To investigate the application effect of the standard operating procedure (SOP) in the prevention of venous thromboembolism (VTE).  The clinical data of patients admitted to respiratory, cardiovascular, neurological, and geriatric departments in the hospital (November 2020–May 2021) were retrospectively analyzed, and the patients in line with the inclusion criteria were equally randomized into the observation group (OG) and the control group (CG). The CG was treated with the routine nursing, and the OG received the SOP of VTE prevention additionally. After the record of the incidence of VTE and nursing satisfaction of the two groups, scores of VTE awareness were compared. P > 0.05). Compared with the CG, the incidence of VTE of the OG was obviously lower (P < 0.05). After nursing, compared with the CG, scores of VTE awareness in the OG were conspicuously higher (P < 0.001), and scores of VTE awareness of the nursing staff were conspicuously higher than those before nursing (P < 0.001). Compared with the CG, nursing satisfaction of the OG was obviously higher (P < 0.001).  One hundred and twenty patients were included in this study, and no obvious difference was found in the general data of patients ( SOP can reduce the incidence of VTE of patients, improve their disease awareness, and enhance their nursing satisfaction, which should be popularized in practice. Venous thromboembolism (VTE) is known as the venous reflux disorder, referring to a condition in which a blood clot forms in the deep veins  and in the lungs  , 2. EpidReviewing the literature at home and abroad, standard operating procedure (SOP) is often used in first aid and intensive care . This nuThis retrospective study was conducted in the hospital (November 2020–May 2021) to explore the application effect of the SOP in the prevention of VTE. As a double-blind study, neither the study subjects nor the investigators were aware of the trial grouping, and the study designer was responsible for arranging and controlling the whole trial.The clinical data of patients admitted to respiratory, cardiovascular, neurological, and geriatric departments in the hospital (November 2020–May 2021) were retrospectively analyzed. The inclusion criteria were as follows: (1) the scores of Padua  of patieThe procedures of the study are shown in The study was in accordance with the principles of Declaration of Helsinki (2013) . After eThe CG received routine nursing . (1) Basic prevention: basic health education was given to patients to enhance their awareness on VTE prevention. Patients were encouraged to exercise regularly, such as ambulation in the morning and ankle exercises in bed. Patients were asked to drink more water, with the water intake of 1500–2000 ml daily. Patients who took dehydrating drugs and had more perspiration should be rehydrated promptly to maintain effective circulating blood volume. Venipuncture should be away the hemiplegic side and lower limbs. (2) Drug prevention: if necessary, patients should be treated with low-molecular-weight heparin, unfractionated heparin, and anticoagulant. (3) Mechanical prevention: it included graduated compression stockings, and pneumatic cyclic actuation device was used, and it could not be applied in patients with contraindications to mechanical prevention, local gangrene, acute dermatitis, severe deformity, and peripheral vascular diseases.The OG was treated with the SOP of VTE prevention. (1) Evidence-based nursing was adopted. After fully understanding the SOP of VTE prevention, nursing scheme was formulated by using Chinese and English databases and online resources, extensively reading the literature, and combining with the actual situation of patients. (2) The risk assessment of VTE was performed in all patients after admission. ① Disease condition of patients was evaluated and recorded within 24 hours after admission. ② The risk of VTE was assessed by the Padua prediction score. ③ The responsible nurses were responsible for information acquisition. 0–3 points indicated low risk, 3 points indicated middle risk, and more than 3 points indicated high risk. ④ Basic precautions were given to low-risk patients, while high-risk patients as well as those who stayed in bed for ≥3 days were observed for the VTE symptoms, and leg circumference was measured along with performing bedside B-ultrasound examination  in the case of the presence of VTE outside the hospital. The responsible nurses were responsible for informing doctors of the results and took corresponding nursing precautions. ⑤ After risk assessment by doctors, mechanical prevention and drug prevention were used for patients with no or low risk of bleeding, and mechanical prevention was used for patients with high risk of bleeding. ⑥ Warning signs were made according to the risk levels, and the bedside card was marked with corresponding color, with high-risk warning cards for high-risk patients. (3) According to the risk levels, corresponding nursing precautions were carried out for patients. Health education was performed during the whole hospitalization including basic introduction of VTE, the hazards of VTE, clinical manifestations of VTE, and precautions that need to be taken in the way of slides to enhance patients' awareness of the disease. ① Basic precautions were applied to all patients, and other precautions were performed based on VTE risk assessment. The specific operation was the same as that in the CG. (4) Quality evaluation. ① The thrombosis prevention evaluation form was established to record the implementation of preventive nursing measures, lower limb blood circulation, and daily leg circumference measurement. Patients with signs of DVT were given timely treatment in the case of VTE. ② A VTE team was established to regularly discuss and summarize the problems during the prevention process, to resolve the nursing problems in practice by reviewing the literature, and to supervise the prevention process by the head nurse and a senior nurse.General data: they included patients' gender, age, department of treatment, marital status, ethnic groups, education degree, occupation, hospitalization time, times of operation, and living habits.Incidence of VTE: the study group received training to clarify the screening criteria of VTE. Patients were screened weekly after admission, which was also performed for patients with VTE symptoms. ① DVT assessment: D-D detection was performed for low-risk patients. If negative, they were excluded. If positive, venous ultrasound examination of the lower extremity will be performed to determine whether it was DVT. The same examination was firstly performed for middle-risk and high-risk patients. Treatment was given to positive ones, and the negative ones continued to be observed. ② PTE: low-risk and middle-risk patients were tested for the D-D level. Negative ones were excluded, and positive ones received CT pulmonary angiography (CTPA) examination  certified no. 20083303600). If they were still positive, the diagnosis was confirmed, and treatment was started. CTPA examination was performed for high-risk patients. Negative ones were excluded, and positive ones received treatment. The total number of patients with VTE was recorded. VTE incidence = (DVT + PTE)/120 × 100.0%.Scores of VTE awareness: the questionnaire of VTE awareness was formulated after reviewing the domestic and foreign literature and based on Guidelines of Venous Thromboembolism Prevention after Major Orthopedic Surgery in China , ChineseNursing satisfaction: the self-made scale of our hospital was used to evaluate service quality, service attitude, and communication effectiveness, with total scores of 100 points for each item. Higher scores indicated higher satisfaction of patients.X2 and expressed by frequency and percentage. Measurement data were tested by t and expressed by (‾x ± s). A test level of α = 0.05, and the differences were statistically significant at P < 0.05.In this study, the data were processed by SPSS 20.0 and graphed by GraphPad Prism 7 . Enumeration data were tested by P > 0.05)  see .P < 0.05)  see .In the OG, numbers of cases with DVT, with PTE, and without VTE were 2 (3.3%), 0 (0.0%), and 58 (96.7%). In the CG, numbers of cases with DVT, with PTE, and without VTE were 6 (10.0%), 2 (3.3%), and 52 (86.7%).P < 0.001), and scores of VTE awareness of the nursing staff were conspicuously higher than those before nursing (P < 0.001)  see .P < 0.001)  see .P < 0.001).Compared with the CG, scores of service quality, service attitude, and communication effectiveness of the OG were obviously higher , indicating that the SOP of VTE prevention has good operability and can effectively reduce the incidence of VTE for patients.In 2004 and 2008, the American College of Chest Physicians issued guidelines for VTE prevention, and the antithrombotic guidelines (2012) detailed the VTE prevention measures that should be taken in different situations, including VTE prevention in nonsurgical patients . ChineseP < 0.001), and scores of VTE awareness of the nursing staff were conspicuously higher than those before nursing (P < 0.001), indicating that SOP could be cooperatively performed by both sides to improve the clinical practicability. Meanwhile, the incidence of VTE was lower and the nursing satisfaction was higher in the OG (P < 0.001), showing that SOP could reduce the nursing disputes. Bryce et al. found that nurse-patient communication was an important reason that impacted on the effect of nursing [Against the background of the laggard SOP of VTE in China and limited knowledge of some medical staff, the maximum effect of precautions cannot be achieved. In addition, without clear awareness of VTE, patients have poor prevention compliance. After systematic health education, awareness of VTE of patients and nursing staff was significantly deepened. Therefore, after nursing, compared with the CG, scores of VTE awareness in the OG were conspicuously higher ( nursing . TherefoIn conclusion, SOP can reduce the incidence of VTE of patients, improve their disease awareness, and enhance their nursing satisfaction, which should be popularized in practice.


Despite the availability of various guidelines, rules, and strategies, hand hygiene adherence rates among healthcare workers are reported significantly lower than expected. The aim of this meta-analysis is to determine the most effective interventions to improve hand hygiene and to develop a logic model based on the characteristics of the most effective interventions.  A literature search was conducted on PubMed, ProQuest, Web of Knowledge, Scopus, Cochrane Library, and ScienceDirect databases up to December 21, 2019, with no time limit. Randomized clinical trials which had designed interventions to improve hand hygiene were reviewed. Data were extracted independently by two authors. All statistical analyses were performed using Comprehensive Meta-Analysis (CMA) software (version 2.0). A random-effects model was used to estimate odds ratios.  Although 14 studies were initially reviewed, only 12 studies entered the meta-analysis, since they had identified percentage rates of hand hygiene compliance. The most effective intervention ) was a multilevel strategy that influenced the determinants of hand hygiene behavior at individual, interpersonal, and organizational levels. Following this, a theory-driven logic model was mapped out to promote hand hygiene, based on situational analysis.  This study suggests that designing integrated interventions based on a multilevel socioecological approach has the greatest potential to improve hand hygiene compliance in healthcare workers. The logical model proposed in this study can thus provide a useful guide for designing and conducting future experimental research. Hospital infections can pose significant threats to healthcare systems, affecting the rates of illness, mortality, and length of in-hospital stay, while also increasing healthcare costs –5. A gloThe reasons for poor hand hygiene adherence may include lack of facilities, lack of staffing, busy workplaces, skin irritation, lack of role models, and disregard for instructions , 12–14. Previous studies have also employed multifaceted strategies, which have included management and procurement support, education and training, reminders, monitoring, performance feedback , empowerThe success of a multifaceted intervention depends on the success of a complete simultaneous sequence of influencing factors . AccordiThis review was conducted based on the PRISMA checklist .What are the most effective interventions for improving hand hygiene compliance?How can a logic model be drawn based on the characteristics of effective interventions?The research questions were as follows:In order to find interventional studies on improving hand hygiene adherence, PubMed, ProQuest, Web of Knowledge, Scopus, Cochrane Library, and ScienceDirect databases were searched up to December 21, 2019, without a time limit. Additionally, a list of references of similar studies and relevant systematic reviews was examined for further information. The search strategy was developed by the experienced research team (Appendix).∗).The keywords used in the initial search were (Compliance OR adherence) AND  AND  randomized controlled trials (RCT), in which at least one intervention had been performed to improve healthcare provider compliance to hand hygiene; (b) studies that determined the level of hand hygiene compliance; and (c) studies conducted on health practitioners working at hospitals. The exclusion criteria were as follows: (a) abstracts without full text, (b) abstracts and congress and conference reports in nonarticle structure, (c) studies that were not original articles, and (d) non-English language studies.An initial search for studies was conducted by two authors of this study (M. MJ and S. H). Screening, extracting the results, and assessing the quality were carried out by these two individuals separately. In case of inconsistency between the two judgments, the supervisor determined the final comment on that article (MH. K).A random-effects model was used to reduce the risk of bias in studies. The Egger test and funnel plot were used to examine publication bias.I2 statistics. In the case of heterogeneity, a random-effects model with the inverse-variance method was applied. All analyses were performed using Comprehensive Meta-Analysis (CMA) software version 2.Heterogeneity among studies was measured using Cochran's test (with significance level <0.1) and their combination was examined using The effect size used in this study was the calculated odds ratio (OR) index. Odds ratio indicator allows the different results to be combined and presented in a comprehensible way. CMA software has the ability to combine different indices, as well as combining the effect of the sample size and the difference of the index being compared. Thus, the reasons for using the odds ratio were the different indicators, measurement scales, and data analysis methods based on the subgroups in the studies.The calculated OR eliminates all these restrictions and provides a more meaningful indicator. The calculated OR can be interpreted in the following way: if the OR is greater than one, the intervention is beneficial. If the OR is equal to 1, the odds of one event are the same for both groups, while if the OR is less than one, the intervention has a reverse effect.Finally, a logic model was created and developed based on the characteristics of effective interventions to provide a conceptual framework for the improvement of hand hygiene adherence. A logic model clarifies the logic of a program in terms of achieving its goals and objectives . The comThe checklist for a randomized controlled trial prepared by the Joanna Briggs Institute (JBI)  was usedAfter searching all international databases, 2363 articles were initially found. After removing duplicate articles, 1920 articles were examined in terms of topic and abstract, out of which 141 articles entered the next stage. At this stage, the full texts of the articles were examined, and 14 RCT articles entered the final analysis. It should be noted that the references of the articles included were also reviewed to add relevant studies. In the screening stage, some studies were excluded for several reasons, due to irrelevant topics and irrelevant study populations. The flowchart of the included studies is presented in 14 randomized clinical trials were found by the researchers, of which 4 studies were conducted in the Netherlands, while the rest were conducted in China, Germany, Indonesia, Sweden, Finland, Hong Kong, Spain, England, Canada, and the United States –43. Of tI2 index indicated that there was considerable between-study heterogeneity. Due to the high heterogeneity in results, the random effect model was used to estimate the overall odds ratio.The result of the chi-squared test and the P < 0.001. The results of the meta-analyses are displayed in In this study, the overall odds ratio was 1.74 with a 95% confidence interval (1.62–1.86), P < 0.001, I2 = 95.8%, P < 0.001).The results showed that the multimodel strategy  conducted by Ho et al. , with a P < 0.001, I2 = 99.1%, P < 0.001).In a study conducted by Martín-Madrazo et al. , the intP < 0.001, I2 = 95.8%, P < 0.001).In Huis et al.'s study in 2011 [35], an extended strategy targeting social impact and sustained leadership in the intervention group showed more effectiveness, compared with a control group , P=0.01, I2 = 95.2%, P < 0.001).In another study performed by Stewardson et al. , the intP=0.005, I2 = 88.0%, P < 0.001).The research conducted by Mertz et al.  revealedP < 0.001, I2 = 99.3%, P < 0.001).Xiong et al.  indicateP < 0.001, I2 = 85.9%, P < 0.001).Huis et al. conducted two studies in 2013 , 36. A tFinally, the results of the intervention groups in four studies included an intervention using active presentation and role modeling , a tailoP < 0.001). Based on the results of Egger's test, publication bias was observed among the studies  and organizational (sustained leadership and managers) , 36. TheBased on the results, performance feedback  in conjunction with feedback involving patient participation  was another successful strategy . JanssonAnother strategy involving mixed-media education and feedback had a significant impact on promoting hand hygiene adherence at both interpersonal and organizational levels . It seemAccording to the results, there is a missing point in designing the successful strategies; they did not pay attention to situational analysis and therefore the interventions were not systematically designed. Situation analysis is important because it refers to information gathering and analysis of the context's current state in terms of physical conditions, material, human resources, and so forth, which can have a significant impact on the selection of appropriate and accurate strategies . Since lThe proposed logic model was designed based on a socioecological approach . In the first step, a situational analysis of the current state of the context in terms of hand hygiene behavior in employees, group norms, physical environment characteristics, nosocomial infection rate, and organizational dynamics  is performed .In the input part of In the process section, at the individual level, it is important to use different activities to improve knowledge, perceptions, and attitudes towards hand hygiene compliance. The best theories for planning activities at this level involve using empowerment-oriented behavior change theories, such as Theory of Planned Behavior (TPB)  and FreiAt the interpersonal level, activities may be planned according to social norms theory , 58, whiOne of the most important limitations of this study was the existence of different reports on the effectiveness of each intervention, which made it difficult to combine the studies. However, combining the results was made possible by using the capabilities of CMA software. A second limitation was reviewing only studies that measured hand hygiene adherence as a percentage via behavioral observation so that the studies were excluded involving self-reporting and assessing the quality of the process. The last limitation was that almost all studies were conducted at well-equipped hospitals in developed countries, so generalization of the results to other hospitals or less developed countries should be made with caution.The present meta-analysis identifies that the use of a socioecological approach in planning comprehensive and coordinated interventions  is significantly more effective than other multiple-level strategies. Therefore, the authors of this study present a new theory-based logic model that can be an appropriate guide for planning, implementing, and evaluating an intervention at these three levels. It is suggested that decision-makers, planners, and managers in hospitals use this proposed logic model for setting up interventions to improve hand hygiene so that they can design a comprehensive and effective intervention. Future studies can be performed to determine the effectiveness of the proposed logic model in the field and different healthcare scenarios.


Due to the excessive use of antibiotic and antimycotic treatments, the risk of resistant microbes and fungi is rapidly emerging. Previous studies have demonstrated that many women with (recurrent) urinary tract infection (UTI) and/or vaginal infections (VIs) welcome alternative management approaches to reduce the use of antibiotics and antifungals and avoid short- and long-term adverse effects. This study aims to determine which complementary medicine (CM) and self-care strategies are being used by women suffering from (recurrent) UTI and VI in The Netherlands and how they perceive their effectiveness in order to define directions for future research on safety, cost-effectiveness, and implementation of best practices. A cross-sectional online survey was performed among women, ≥18 years old, with a history of UTIs; 162 respondents were included in the data analysis, with most participants aged between 50 and 64 years (36.4%). The women reported having consulted a CM practitioner for UTI-specific symptoms (23.5%) and VI-specific symptoms (13.6%). Consultations of homeopaths, acupuncturists, and herbal physicians are most often reported. Overall, 81.7% of the women suffering from UTI used complementary or self-care strategies besides regular treatment, and 68.7% reported using CM/self-care strategies to treat vaginal symptoms. UTI- related use of cranberries (51.9%), vitamin C (43.8%), and D-mannose (32.7%) were most reported. Perceived effectiveness was mostly reported for homeopathic remedies and D-mannose. The results showed a substantial burden of UTI and VI on daily and sexual activities. Besides the frequency of use, the indication of perceived effectiveness seems to be an important parameter for further and rigorously designed research to encourage nonantibiotic/antifungal treatment implementation into daily clinical practice. The discovery of antibiotics is one of the most important events in medical history, and it would have added a decade to people’s life expectancy . HoweverC. albicans, as shown by epidemiological studies in the United States [C. albicans infections is fluconazole, to which resistance is rising [In addition to AMR, fungi can also develop resistance to antifungals . Fungal d States , Europe d States , and thed States . Vulvovad States , and vagd States ,24. The d States . Past red States ,27, and d States . The mosThe emergence of antibiotic and antifungal resistance asks for an urgent broader view on possible solutions. The use of complementary therapies (CM) could be one direction for novel solutions. A web-based analysis performed by Flower et al.  revealedThe aim of this study is to determine the use and patient-perceived effectiveness of CM and self-care strategies for (recurrent) urinary tract infections and vaginal infections in women in The Netherlands in order to define directions for future research on safety, cost-effectiveness, and implementation of best practices.A cross-sectional online survey on the use and patient-perceived effectiveness of CM and self-care strategies in women with (recurrent) urinary tract infections and vaginal infections was carried out in The Netherlands between June 2020 and October 2020. For this study, CM has been defined as a group of diverse medical and health care professionals, practices, and products that are not generally considered part of conventional medicine , and selFemale participants, ≥18 years old, with a history of UTI, were recruited on the internet. Study information and a link to the online survey on the Survey Monkey platform were shared on the Facebook pages: “interstitiele Cystitis Patienten Vereniging ICP” from the Interstitial Cystitis Patient Organisation, “Eeuwige blaasontsteking”, “Vrouwenpoli”, and on the Instagram account “Vrouwenpoli” from the Ellesie Female Clinic, The Netherlands.The survey consisted of 36 single-choice and multiple-choice questions , including questions about demographics (3 questions), incidences of UTI/VI (4 questions), consultation and treatment of UTI/VI (16 questions), and perceived effectiveness of self-care/CM treatment options (6 questions), as well as questions regarding the impact of suffering from UTI/ VI on daily activities, sexual activities and mood (6 questions). The survey had been piloted to test the validity and reliability of the tool. The demographic characteristics collected were age, living area, and level of education. Education was classified as higher education ((applied) university/postdoctoral level), secondary education (middle and higher secondary education), and lower education (no school/primary school only/lower secondary education). Recurrent UTIs were defined as a minimum of 2 (self-reported or physician-confirmed) UTIs in 6 months or a minimum of 3 (self-reported or physician-confirmed) UTIs in 12 months .At the start of the survey, participants were informed of the anonymous and summarized reporting of their data. Completion of the survey was regarded as an indication of participant’s consent to the study. All data were anonymously collected and reported. The anonymous nature of the web-survey did not allow us to trace, in any way, sensitive personal data. The study protocol was reviewed by the Medical Ethical Reviewing Committee of Wageningen University, The Netherlands. A letter was received from the committee (dated 17 June 2020), stating that the study did not fall within the remit of the Dutch Medical Research Involving Human Subjects Act (WMO) and was, therefore, exempt from further medical ethical review.p-value < 0.05.Descriptive statistics such as measures of central tendencies, frequencies, and proportions were used to evaluate the responses. Data are represented as numbers and/or percentages for categorical variables or mean and standard deviation for continuous variables. Pearson’s chi-square tests were performed to identify differences in sociodemographics (age and education level) and CM use in general and for UTI/VI specifically. For these analyses, age was recoded into two age groups (18–49 and ≥50), education was recoded into “lower to secondary” education and “higher” education. Statistics were carried out using Statistical Package for Social Sciences (SPSS) v. 26.0. Results were considered statistically significant with a n = 1) or did not complete the questions on baseline characteristics (n = 7) were excluded. In addition, respondents without a history of at least one physician-diagnosed UTI were excluded from the dataset (n = 34). Another 21 respondents filled out their date of birth incorrectly, resulting in their age being classified as unknown. Of the 162 women with a history of at least one physician-diagnosed UTI, 80 women had a history of VI as well.A total of 204 women completed the online questionnaire. After validation of the data, 162 respondents were included in the study. Respondents who were younger than 18 years old (As shown in n = 66) suffered from rUTIs (a minimum of 2 (self-reported or physician -confirmed) UTIs in 6 months or a minimum of 3 (self-reported or physician-confirmed) UTIs in 12 months); 41.8% of all respondents received two or more treatments for UTI symptoms over the past two years, while 35.1% did not receive any treatment. More than half of the women with a history of UTIs (56.4%) also received treatment for VIs in the past 2 years; 81.7% of our study population used CM or self-care to treat UTI symptoms, while 68.6% used CM or self-care to treat their vaginal symptoms . Women who seek advice on CM/self-care strategies for UTI/VI most often use the internet (42.0%) to gather information. In addition to the internet, women ask their GP/treating consultant (21.0%) or friends and family (18.5%) for advice. Only 6.2% of the women rely on patient associations for advice on UTI-specific CM/self-care strategies, and only 5% rely on patient associations for advice on VI-specific CM/self-care strategies. For both UTI and VI, women additionally reported seeking advice on orthomolecular medicine .p = 0.36; χ2 = 0.020, p = 0.90; χ2 = 3.2, p = 0.36, respectively), UTI-specific CM/self-care use , and VI-specific CM/self-care use .Age, education, and history of recurrent UTIs were not statistically significantly associated with CM/self-care use in general . About half of the women (51.2%) who used homeopathic remedies for UTIs reported this treatment as effective (versus 12.2% reporting the remedy not to be effective). Positively perceived effectiveness for UTI symptom relief was also frequently reported (43.3%) for the use of D-mannose.n = 31) and report this as being effective in 45.2% of the cases; 29 women reported the use of probiotics (which was perceived to be effective by 17.2% of the cases), and 15 women indicated the use of a vaginal shower . Only 11 women used homeopathic remedies; however, over 50% of these women indicated the homeopathic remedy as effective, and none of them perceived it as not effective. Very few women (n = 4) used acupuncture as CM treatment for their VI, but 3 out 4 respondents perceived this treatment as effective.Women suffering from VI most often use antimycotic cream (n = 82), 28.0% reported not to be in the mood for sex anymore, 25.9% experience hassle and pain, and 22.5% had no sex anymore. Some respondents further explained in the open answer category that they have less or no sex to protect themselves from recurrent UTIs, which might indicate that sexuality is affected in general and not only during an actual infection. Within the VI-group, 21.4% (12 out of 56) did not have sex anymore, and 21.2% did not have sex spontaneously or experienced pain (11 out of 52), closely followed by not being in the mood for sexual activities .This study aimed to determine which complementary medicine and self-care strategies are used by women suffering from (recurrent) UTIs and VIs in The Netherlands and how the effectiveness of those strategies are perceived. More than three-quarters (81.7%) of the women suffering from UTIs and more than two-thirds (68.7%) of women suffering from VIs indicated using CM/self-care strategies. Cranberries, vitamin C, and D-mannose are most commonly used to self-treat UTIs, with a high percentage of women indicating a strong perceived effect when using D-mannose. VIs are mostly self-treated by using antimycotic creams, probiotics, and/or vaginal showers, although, for the latter, the perceived effectiveness is lacking. The extent to which UTIs and VIs are reported to affect women’s daily life activities, especially sexual activity, is striking. This study also indicates that about half of the women consulting their GP are still expecting to receive antibiotics to treat their UTI or antimycotics for VI. Besides frequency of use, the indication of perceived effectiveness of the reported CM/self-care strategies seems to be an important parameter for further and rigorously designed research to encourage nonantibiotic/antifungal treatment implementation into daily clinical practice.As stated in the Dutch guidelines on the treatment of UTI , antibioWe found cranberry juice or cranberries to be the most commonly reported self-care method for UTI treatment. About a quarter of the women perceived cranberry juice/cranberry-containing products to be effective, whereas another quarter did not notice any effect. This might be explained by the fact that there is a substantial group in this study who uses the remedy as curative instead of preventive. Since the data in this study is too limited to clearly distinguish between curative and preventive use, it might be worth investigating whether cranberry juice and cranberries can best be used as preventive, curative, or both. However, the effectiveness of cranberries for the prevention or treatment of UTIs is still under scientific debate. Luis et al. concluded, based on a meta-analysis and sequential analysis of clinical trials, that the use of cranberry has a clear positive effect on the prevention of recurrent UTIs . Thus faThe second most-used self-care method in our study population is vitamin C. The number of women who find this remedy effective is similar to cranberry; however, no clinical evidence is available to support the use of vitamin C to prevent or treat rUTIs .Although the number of studies is small, a recent systematic review and meta-analysis concluded that D-mannose protects against rUTIs and its effectiveness seems similar to antibiotic treatment . In our Probiotics have also been reported by our participants with regards to UTIs, but the reported perceived effectiveness, based on the small number of users, was not convincing. This is in line with the literature stating that so far, no strong evidence in favor or opposed to the use of probiotics has previously been found . The oftThe current study shows the homeopath to be the most popular CM health practitioner to be consulted in general, as well as for UTI and VI specifically. However, only 25% of the women used homeopathic remedies to treat UTI, with only 14% using them to treat VI. Interestingly, the majority of homeopathic remedy users perceived the treatment as effective (over 50% for both indications). The number of convincing good-quality studies supporting the evidence of homeopathy is scarce. More pragmatic research should be performed to determine the effectiveness of homeopathic treatment for UTI /VI compared to or in addition to regular treatment.Some treatment options were only very little reported in our study, but, in contrast to frequency, the reported perceived effectiveness was rather high. For example, acupuncture for treating VI was rated as effective by 3 out of 4 respondents as well as neutral to highly effective for treating UTI . This latter finding is in line with a recent review hinting towards the positive effects of acupuncture on recurrent UTI . The samLess common but interesting self-care methods that were mentioned by some respondents were drinking baking soda, orthomolecular therapies, mesology, pelvic floor therapy, and the use of a limited-sugar diet. Future systematic literature reviews should include these modalities to provide more knowledge on the existing evidence.When considering popular self-care options to treat VI, it is interesting that probiotics are quite often used, although only 17.2% of its users reported the treatment as effective. A Cochrane review concluded that evidence of its effectiveness in VI treatment is not yet convincing; hence, more well-designed studies are needed . RecentlAnother strategy that is frequently used to treat VI is a vaginal shower. None of our respondents reported this as effective, which is consistent with previous studies concluding that vaginal showers with lactic-acid-containing products  or with Several strengths and limitations of this study need to be noted. Our study has been strengthened by the fact that the survey focused not only on the use of CM and self-care strategies but aimed to explore the perceived effectiveness of these strategies as well. This information provides the foundation for future research, where safety (synergetic use), (cost)-effectiveness, implementation, and evaluation should be central. Real-world evidence (RWE) data might be a very helpful source for discovering promising strategies. Most survey answer categories included an open-text category that motivated the respondents to respond and thereby strengthened our study by exploring all additional CM and self-care strategies being used.Our results are limited by the use of a self-reported questionnaire. The assessment of CM and self-care strategies was based on individual recall methods and not by direct measurement of use. Respondents may, thus, have either overestimated or underestimated the perceived effects. The reported perceived effectiveness of the different strategies used is subjective. It cannot be concluded whether (r)UTIs were successfully treated by the chosen complementary remedy or if the (r)UTI could be healed on its own or by having conventional treatment only. Additionally, some respondents used multiple remedies at once, so the effectiveness could not be attributed to one specific remedy. This study does not aim to demonstrate the differences in effectiveness among several strategies or between preventive and curative strategies; nevertheless, this study supports the idea that there are alternatives to antibiotics and antifungals that are perceived to be effective. An obvious other limitation of a cross-sectional study design is that it does not allow causal inferences about relationships and, thus, limits any claim about the directionality of the results.Since the recruitment of subjects was targeted to women with a history of UTIs and took place via selected social media, we cannot exclude the possibility of overrepresentation of women with severely complicated UTI symptoms, which might influence the representativeness of our study population. CM and self-care use and perceived effectiveness might therefore differ in women with only acute, noncomplicated UTIs. This survey was performed on the general public, not on patients; therefore, differentiating between women with UTI symptoms or culture-proven UTI in relation to CM use cannot be determined in this study. For future studies, determining the use of CM and their perceived effectiveness in women consulting their GP with UTI symptoms would be of interest to differentiate between women with UTI symptoms and women with a culture-proven UTI.Fortunately, in the past years, there has been growing interest in the use of nonantibiotic treatments for common infections, such as UTIs, in order to reduce AMR. Our findings emphasize the enormous impact of UTI and VI on daily and sexual activities and, thereby, support the importance and urgent need to further investigate nonantibiotic/antifungal treatment options. The reported effectiveness based on our study is subjective. However, the reported positive experiences highlight the need for more rigorously designed research on some promisingly reported CM and self-care strategies used in addition or as alternatives to antibiotics in order to encourage the implementation of these remedies in daily clinical practice. Future research should also focus on the impact of CM and self-care treatments on antibiotic prescription and use and take into account the perception of healthcare professionals on synergetic use.


Background: The dual task (DT) was commonly used to assess the risk of falls in older adults and patients with neurological disorders. However, the performance on DT conditions has not been well investigated in patients with cerebral microbleed (CMB). This study is aimed to compare the performance in DT tests between older adults with and without CMB, and to explore the association between CMB and cognitive performances of DT.Methods: This is a cross-sectional study. A total of 211 old adults participated, involving 68 CMB patients. The task protocol involved two global cognition tests, two single cognitive tests , two single motor tasks [8-m walking and timed up and go test (TUG)], and three DT tests . The time taken to complete each task and the number of correct responses were recorded. For each DT condition, the correct response rate (CRR) and the dual-task effect (DTE) for the correct number were calculated.Results: Compared with subjects without CMB, CMB patients had worse cognitive performances on DT condition in CRR of WSS (p = 0.003), WSF (p = 0.030) and TUGSS (p = 0.006), and DTE of WSS (p = 0.017). Binary logistic regression analysis showed that the presence of CMB was an independent risk factor for the impairment group for CRR of TUGSS  with the adjustment for confounders, rather than CRR of WSS and WSF, or DTE of WSS. Multiple linear regression analysis showed that CRR of TUGSS decreased with the increase of CMB number grades .Conclusion: The present study indicated that CMBs were closely associated with poor cognitive performances on DT in the elderly. Strongest effect size was seen for CRR of TUGSS, where performance deficits increased in proportion to the degree of CMB burden. Dual task (DT) refers to a paradigm that an individual performs two attention-demanding tasks with different goals simultaneously. Taking two tasks concurrently has negative effects on the performance of both tasks .Inclusion criteria were age ≥60 years, available clinical data and brain magnetic resonance imaging (MRI), and agreement to participate in this study. The exclusion criteria included: (1) acute cerebrovascular diseases such as acute cerebral infarction, cerebral hemorrhage, venous sinus thrombosis and so on; (2) history of the massive relevant cerebral infarction (recent infarct > 2.0 cm in diameter and the correspondent lacuna > 1.5 cm in diameter) and cerebral hemorrhage with neurological sequelae; (3) the neurodegenerative disease , history of nervous system infection, inflammatory demyelinating disease, brain trauma, poisoning, radioactive encephalopathy and metabolic encephalopathy; (4) severe neuropsychological diseases and mental illnesses affecting the results of cognitive function assessments; (5) patients with cardiac insufficiency, hepatic failure, kidney failure or other medical conditions that were too weak prevented the patients from performing a proper assessment; (6) orthopedic conditions or pain affecting natural motor function; (7) taking cognitive-affecting drugs within 24 h; (8) severe visual or hearing impairment; (9) incomplete data of clinical records, motor function assessments and neuropsychological tests, or brain MRI with poor quality.Baseline information including age, gender, years of education, height, weight, smoking and drinking status, medication use and medical history of hypertension, diabetes, hyperlipidemia, stroke, transient ischemic attack, or coronary artery disease was collected from all participants according to medical records and questionnaires.2), T2-weighted imaging , T2-weighted fluid-attenuated inversion recovery sequence , diffusion-weighted imaging , and susceptibility-weighted imaging .MRI was performed on a 3.0-T MRI scanner . The parameters of the MRI examination were as follows: T1-weighted imaging  and Montreal Cognitive Assessment (MoCA). Besides, the serial 7 subtraction task and semantic fluency task  in MoCA were selected as two kinds of single cognitive tasks. For the serial 7 subtraction task, subjects were asked to calculate at least 60 s and at least five times. If the subject cannot perform the subtraction, the time for this item was limited to 60 s. For the semantic fluency task, subjects were asked to generate as many nouns as possible within 60 s. Besides, we recorded the subjects' responses and noted the number of correct answers. Cognitive assessments and DT tests were conducted within 5 days after the MRI scan.Subjects performed all the following five tasks walking over a tiled floor. On the DT condition, subjects walked with the instruction to “perform both tasks as well as possible without giving priority to either motor or cognitive task”. Subjects' responses were recorded, and we also noted the number of correct responses.Eight-meter walking task: Participants were asked to walk on level ground along an 8-m pathway at their usual and comfortable pace.Walking and serial subtraction task (WSS): Participants walked along the 8-m walkway while repeatedly subtracting 7 from a random number concurrently.Walking and semantic fluency task (WSF): Participants were instructed to walked along the 8-m walkway while doing semantic fluency task (vegetables) concurrently.Timed up and go test (TUG): Participants were asked to stand up from a chair, walk 3 m, turn 180°, then walk back, and sit down at their usual and comfortable speed.TUG and serial subtraction task (TUGSS): Participants performed the TUG test and serial 7 subtraction task from a random number simultaneously.To avoid the learning effects, the rater assigned different word categories  or random numbers (between 80 and 100) when assessing the single cognitive test and the DT test. And our pilot study found that different sets of numbers or word categories produced comparable difficulty among participants.Subjects' motor data were captured using the Intelligent Device for Energy Expenditure and Activity  system. The main recorder of IDEEA system was secured on the left waistband. One sub-recorder was taped above each lateral malleolus. Five sensors were placed on the sternum and bilaterally on the plantar aspect of foot and midline of the anterior aspect of thigh. The IDEEA system automatically recognized the movement of body and the change of posture, and recorded various parameters of tests including the start and end time, duration, gait, etc. The data was downloaded from the recorder to the computer after performing tests on each subject. Two gait parameters on each DT condition, the walking speed (m/s) and stride length (m), were included in this analysis.The correct response rate (CRR) was calculated using the duration and the number of correct responses in each DT test for measuring the cognitive performance under the DT condition. The CRR was computed as  to assess the influence of the added motor task on the cognitive performance. The DTE was computed as , while the positive value indicates the improvement of performances (“cognitive benefits”)  minus the correct number of semantic fluency , and the correct number of TUGSS minus the correct number of single subtraction task, respectively. The time to count responses in each single cognitive task was matched to the duration of the corresponding DT test.Impaired cognitive performance on DT was defined as the lowest quartile of CRR or DTE. Those participants with impaired cognitive performance were considered as the impairment group, the others were assigned to the control group.2, Mann-Whitney U or Kruskal-Wallis H test where appropriate.Data were presented as n (%) for categorical variables, mean (standard deviation) for normally distributed variables, or median (quartiles) for continuous data with non-normal distribution. The severity grade of WMH, PVS and PA was represented by the median (range). Differences among groups were determined using χThe univariate analysis was used to identify the statistical differences of parameters in the cognitive performance between CMB patients and non-CMB subjects. Next, subjects were divided into the impairment group and the control group according to each parameter with statistical difference, separately. Then, age, sex, years of education and variables with significant differences between the impairment group and control group were adjusted in the following regression analysis as confounding factors.p < 0.05.Binary logistic regression analysis was performed to determine whether the presence of CMB was an independent risk factor of the DT performance. Multiple linear regression analysis was used to explore the trend of the DT performance with the increase of CMB number grades. All analyses were performed with Statistical Product and Service Solutions 22.0, and the statistical significance was considered at Sample characteristics are depicted in p = 0.012) and MoCA (p = 0.001), and worse cognitive performances on DT in CRR of WSS (p = 0.003), WSF (p = 0.030) and TUGSS (p = 0.006), and DTE of WSS (p = 0.017). There were no significant differences in the increased correct number or time of WSS, WSF and TUGSS, or DTE of WSF and TUGSS between CMB patients and non-CMB subjects   vs. 3 , p < 0.001], while no significant difference was observed in the semantic fluency . After comparing gait parameters on each DT condition between two groups, CMB patients had slower stride speeds and shorter stride lengths, while the differences were statistically significant only in the stride length in TUGSS (p = 0.045)  . In CMB = 0.045) .p = 0.003) and Fazekas scores of DWMH (p = 0.046) between the impairment group and the control group. Grouped by CRR of WSF, significant differences were found in diabetes (p = 0.013), hyperlipidemia (p = 0.044), antidiabetic drug (p = 0.037), presence or absence of lacuna (p = 0.046), Fazekas scores of DWMH (p < 0.001) and PVH (p < 0.001) and severity of BG-PVS (p = 0.044) between the impairment group and the control group. As for DTE of WSS, statistical differences were found in education (p = 0.003) and DWMH (p = 0.046) between two groups. In each grouping method, statistical differences were found in scores of MMSE (p < 0.05) and MoCA (p < 0.05) between the impairment group and the control group.Subjects were divided into the impairment group (the lowest quartile of CRR or DTE) and the control group (the other subjects) based on CRR of WSS, WSF and TUGSS, and DTE of WSS, respectively. Grouped by CRR of WSS, there were statistical differences in years of education (p = 0.014), smoking (p = 0.022), hyperlipidemia (p = 0.011), lipid-lowering drug (p = 0.011), MMSE (p < 0.001) and MoCA (p < 0.001) scores between the impairment group and the control group  with the adjustment of age, sex, education, smoking, hyperlipidemia, lipid-lowering drug, MMSE and MoCA  (p = 0.028) after the correction of age, sex, education, smoking, hyperlipidemia, lipid-lowering drug, MMSE and MoCA.Participants were further classified into four grades according to the number of CMB lesions. There were 143 participants without CMB, 32 participants with 1 CMB, 12 participants with 2 CMB lesions and 24 participants with more than 2 CMB lesions. A significant difference was found in CRR of TUGSS among four CMB number grades (= 0.032) . MultiplOR, 1.79; 95% CI, 0.85–3.74; p = 0.125), CRR of WSF  or DTE of WSS  after adjusting confounding factors respectively (Moreover, binary logistic regression analysis suggested that the presence of CMB was not an independent risk factor for the impairment group on CRR of WSS (ectively .When people perform a cognitive task and a motor task at the same time, there will be competition or interference between different tasks leading to the deterioration in one or both task performances. This is known as cognitive-motor interference, a specific kind of DT interference (Leone et al., Based on these theories, DT tests have been widely used to study the cognitive-motor interference and the risk of falls in different populations, such as patients with stroke, Alzheimer's disease, Parkinson's disease, or multiple sclerosis (Mofateh et al., In this study, the combined protocol of various DT tests and single tasks was used to describe the feature of cognitive performances on DT of CMB patients. The results showed that the global cognitive function of CMB patients was worse than that of subjects without CMB, which was consistent with previous studies (Akoudad et al., As for the design of DT paradigm, the difficulty of DT can be changed by adjusting the level of complexity and novelty of each task (McIsaac et al., The underlying pathophysiological mechanisms of CMB-related cognitive and motor impairment have not been fully elucidated. The direct damage of CMB lesions on focal brain tissues may cause myelin loss, neuronal loss and variable extent of gliosis, and lead to the brain function disorder. The remote effects manifested by white matter microstructure changes and cortical thinning may also be an indirect damage to brain function caused by CSVD (Ter Telgte et al., To our knowledge, this is the first study targeting the influence of CMB lesions on the cognitive performance under DT conditions in old adults. And the compound protocol of global cognition assessments, basic gait tests and different DT designs makes the functional assessment more diversified in this study. Moreover, the IDEEA, a microcomputer-based portable gait analysis system and physical activity monitor, has advantages in the detection and analysis of multiple gaits, postures, limb movements, and the energy expenditure with great accuracy (Huddleston et al., However, there are still some limitations to this study. This is a single-center cross-sectional study, and the sample size is relatively small. So, we did not perform the subgroup analysis based on the CMB location or cognitive domains. Not all the gait parameters were included in the analysis, because this study paid more attention to the cognitive performance on DT that other studies had focused less on in CSVD patients. In the future, the sample size will be further expanded to conduct the interested subgroup analysis, and the motor function such as gait and balance will be complementally analyzed. In addition, those semi-quantitative scales were relatively subjective for the assessment of CSVD imaging markers. It may have some impact on the effectiveness of proving the tendency that cognitive performances on DT are changing with the severity of CMB burden. Further studies with advanced imaging techniques and post-processing methods may be of great value to provide more information and solve this problem.The presence of CMB was an independent risk factor for the cognitive impairment group of TUGSS on the DT condition, where performance deficits increased in proportion to the degree of CMB burden. Failing to consider the effect of DT may lead to an underestimation of the difficulties in CMB patients' daily life, including those with mild impairments. In the future, more large-scale studies with longitudinal designs are needed to clarify the causality between CMB and DT performances and to explore the mechanisms using multimodal imaging techniques and experimental sciences.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Ethics Committee of Beijing Chao-yang Hospital, Capital Medical University. The patients/participants provided their written informed consent to participate in this study.XL and WH contributed to conception and design of the study. XL, SY, WQ, YH, and QH collected the data. XL, YL, and SY performed the statistical analysis. XL wrote the first draft of the manuscript. WH, WQ, and LY contributed to the critical revision. All the authors contributed to manuscript revision, 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.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.


Delays in early child development are among the aspects underlying the persistent developmental gaps between regions and social strata. This study seeks to examine the relationship between the home environment and early child development in less-developed rural areas by drawing on data from 445 children from villages in Guizhou province in southwest China. A demographic questionnaire, the Home Observation Measurement of the Environment (HOME), and the Bayley Scales of Infant Development, version III (BSID-III), were used to measure the child’s demographic characteristics, home environment, and early development outcomes, respectively. Our data show that the sample children suffer a delay in various dimensions of child development and a deficit in the HOME scale. The results from a hierarchical regression model suggest that the availability of learning material at home, caregivers’ responsiveness and organization sub-scales are significantly positively correlated with the early development of sample children, after controlling for general socioeconomic status, health, and nutrition, and this correlation differs by gender. These results imply that the provision of learning material to households, promoting caregivers’ responsiveness and organization in less-developed rural areas could improve early child development among deprived children. An individual’s well-being is strongly related to his or her development between 0 and 8 years of age. Key early child development dimensions include physical, cognitive, motor, and social–emotional development . Delays Worldwide, many children are subject to various deprivations that fundamentally hinder their developmental progress. As estimated by a study in The Lancet, deprivation is so profound that nearly half 43%) of children in low- and middle-income countries may not achieve their full development potential [% of chilGiven its importance, a natural question emerges regarding what contributes to early child development. Empirical research has provided ample evidence with regard to the crucial impact of households’ socioeconomic status (SES) on child development . Lugo-GiMany recent studies have examined the importance of the home environment in early child development. The home environment is defined as a safe and well-organized physical environment, with opportunities to play and explore, in which learning objects, toys, and books are supplied . The WHOInformed by these findings, it has been argued that improving the home environment can crucially promote child development, particularly in the early years . MoreoveUnfortunately, detailed and valid evidence on the role of the home environment in early childhood development among rural Chinese households is scarce. The majority of existing studies focus on parenting styles  or the dTo date, even fewer studies have explored the role of parenting practices in early child development in the context of China. Using data on migrant children from urban China, Liu et al.  found a This study aims to close this research gap by providing novel evidence of the connection between various dimensions of the home environment and child development. In doing so, we draw on data from a unique comprehensive survey of the home environment and early child development among 445 children in underdeveloped rural areas of China. To assess their home environments, we employed the Home Observation Measurement of the Environment (HOME), which is based on observations by trained enumerators and reports by caregivers in six dimensions of the home environment. To measure child development, we used the Bayley Scales of Infant and Toddler Development, version III (BSID-III). In terms of socioeconomic and health/nutrition factors, we drew on information collected by an accompanying questionnaire conducted by trained enumerators with primary caregivers.The rest of the paper is organized as follows: Our study builds on a dataset collected in Guizhou, one of the provinces with the lowest average income in China. The sample township was randomly selected from the list of all townships (excluding the township where the county seat is located) in a sample county in the sample prefecture, which is one of the poorest prefectures in the province. The sample township has 41 rural settlements in 9 villages, all of which were eligible to participate in the study. In total, 445 children, aged 4–26 months, and their caregivers participated in the study. While children were assessed for the BSID-III, their caregivers answered a general questionnaire, which included 39 items used for the HOME scores.The Peking University Institutional Review Board (PU IRB), Beijing, China, approved the ethical assessment of the study (No. IRB00001052-17056). The purpose of the study was explained to the parents or guardians of all children, and verbal informed consent was obtained.The data we used in this study were collected from sample households over a three-week period in May 2017. A list of all registered births in each village was obtained from the local health officials. All children in the targeted age range in the sample villages were enrolled in the study. Teams of trained enumerators collected socioeconomic information from each sample household to measure the characteristics of the child, the caregiver, and the household. For collection of data pertaining to children, we recorded his/her gender, siblings, birth height, and weight. The exact age of each child was obtained from his or her birth certificate. At the caregiver level, we recorded his/her age and education level, as well as his/her relationship with the child. At the household level, we collected information about their socioeconomic status. Moreover, our survey also included a series of questions on the household’s parenting environment, in particular the parenting behavior toward the child.We employed the BSID-III to measure child development. This test is a well-recognized and established tool in the psychological literature to diagnose certain developmental disorders . The BSITo assess the four sub-scales, the test measures a child’s performance on a series of tasks using a standardized toy kit. For each passed task or item, one point adds to the total raw score in the respective dimension. Overall, the cognitive sub-scale consists of 91 items, the language sub-scale of 97 items, the motoric sub-scale of 138 items, and the social–emotional sub-scale of up to 35 items. Raw scores are converted into scaled scores by considering the developmental progress according to child age and composite scores, which allows for a comparison between scales.The test was administered one-on-one using a set of standardized toys and a detailed scoring sheet. All enumerators attended a weeklong training course on how to administer the BSID-III in the field.While many studies typically use one of these norm-referenced scores , we followed Attanasio et al.  or SylviWe employed HOME to assess the quality of a child’s family environment. The infant and toddler version of HOME includes six dimensions: (a) responsiveness; (b) acceptance (lack of punitive action); (c) organization; (d) play/learning material; (e) involvement (stimulation of development); and (f) variety of experience ,43. The To achieve our research objectives, we needed to differentiate between aspects of the home environment. Broadly, we focused on two aspects: aspects that are mostly driven by income , and aspects related to non-material parenting styles (such as responsiveness or acceptance). To this end, we introduced not only the aggregated home scores, but also the underlying sub-scores.For this study, we used a slightly shortened version of HOME to adapt to the local context. According to Bradley and Corwyn , such adTo estimate the association between the home environment and child development, we employed a hierarchical multiple regression model . This moVariables are entered in sequence of their causal priority and presumed theoretical importance in the hierarchical multiple regression model . In the Following the literature, we controlled for the following socioeconomic variables. Specifically, we controlled for low-income levels  as a proxy for a poor economic environment. To control for potential cultural effects, we included a binary variable for ethnic minorities. Due to the potential interaction of parents’ education and parenting as well as child development , we alsoWe also took into account the effects of nutrition and health impacts ,9,10,11.To assess the overall performance across dimensions, As expected, the development of raw scores increased with the age of children . We obsep < 0.01). At the same time, we found a statistically significant difference between the genders in terms of gross (p = 0.021) and fine motor development (p = 0.024). Gender differences in terms of language and social–emotional raw scores were not statistically significant  was slightly higher than their female peer group’s raw score . The difference between the genders in terms of cognitive development was statistically significant  than Han households (5.3) .p < 0.001), gross motor (p < 0.05), and social–emotional development (p < 0.001). For each additional point increase in the HOME score, the receptive communication, expressive communication, gross motor, and social–emotional sub-scores (raw scores) increased by 0.10, 0.17, 0.11, and 0.23 points, respectively. The contribution of HOME score to the total model’s prediction power (measured by ΔR2), however, was small, from 0.001 for the cognitive score to 0.014 for expressive communication.Our regression results show that the HOME score is statistically significantly related to children’s language (p < 0.001) and a 0.96-point lower receptive communication raw score (p < 0.05). This significant correlation indicates the importance of material welfare for parenting quality. Furthermore, we found that, with each additional sibling, both the cognitive raw score and the expressive communication raw score decreased by 0.63 points and 0.56 points, respectively. This finding reflects the ambivalent role of siblings in early child development, where potential positive effects on cognitive and language development can be outweighed by the need to split attention and resources [A stronger effect was found for socioeconomic, nutrition, and health-related variables. As expected, an increase in age of one month at the mean translated into a significant increase in all development scores, with a monthly average growth rate of between 0.70 (receptive communication) and 2.41 . However, being in the lowest income class was statistically significantly related to a 2.63-point lower cognitive raw score  was related to a 0.30-point increase in the cognitive raw score and a 0.20-point increase in fine motor raw score. Children that had been breastfed at some point in their infancy had a 1.13-point higher level of gross motor development on average. In smokers’ households, children had significantly lower receptive communication raw scores (0.59 points) and motor raw scores (0.61 points).The second series of hierarchical regression models reveal further insights into the particular effects of home environment components. This time, the regression was conducted for the six HOME sub-scales separately: acceptance, responsiveness, involvement, organization, variety, and learning material.The results of this more detailed analysis are displayed in Among all HOME sub-scales, learning material had both the strongest and the most diverse connection with child development. A one-point increase in learning material was associated with considerable and statistically significant increases in terms of cognitive scores (0.525 points), expressive communication score (0.256 points), fine motor score (0.272 points), and gross motor score (0.399 points). Furthermore, a one-point increase in learning material was also related to an increase in receptive communication (0.201 points), though only at the 10% significance level. For the acceptance, involvement, and variety sub-scales, no significant connection with child development could be found.This study shows that the sample children exhibited a delay in various dimensions of child development, reaching only 82–89% of these benchmarks of healthy population means, indicating that the sample population lagged behind healthy populations by 11–18%. We also found that these delays were closely related to HOME scale. Compared with the international benchmark, our sample households showed considerably lower scores for learning materials, organization, variety, and responsiveness. While this finding certainly requires a comparison with samples from other countries, it does confirm patterns revealed by other studies, placing an emphasis on parenting, specifically parents’ involvement.Previous studies have shown a moderate correlation between HOME scale and the cognitive and language development of children across all age cohorts, as summarized by Bradley . HoweverMany studies argued that there is evidence of a more specific influence when investigating the disaggregated effects of each HOME sub-scale ,56. ThisHowever, the influence of HOME scales on social–emotional development could not be supported by the disaggregated data. A possible explanation for this finding may be the cultural particularities of the sample. Guizhou is one of the provinces with the highest share of ethnic minorities. As investigated by various studies (e.g., Bornstein  and RichIn conclusion, this study shows that the sample children suffer a delay in cognition, language, motor, and social–emotional development and a deficit in the parenting environment according to the HOME scale and sub-scales. The results also demonstrate the existence of a positive correlation between HOME scale and children’s language, gross motor, and social–emotional development. Our findings further reveal a heterogeneous effect among HOME sub-scales and child development, in which the learning material, responsiveness, and organization sub-scales are positively associated with early child development. These results imply that parenting services on the provision of learning material, the improvement of caregivers’ responsiveness and organization in less-developed rural areas could contribute to early child development among deprived children and narrow the persistent gaps early child development.


Aim of this cross-sectional study was to investigate the association between PDFF over the supraclavicular fat region as a proxy of BAT proportion and resting metabolic rate (RMR). In addition, the association between the single nucleotide polymorphism (SNP) rs1421085 at the 2) were included in the analysis. The RMR was measured by indirect calorimetry. The magnetic resonance imaging (MRI) was used for the measurement of visceral and subcutaneous adipose tissue  volumes and for the measurement of adipose tissue PDFF.Anthropometric, clinical, and lifestyle data from 92 healthy adults , no association was found between supraclavicular PDFF (p = 0.346) and gluteal PDFF (p = 0.252), respectively, and RMR, whereas statistically significant evidence for a negative association between delta PDFF  and RMR (p = 0.027) was obtained. No statistically significant evidence was observed for per FTO rs1421085 variant is not associated with either RMR or PDFF. Further studies are needed to elucidate the effect of BAT on RMR.Supraclavicular PDFF as a surrogate marker of BAT presence is not a determinant of RMR under basal conditions. In the present study, the  Understanding the determinants that influence resting metabolic rate (RMR) as the main component of energy metabolism is fundamental in obesity research. Main determinants of RMR variability include fat-free mass (FFM), sex, age, and body temperature –3. In paThe FM consists of white adipose tissue (WAT), composed of lipid-storing white and – to a poorly defined, but much lower extent - lipid-burning “beige” adipocytes, and brown adipose tissue (BAT) in specific depots , 9. WherOver the last decade, functional imaging provided evidence for the existence of BAT in adult humans , where Bfat mass and obesity associated (FTO) locus and preadipocyte differentiation  the association between supraclavicular PDFF, as a surrogate marker for the presence of BAT, and RMR as well as (II) associations between the Recruitment of study participants started in October 2013 at the Else Kroener-Fresenius Centre for Nutritional Medicine in Munich, Technical University of Munich, Germany. Adults with a body mass index (BMI) equal to or above 18.5 kg/m² were included. Participants were excluded if an acute inflammatory state, a history of severe diseases, surgeries within the last three months or physical limitations were reported. Pregnant and breast-feeding women and persons on specific medications such as beta-blocker were also excluded. Written informed consent was obtained before participation in the study. The study protocol and the standard operating procedures were approved by the ethical committee of the Technical University of Munich, Germany (Number 2719/10 S).Height was measured in a standing position without shoes using a stadiometer  and reported to the nearest 0.1 cm. Body composition, including FFM and FM, was assessed using bioimpedance analysis . Measurements were performed before indirect calorimetry in light clothing and with voided bladder, with subtraction of 1.0 kg for clothes. The BMI was calculated as quotient of weight in kg and squared height in m (kg/m²). Blood pressure and heart rate were obtained using a validated electronic device  according to the recommendations of the American Heart Association .2) and carbon dioxide (VCO2) expiration resulting from substrate oxidation, while participants were fully awake and motionless. The respiratory quotient (RQ) was calculated as VCO2/VO2 ratio. For RMR calculation, the following equation was used: RMR  = [3.941 × VO2 (ml/min) + 1.106 × VCO2 (ml/min)] × 1.44 . The RMR measurement was performed with the following requirements: overnight fast (10 to 12 hours), no smoking, and abstinence from physical activity the day before. The 30-minutes measurement started after an acclimatization time of five minutes. The flow rates were assessed as recommended by the manufacturer. The Quark RMR software analyzed oxygen consumption . For PDFF analysis, a semi-automatic segmentation tool based on Matlab  was used. Weight data at the time of MRI measurement was self-reported. Detailed data analysis of MRI measurement was performed as previously described . The proFTO polymorphism rs1421085 was carried out by the company Eurofins  with Cycle Sequencing Technology (dideoxy chain termination/cycle sequencing) using Applied Biosystems 3730xl DNA Analyser. Call rate was calculated with 96.1% showing a high quality of the genotyping procedure. Calculated minor allele frequency (MAF) of the risk C allele was 43%. Hardy-Weinberg equilibrium (HWE) was fulfilled.Deoxyribonucleic acid (DNA) was isolated from EDTA full blood samples according to a standard protocol following manufacturer`s protocol . Polymerase chain reaction (PCR) was used for amplification of DNA. Sequencing of the FTO genotype and PDFF and RMR. Due to time intervals between the RMR and MRI measurement, all statistical analysis were adjusted for the body weight difference (“weight change”) between the time of RMR and MRI measurement. RMR is known to be significantly associated with age, sex, and FFM  and percentages (%). For comparison of variables, the unpaired student t-test was conducted for normally distributed variables, otherwise Mann-Whitney U-test was used. Analysis of variance (ANOVA) were conducted to compare more than two variables. Regression analysis was calculated for associations between different variables. Additive, as well as dominant and recessive linear models were used to identify associations between the  and FFM , 26, 27. and FFM .In total, 92 participants  were included in the analysis Table 1.Supraclavicular PDFF was positively associated with RMR, if data was unadjusted , however significance disappeared after adjustment in model 2 and model 3  Table 2.Evidence for a significant association between VAT and RMR was observed in the statistical models 1 and 2  Table 2.To exclude effects of overweight and obesity on the relationship between PDFF and RMR, a sub-group analysis of participants with normal weight  was performed. Evidence for a statistically significant negative association between gluteal PDFF and RMR was obtained in the unadjusted model 1  as well as in the full adjusted model 3  Table 3.FTO genotypes and the RMR were seen in the additive as well as in the dominant or recessive genetic models , respectively. No evidence for any significant association between the FTO SNP rs1421085 and the adipose tissue variables under investigation was obtained, independent of the genetic model . Moreover, the negative association between delta PDFF and RMR remained statistically significant after adjusting for age, sex, weight change, FFM and FM. However, the negative correlation disappeared after exclusion of persons with overweight and obesity. These results were in contrast to our hypothesis as we assumed (I) the lower the supraclavicular PDFF, the higher the content of BAT and beige fat cells (II) resulting in a higher delta PDFF and in a higher RMR. The associations may indicate that the adipose tissue composition of the supraclavicular region might not be relevant for energy expenditure, at least under thermoneutrality. Inverse correlations between outdoor temperature and BAT activity were found in different studies, in which BAT was detected a PET-CT , 30. Morutrality  leading The significant difference between supraclavicular and gluteal PDFF as demonstrated in this study is in line with other studies , 14 indiFrom previous studies, it is well known, that FFM is the major determinant of RMR , 26, 34,FTO SNP rs1421085 was of interest. No association was detected between the rs1421085 obesity C risk allele and PDFFs. However, this negative finding should be dealt with caution as the sample size was limited and, therefore, the number of homozygous C risk allele carriers was rather small. Another explanation might be that the effect of the FTO risk genotype may only become apparent when BAT is metabolically active, e.g. after activation by cold exposure. As MRI-derived PDFFs do not reflect current BAT activity, an association between the FTO genotype and BAT activity is not excluded and may require further studies.Based on the findings of Claussnitzer et al. , the invThe present analysis investigated the relationship between PDFF as a proxy of BAT and RMR in humans. However, PDFF is not specific for the presence and the proportions of brown or beige adipose cells in a defined adipose tissue depot. A low PDFF in the supraclavicular adipose tissue may suggest a large proportion of less lipid-loaded brown fat cells, but suffers from partial volume effects and cannot reflect the real volume of brown adipocytes in the human supraclavicular fossa comprising a heterogeneous mixture of brown and white adipocytes . In addiFTO SNP rs1421085. Our results did not provide evidence for a significant association between supraclavicular PDFF and RMR. In addition, our analysis did not reveal an association between supraclavicular PDFF and the FTO genotype. Future studies on the association between BAT and RMR should consider the activation of BAT.In conclusion, our analysis is the first to investigate the associations between PDFF, as a surrogate marker for BAT and beige fat cells, and RMR and the The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethical committee of the Technical University of Munich. The patients/participants provided their written informed consent to participate in this study.HH, DK, and CHo contributed to conception and design of the study. TD and DJ organized the database. TD, WM, CHe, and DJ performed data collection and analysis. TD and SB performed the statistical analysis. TD, SB, and CHo wrote the manuscript. All authors contributed to the article and approved the submitted version.Else Kroener-Fresenius-Foundation, Bad Homburg, Germany, and the Helmholtz cross-programme topic “Metabolic Dysfunction”.DK receives grant support from Philips Healthcare.The remaining 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.


Becoming a mother is an innate process, without any culture-dependent instruction. While it is a pleasant experience, it can sometimes be associated with problems resulted from baby caring. Preterm birth can be a challenge for the maternal role adaptation (MRA). Therefore, the present study was conducted to determine the maternal role adaptation in mothers with preterm neonates.The present study is cross-sectional, with a sample including 114 mothers of preterm infants in the NICU. We collected the data using a two-section questionnaire. The first section was a demographic questionnaire and the second section was a standardized questionnaire? “Maternal role adaptation scale in mothers with preterm neonates admitted to neonatal intensive care units” (MRAS: NICU). We ran the statistical analysis using descriptive and inferential statistical methods with the SPSS 21 software.The total MRA score was strong in half of the participants. The participants had a university education, were employed and satisfied with their economic status, and had a high score on adaptation to the maternal role. There are different domains to the MRA, the highest score was allocated to the participation in care (56.24±0.13), and the lowest score was allocated to growth and development (3.12±0.28).According to the results of this study, the most important factors associated with MRA are the mother’s age, education, and economic satisfaction. Determining the factors related to the mothers’ adoption of premature infants could increase the ability of mothers to cope with problems and negative emotions, and enhance the adoption of maternal roles. One of the most important roles of a woman is the maternal role . This psPreterm and low birth weight infants have needs that require intensive neonatal care. These infants not only require intensive care immediately after birth, but they also have a higher morbidity rate . The motSince successful adaptation to the maternal role results in self-esteem and the satisfaction of her abilities in caring and nurturing the child; and awareness of its related factors in mothers of preterm infants admitted to the NICU can improve the quality of postpartum care . The resThe present study is a descriptive analysis. The participants were 114 mothers of premature infants admitted to the NICU. The inclusion criteria included consent to participate in the study, reading and writing skills, aged 18 and over, without any mental disorders, living with spouse, first marriage, first maternal experience, single infant, premature , without any apparent abnormalities, and the reluctance of the mothers to continue participating in this study was the exclusion criteria.The necessary information regarding the objectives of the study was explained to each participant. All participants signed a written consent, and their confidentiality and privacy were maintained. In addition, we considered ethical principles in data gathering and analysis.Data were collected using a three Self-reported questionnaire, including demographics, the standardized tool: “Maternal role adaptation scale in mothers with preterm neonates admitted to neonatal intensive care units” (MRAS: NICU) and related factors. The demographic questions consisted of items regarding age, education, ethnicity, occupation, average monthly income, alcohol, drug use and smoking.et al. (2016).MRAS: NICU was developed by Heidarpour et al. The MRAS: NICU is a 32-item-scale, designed to measure maternal role adaptation. This scale consists of 6 domains, including participation in care (14 questions), self-efficacy (6 questions), distant mothering (3 questions), uncertainty (4 questions), Interaction (3 questions), growth and development (2 questions) that correspond to a 5-point Likert scale, ranging from “1” Strongly Disagree to “5” Strongly Agree. The score of each domain was calculated as the sum of the scores of the items in that domain, and the total score of the scale was calculated as the sum of the domain scores, then the scores were converted to percentages and classified in three levels: Poor (0-33%), moderate (34-66%) and strong (67-100%). The mean for the full scale was used where the scores ranged from 1 to 5. The higher scores indicated higher maternal role adaptations. The instrument reliability with Cronbach’s alpha coefficient of 0.90 and its stability after re-test with correlation coefficient of 0.81, were confirmed by Heidarpour Maternal role adaptations related factors included maternal factors ; paternal ; and infant factors , Fertility history .After data collection, data was inserted in SPPS version 21, for determining the score of the” Maternal Adaptation” questionnaire as a whole, and we divided the domains’ statistical indices including mean, mode, minimum, maximum and standard deviation.The mean age of mothers and their husbands was 29.34 (SD=6.06) and 31.11 (SD=6.91) years old, respectively. Most of the mothers were housewives (60.5%) and 40.4% were college graduates (40.4). Most of the fathers were self-employed (50.4%) and had a Diploma (45.6%).As far as ethnicity of mothers is concerned, 94.73% were pf Guilanian ethnicity and 60. 5% were housewives. 52.4% of the mothers were satisfied with their economic status. In case of neonatal sex, 55.26% had boys and 69.29% planned their pregnancy.The mean MRAS score: NICU was 118.77±3.31. MRA in 45% of mothers was strong, 23% moderate and 32% poor.Overall, the highest score of six sub-scales was Participation in care (80.34%); and the lowest score was Growth and development (52%) ; Self- efficacy ; Maternal distance ; Uncertainty ; Interaction ; Growth and development . nt (52%) .According to the T-test, the gender of the infant , the Smoking (yes or no), mother’s and ethnicity (Guilanian or Non-Guilanian) and according to the Analysis of Variance (ANOVA) test, father’s job  and mother’s job  did not have a significant effect on the mean MRAS score: NICU. In addition, there was a significant correlation between the MRAS score: NICU and the mother’s age, education, and economic satisfaction were significantly related to the MRA . Another study by Horst et al., reported that having knowledge and skills to care for mothers with premature babies was the first priority for these mothers (mothers’ educational levels were significantly associated with the increased knowledge on premature childcare, the findings of this study are consistent with other similar studies.The results of this study showed that mothers with higher education had higher maternal role adaptation scores. According to the results from the Heydarpour study, lack of adequate information on what happens after delivery following preterm birth is confusing to mothers ( mothers . Since mThe results are indicative of the fact that employed mothers had a higher maternal adaptation score. The results of this study showed that mothers who were satisfied with their economic status had higher maternal role adaptation scores. According to the results from the study by Holden et al., a better economic status will increase the self-efficacy of preterm infants’ mothers . The resAccording to the results on the score of adaptation to the maternal role by domains, the highest score relates to maternal participation in childcare, and continued confidence accounts for the lowest score. Most of the mothers whose infants are admitted to intensive care, have to share their maternal role with nurses and other caregivers, and their opportunities for infant care are limited (Adaptation to the maternal role is a phenomenon that starts during pregnancy and continues after delivery. Mothers with preterm labor, face disorders in this process. Among the various factors, the mother’s age, education, and economic satisfaction, increase adaptation to the maternal role. In so doing, providing appropriate information to mothers, social and emotional support for them, and through proper interaction between nurses and physicians with these mothers, an appropriate step can be taken to design effective interventions to increase adaptation to the maternal role in this group.Due to the complexity of adaptation in parenthood, a mixed-method, including a quantitative and qualitative study is recommended, to determine the factors affecting MRA.