the ROI size, contrary to Vmax, as previously discussed. With Jim, manually selecting a different pixel of the border produces a higher/smaller contour, and consequently a lower/higher Vmean, respectively. Since the average flow rate is computed from average Vmean, and net volume is computed from the average flow rate, even worse ICC could be expected for them in this case, as we found. These variables had a better ICC with SPIN and Segment; in particular, SPIN makes it possible to segment by indicating a pixel inside the AoS, a method that is not affected by the visual definition of border pixels and so it is more repeatable. We obtained good ICC with Segment as well, probably because the manual segmentation was automatically adapted to the border with the automatic “Refine” tool. The dependence of the average Vmean, average flow rate and net volume on the ROI position and size, at least with one of the used software packages, could be due to the low values of these measures. This is due to the kind of CSF flow, which has a typical bidirectional and sinusoidal shape, as discussed in the work of Wåhlin and colleagues . They foGiven the results we obtained when modeling the PC-derived variables using the GLM approach , we alsoAs for our clinical results , we founWhen we separately evaluated data obtained with the three methods, only Vmax was reproducible, and was significantly different between pwMS and NC with all software packages. Significant post hoc differences for CSA and flow rate diastolic peak were also obtained with Jim, but not with the other software.A limitation of this study is that all the analyses were performed by a single operator, and no inter-rater reproducibility was conducted. Future analyses should aim at determining the extent of inter-rater differences, in one or all of the aforementioned software packages.In conclusion, the CSF flow estimated using manual and semiautomatic contour drawing from PC-MRI provides measures of interest that are repeatable. Vmax is a reliable measure regardless the ROI position and shape, being at the center of the AoS. Its diastolic peak has excellent repeatability, and is reproducible, being significantly higher in pwMS compared to NC, regardless of the software used.


Opuntia) and Miúda  on the intake and digestibility of nutrients, ingestive behavior, performance, and ultrasound measurements of growing lambs.To evaluate the effects of the carmine cochineal-resistant spineless cactus genotypes cv. Orelha de Elefante Mexicana  and 12 replications, using initial weight as a covariate. The experimental period was 86 days, with the first 30 days used for the adaptation of the animals to the facilities, diets and management, and the remaining 56 days used for evaluation and data collection.Thirty-six male (non-castrated) Santa Inês lambs were used, with an average age of 6 months and an initial average weight of 22.0±2.9 kg. They were distributed in a completely randomized design with 3 treatments  increasing DM intake (g/kg and % body weight [BW]), CP, TDN, and TC digestibility, whereas the Tifton hay diet led to a high (p<0.001) neutral detergent fiber corrected for ash and protein (NDFap) g/d intake, NDFap (BW %) and digestibility of said nutrient. There was no effect of treatments (p>0.05) on feeding time, however, rumination time and total chewing time were higher (p<0.05) for animals fed Tifton hay. The performance of the animals was similar (p>0.05). For the ultrasound measurements, Nopalea promoted an increase in the final loin eye area, compared to Tifton hay.The intake and apparent digestibility of dry matter (DM), organic matter (OM), crude protein (CP), neutral detergent fiber (NDF), total carbohydrates (TC), non-fibrous carbohydrates (NFC), and total digestible nutrients (TDN) showed a significant difference (p<0.05) as a function of the diets, with the The use of spineless cactus variety Miúda leads to the greater intake and digestibility of nutrients. The evaluated carmine cochineal-resistant spineless cactus genotypes are alternatives for semi-arid regions as they do not negatively affect the performance of growing lambs. The use of alternative food resources, which are readily available in socially vulnerable regions, can be adopted as a means of alleviating food shortages, especially during times of deficit . Thus, iSpineless cactus is a good food alternative for sheep in semi-arid regions, which contributes to an increase in the productivity of these animals . CardosoDactylopius opuntiae) has been a limiting factor for the cultivation of spineless cactus, mainly of the Redonda and Gigante varieties, directly affecting its production. The use of resistant genotypes has become a necessary strategy as an alternative to the utilization of spineless cactus in regions that are susceptible to this pest, with an emphasis on two cultivars: Miúda  and Orelha de Elefante Mexicana  [However, in recent years, the propagation of the carmine cochineal pest (ia spp.) .Although some benefits of feeding small ruminants spine-less cactus are already known ,4–6, resGiven the above, it was hypothesized that lambs fed with spineless cactus OEM would present a nutritional and productive response similar to those fed with the spineless cactus variety Miúda, and superior to those fed with grass hay. Therefore, the objective of this study was to evaluate the effects of the use of spineless cactus Miúda and OEM on the nutrient intake and digestibility, ingestive behavior, performance and ultrasound measurements of growing lambs.This research was conducted in the lamb’s sector of the Animal Science Department of the Federal Rural University of Pernambuco (UFRPE) in Recife, Brazil.The animals were handled and cared for according to the guidelines and recommendations of the Animal Use Ethics Committee (CEUA) of UFRPE, under license number (142/ 2018). Thirty-six male (non-castrated) Santa Inês lambs were used, with an average age of 6 months and an initial average weight of 22.0±2.9 kg. The lambs were distributed into 3 treatments and 12 replications, in a completely randomized design, with the initial body weight (IBW) being used as the covariate. The experimental period was 86 days, with the first 30 days used for the adaptation of the animals to the facilities, diets and management, and the remaining 56 days used for evaluation and data collection. The experimental area was composed of individual bays (1.0×1.8 m), including drinkers and feeders, arranged in a covered shed. Before the start of the experiment, all the animals were identified, treated for the control of endoparasites with doramectin 1%  at the dose of 200 mcg/kg of body weight (BW), and vaccinated against clostridiosis.Nopalea, spineless cactus cv. Miúda ; and iii) Opuntia, spineless cactus cv. Orelha de Elefante Mexicana (Opuntia spp.). The ingredients and chemical composition of the experimental diets are presented in The diets were formulated to be isonitrogenated to meet the nutritional requirements of lambs weighing 25 kg, with an average daily gain (ADG) of approximately 200 g, according to the nutritional recommendations of the National Research Council . ExperimThe spineless cactus was crushed daily, in a machine suitable for forage cactus processing. The hay was ground in a forage machine with an 8-mm sieve screen to reduce selection by the animals, and mixed with the other ingredients to be supplied as a complete feed.Samples of the ingredients, leftovers, and feces were collected and pre-dried in a forced ventilation oven at 55°C for at least 72 hours, then milled with Willey-type knives, with 2.0 and 1.0 mm sieve screens, and analyzed according to Association of Official Analytical Chemists (AOAC) recommendations . The DM Non-protein nitrogen  and neutral detergent insoluble proteins and acid detergent insoluble proteins (fraction C) were determined according to Licitra et al . The truTo estimate voluntary intake, the leftovers were collected and weighed before each feeding. The intake was measured by the difference between the feed supply and the leftovers of each animal per day; the amount supplied was adjusted daily, based on the voluntary intake of the animal, with an estimated leftover of 15%. For the digestibility assay, fecal samples were collected for five consecutive days at alternate times , after the rations were provided, directly from the rectal ampulla. Samples were mixed per animal to form a composite sample for the period.For the estimation of fecal dry matter production (FDMP), indigestible neutral detergent fiber (iNDF) was used as an indicator. Samples of 1.0 g of the concentrated feed and 0.5 g of hay, feces, and leftovers were incubated for 264 hours in the rumen of a fistulated buffaloe, according to the methodology described by Valente et al . The remDCP+ DNDFap+DNFC+DEE×2.25), where: DCP, digestible crude protein; DNDFap, digestible neutral detergent fiber corrected for ashes and protein; DNFC, digestible non-fibrous carbohydrates; and DEE, digestible ether extract.For the estimation of total digestible nutrients (TDN), the equation described by Weiss  was usedin situ technique using non-woven textile bags (100 g/m2), in which food samples were incubated  in the rumen of a fistulated sheep. Data on the disappearance of DM were adjusted by a non-linear regression, which predicts the potential degradability (PD) of food using the model proposed by Mehrez and Ørskov [−ct), where a, soluble fraction; b, potentially degradable fraction; and c, rate of degradation of fraction “b”. Effective degradability (ED) was calculated according to Ørskov and McDonald [The DM degradability was estimated by the d Ørskov : PD = a+McDonald  as folloObservations of the ingestive behavior of animals were performed using the instantaneous scanning method proposed by Martin and Bateson . The lamThe animals were weighed at the beginning and at the end of the experimental period to evaluate the total weight gain (TWG) and ADG. The TWG was obtained by the difference between the final body weight (FBW) and IBW: TWG = (FBW–IBW). The ADG was obtained through the relation between the TWG and the total days of the performance period until slaughter. Feed conversion (FC) was calculated by the relationship between DM intake and ADG.Longissimus dorsi muscle) and the fat thickness covering this muscle in the 12th and 13th rib were evaluated in vivo using an ultrasonic sweep . The wool from the measuring area was removed by shearing. The transducer was placed between the 12th and 13th ribs, alongside the spine and parallel to the rib, to obtain measurements. The animals were manually immobilized and the acoustic gel was used for contact between the probe and the skin. All measurements were made on the left side 4 cm from the spine. The scanned images were measured using Imagej software to determine the initial loin eye area (ILEA), final loin eye area (FLEA), and subcutaneous fat thickness.At the beginning of the experimental and pre-slaughter period, the loin eye area . The analyzed variables were interpreted using an analysis of variance, at a significance level of 5% as the critical probability level for type I error, using the Statistical Analysis System (SAS) version 9.0 with the general linear model procedure, according to the following model:Yij = the observed dependent variable; μ = overall mean; Ti = treatment effect (i = 1 to 3); β(Xij – X) = covariate effect (IBW); and eij = experimental error. The means were compared by Tukey’s tests (p<0.05).Where Nopalea and Opuntia) presented low levels of DM, NDF, ADF, and high NFC in the chemical composition of diets, with little difference between them. The degradability of DM for the fractions “a”, “b” and ED diverged between treatments  DM intake (% BW), CP, TDN, and TC digestibility, whereas Tifton hay led to higher (p<0.001) NDFap intake (g/d), NDFap (BW %) and the digestibility of said nutrient.The intake and digestibility of DM, CP, OM, NDFap, TC, NFC, and TDN presented a significant difference (p<0.05) as a function of the diets . The NopNopalea and Opuntia) than those who received the Tifton hay diet, but they did not differ between treatments containing spineless cactus. Nopalea provided higher (p<0.05) feed efficiency (g DM/h) compared to the Tifton hay diet, however, it did not differ (p>0.05) from that of lambs fed Opuntia compared to the other treatments. The rumination efficiency (g DM/h) was also lower for the animals fed the Tifton hay diet, compared to the other treatments.There was no difference in treatments (p>0.05) for the feeding time, with mean values of 3.5 h/d . HoweverNopalea and Opuntia) and the Tifton hay diet  between the varieties of spineless cactus  for the ILEA, as expected, however, as a function of the experimental diets, Nopalea promoted an increase in the FLEA, in relation to Tifton hay  compared to Opuntia, it also presents a higher content of NPN (A), of fast degradation. Together with the high rate of passage of both genotypes, part of the true protein (B), which is superior in Opuntia, is overpassed in the rumen, decreasing the retention and degradation time, and thus reducing the production of microbial protein and the digestibility of this nutrient. The same behavior was confirmed by Silva et al [According to the data related to the protein fractionation of different ingredients, although va et al , who evaFor the ingestive behavior presented by the animals, despite the similar feeding time between the treatments, the rumination time, as well as the total chewing time, was reduced with the diets with spineless cactus, compared to Tifton hay. Rumination rates are influenced by total NDF intake, which may be related to the retention of ruminal filling and content, which stimulates chewing, corroborating the previous facts.Nopalea showed a higher feeding efficiency  compared to Tifton hay; that is, they ate more DM per unit of time. Also, the increased rumination efficiency (g DM/h) for the spineless cactus treatments is related to the reduction of the effective fiber of the diets and is a reflection of the ruminal degradation rates and ruminal flow.The animals fed Nopalea treatment, we expected this to be reflected in the productive performance, however, considering the previously reported difference in ruminal filling and dietary rate, it is likely that a greater weight retention of abiotic content occurred in the gastrointestinal tract of the control treatment, which may have concealed the expected weight gain in the muscle and adipose tissues. Statistically, the animals gained similar amounts of absolute weight for each kilogram of DM consumed, regardless of whether they were fed Tifton hay, Nopalea or Opuntia.With the increase in nutrient consumption provided by the Nopalea treatment, before slaughter. There was a high positive correlation between the in vivo ultrasound measurements and the carcass composition [Despite the animals presenting similar final weights, there was a greater indication of muscle development through the FLEA associated with the position , confirmThe use of spineless cactus variety Miúda leads to the greater intake and digestibility of nutrients. The evaluated carmine cochineal-resistant spineless cactus genotypes are alternatives to semi-arid regions as they do not negatively affect the performance of growing lambs.