This study estimated the savings in life-years and costs from early diagnosis of cervical cancer using an A total of 28,797 patients diagnosed with cervical cancer in the period 2002–2009 were identified from the National Cancer Registry of Taiwan, and linked to the National Mortality Registry until the end of 2011. Life expectancies (LE) for cancer at different stages were estimated using a semi-parametric extrapolation method. The expected years of life lost (EYLL) for cancer were calculated by subtracting the LE of the cancer cohort from that of the age-and sex-matched general population. The mean lifetime costs after diagnosis paid by the single-payer National Health Insurance during (NHI) 2002–2010 were estimated by multiplying average monthly expenditures by the survival probabilities and summing up over lifetime.ICC at stages 1 to 4 had an average EYLL of 6.33 years, 11.64 years, 12.65 years, and 18.61 years, respectively, while the related lifetime costs paid by the NHI were $7,020, $10,133, $11,120, and $10,015 US dollars, respectively; the younger the diagnosis age, the higher the savings with regard to EYLL. The mean lifetime costs of managing cervical cancer were generally lower for the earlier stages compared with stages 3 and 4.Early detection of ICC saves lives and reduces healthcare costs. These health benefits and monetary savings can be used for cost-effectiveness assessments and the promotion of regular proactive screening, especially among older women. BecauseThe study commenced after the approval of the Institutional Review Board of National Cheng Kung University Hospital . A total of 28,797 patients diagnosed with cervical cancer in 2002–2009 were identified from the National Cancer Registry of Taiwan , which cAll of the above patients were followed until the end of 2011 and linked with the National Mortality Registry to obtain the survival function via the Kaplan-Meier estimation method. They were further extrapolated to lifetime based on a semi-parametric method using the age- and sex-matched referents simulated from the life tables of the National Vital Statistics of Taiwan, which only requires an assumption of constant excess hazards ,17. The This study estimated the lifetime cost by counting the monthly average dollars reimbursed by the NHI during 2002–2010 for these patients, from the day of validated diagnosis to the end of life or censored ,20. In gex post approach instead of the conventional ex ante one. Our survival data were real follow-up data for over 10 years, and the healthcare expenditures were directly retrieved from the reimbursement data files of the NHI, plus adjustment for the 2010 CPI. The authors also calculated the standard errors of the means by the bootstrap method for 100 repeated samples in these parameters, as stratified by age groups and stages, including life expectancy and EYLL, with a 95% confidence interval for lifetime healthcare expenditures.This study used an In order to validate the extrapolation method, the authors selected sub-cohorts of patients with cervical cancer between 2002 and 2006, and then extrapolated these results to the end of 2011, and the results were compared with the Kaplan-Meier (K-M) estimates of the actual follow-ups. Assuming that the K-M estimates are the gold standard, this study calculated the relative biases for sub-cohorts with cervical cancer. The relative bias (RB) is defined as follows: RB = (estimate from extrapolation – K-M estimate)/K-M estimate.Cervical cancer at stages 1 to 4 had an average EYLL of 6.33 years, 11.64 years, 12.65 years, and 18.61 years, respectively; the differences among different stages were all statistically significant , as shown on Table This study is the first that simultaneously documents the improvements in life expectancy, EYLL, and savings in lifetime healthcare expenditures at different stages of cervical cancer, and the results show that in addition to stage 0, detection of cervical cancer at stages 1–3 can lead to more improvements in life expectancy and costs compared with a more advanced stage Table . In one Studies of cervical cancer screening tend to emphasize detection at stage 0. This study, however, provides solid evidence that detection and treatment of invasive cervical cancer at stage 1 or 2 is also very worthwhile. The calculation of EYLL in Table ex post approach could easily underestimate the actual survival of future cancer populations, because it cannot predict the future development and adoption of newer technologies for cancer diagnosis and management. Therefore, our estimation of the lifetime survival of cancer patients may be a conservative one, while the EYLL might be overestimated. Second, because life expectancy is also a function of co-morbidity, performance states, and recurrence [Although this study has used the most comprehensive national data currently available in Taiwan, it has the following limitations that need to be addressed: First, the lifetime extrapolation is based on current and prior experiences, especially the national life tables; however, it is clear that such an currence , the curcurrence . If thisPap smears are not very popular among women aged 60 and older in Taiwan, which might have resulted in higher morbidity and mortality rates for cervical cancer among this group . This stEarly detection of cervical cancer can save people and reduce costs for the NHI, and details of these benefits can be used to encourage regular proactive screening, especially among women older than 60, who currently are less likely to receive a pap smear in Taiwan. The prospective health benefits for patients with stages 1–3 of invasive cancer, compared to those with more advanced stages, should thus be clearly explained. The authors also recommend future studies consider evaluating the cost-effectiveness of different prevention programs, in which the likelihood of certain events  can be integrated with health outcomes to improve the efficiency and fairness of the related health policies.ICC: Invasive cervical cancer; LE: Life expectancy; EYLL: Expected years of life lost; NHI: National Health Insurance; FIGO: International Federation of Gynecology and Obstetrics; NCCN: National Comprehensive Cancer Network; CPI: Consumer Price Index; K-M: Kaplan-Meier; RB: Relative bias.The author(s) declare that they have no competing interests.Conceived and designed the experiments: J-DW, Y-MC, and M-CH. Performed the data analysis: M-CH and M-TL. Wrote the paper: M-CH, J-DW and Y-MC. All authors read and approved the final manuscript.J-DW is a Chair Professor of Department of Public Health, National Cheng Kung University College of Medicine in Taiwan. Professor Wang’s research focuses on the health services research. Y-MC is a visiting staff of Department of Obstetrics and Gynecology, National Cheng Kung University Hospital in Taiwan. Dr. Cheng’s clinical experience focuses on gynecologic oncology. M-CH is postdoctoral fellow of the Department of Public Health, National Cheng Kung University College of Medicine in Taiwan. Dr. Hung’s background includes gynecologic oncology and public health. Her research focuses on the health services research.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2407/14/505/prepubSensitivity analysis of life expectancy, expected years of life lost, and lifetime expenditures (USD) of cervical cancer -Description of data: The results  show that all the life expectancies were very close (<15% difference) to our original estimates, indicating that our estimates are relatively accurate.Click here for file


Training provided in medical faculties is mainly composed of two phases: preclinical and clinical. Preclinical period, or the first three years, consists of theoretical classes and practical implementations to develop vocational skills. In the clinical period, students are given applied courses.This study aimed to determine the role of demographic characteristics and medical students’ life habits on their academic achievement.For this purpose, a 20-item survey form with two sections developed by the researchers was used. Students were also asked to identify the averages of committee exams as the academic achievement indicator. Participating students (n = 287) were from Mersin University Medical Faculty during 2012-2013 session.Totally, 60.3% of the students were males with an average age of 21.16 ± 1.39, and their general grade point average was 63.39 ± 9.08. Students in their second year (P = 0.000), who were females (P = 0.000), graduated from Anatolian Teachers High Schools (P = 0.002), financially well off (P = 0.026), stayed in state hostels (P = 0.032), did not smoke (P = 0.042) and regularly did sports (P = 0.016) were significantly more successful compared to others.Students’ socioeconomic resources and habits play roles on academic achievement. Solutions that incorporate economic support which can eliminate negative situations leading to inequality of opportunity among students would increase students' achievement. Training provided in medical faculties is mainly composed of two phases: preclinical and clinical. Preclinical period, or the first three years, consists of theoretical classes and practical implementations to develop vocational skills. In the clinical period, students are given applied courses. Physician candidates are required to obtain high academic achievement levels and necessary-sufficient vocational knowledge-skills at the end of the 6-year training course to be graduated , 2. AcadInequality of opportunity problem is observed in cases where the above mentioned variables act as barriers for individuals to obtain educational services , 6. In tThe study had two purposes. The first was to identify the role of demographic characteristics and life habits of medical faculty students on their academic achievement; whereas the second aimed towards establishing and strengthening positive conditions affecting students’ achievement in line with the findings.This descriptive study was conducted on second-year and third-year students enrolled in Mersin University Medical Faculty between April and May 2013 after obtaining ethical committee and institutional approval . Students who did not meet the criteria of studying in the specified university, faculty or semester were not included in the study. Data were collected from 173 of 223 students from the second year, and 114 of 197 students from the third year students who agreed to fill in the survey forms. Target population of the current study included a group of 420 students from second and third years. All students in the university were contacted; however, students who did not agree to participate in the study were excluded since the survey included some personal questions and it was thought that students who were not voluntary would not fill in the survey or answer the questions they were not comfortable with. Therefore, the study was performed with the data collected form 287 students who filled in the survey and answered all the items.Survey form developed by the researchers was used in the study. The form included 20 items regarding the irreversible and changeable characteristics having a role on student achievement. Student residence, source of income, level of anxiety, study habits, smoking, alcohol intake, sports and artistic habits were considered as changeable characteristics. Gender, age, city of residence before starting university, place of family residence, number of siblings, family income level, parental education level and disease/disability situation were grouped as the irreversible characteristics. Students were given the required information about the study before the implementation of survey and they were allowed not to answer any of the items they did not feel comfortable with. Therefore, students who did not answer a particular question were excluded from the analysis of this item, and each item was analyzed separately. Frequency, means and standard deviation were used in data analysis. Average of committee exams given until the implementation of the form was obtained as the students’ academic achievement level indicator. KR-20 values were calculated to determine the reliability of these exams, and the values obtained between 0.75-0.95 indicated the sufficient reliability. Averages of committee exams and the statistical differences regarding students’ irreversible and changeable characteristics were investigated by using T and F tests. Kolmogorov-Smirnov test was used to check the normal distribution of data . In cases where F test provided significant results, Post-Hoc analyses were performed through LSD method and Cohen’s d and eta coefficients were calculated for F and T tests respectively to obtain the strength index for the test. P Value < 0.05 was considered statistically significant.Totally, 173 of 223 second-year students and 114 of 197 third-year students participated in the study. Their mean age was 21.16 ± 1.39, and 36.2% (104) of the participating students were females and 63.4% (182) were males, while one participant did not state his or her gender. General grade point average of the students was 63.39 ± 9.08. It was determined that second-year students were more successful compared to the third-year ones , and also female students to male students , graduates of Anatolian Teachers High School to graduates of other high schools , students with higher income to students with lower income , students who did not work to cover expenses to students who worked to meet expenses , students with no disease or disability to students with a particular disease or disability , students who stayed at state hostels or at home with friends to students who stayed alone , students who studied in the study room at their hostels to students who studied at the library or at home , students who did not smoke to students who smoked , and students who regularly did sports to others . It was identified that the number of siblings , the province where the family resides , the place of residence , parental education , anxiety before-during exams  and changes in nutritional habits during exam times  did not play a role on academic achievement  and 2.The students take approximately 6900-hour classes during the 6-year training in Mersin University Medical Faculty including 1822-hour theoretical classes and 376-hour practical classes during the first three years. The second-year and third-year students in the working group have 541-hour theoretical and 169-hour practical classes and 668-hour theoretical and 61- hour practical classes respectively. Theoretical classes are more concentrated during the first three years and a total of eight theoretical classes such as history of medicine, anatomy, biochemistry, physiology, histology, biophysics, microbiology and behavioral sciences are included in the first and second years' curriculum. Practical classes are also added to the curriculum to develop vocational skills . Third year classes are different from those of the first two years. A total of 20 different theoretical classes including ethics, pharmacology, nuclear medicine, pathology, radiology, biochemistry and microbiology along with others geared towards surgical and internal sciences are included in the third year curriculum. In addition to these classes, practical classes are more concentrated than those of the first and second years classes provided in the curriculum to develop vocational skills . As can be seen from the above explanation, training provided in Medical Faculties is both extended and concentrated compared to the training provided in other faculties. Students need to study more with denser devotion to be more successful (The current study investigated the variables playing role on the academic achievement of medical faculty students, and it was identified that these variables played roles of varying degrees on the achievement of second and third years' students. Especially the association between socioeconomic situation and life habits and achievement was found to be consistent with the results obtained in the literature , 9. We f


Purpose. This study aims to identify triggers of stillbirth in the study setting and to make suggestions to reduce the prevalence. Method. A three-year retrospective case-control study of stillbirths at Ekiti State University Teaching Hospital. Results. The stillbirth rate was 33 per 1000 births. Based on Baird-Pattinson classification of the primary obstetric causes of stillbirth, adverse intrapartum events, hypertensive diseases, and unexplained intrapartum fetal deaths were topmost causes of stillbirths. In comparison with the controls, other identified predictors of SB were grand multiparity (p = 0.016), delays in seeking medical care and/or in receiving treatment (p = 0.001), wrong initial diagnosis (p = 0.001), inadequate intrapartum monitoring (p = 0.001), and inappropriate clinical management (p = 0.001). Conclusion. Stillbirth rate remains high in our setting. Elimination of obstacles to accessing care, effective management of hypertensive disorders in pregnancy, updated health facilities, improved dedication to duty, and retraining of health workers will reduce the prevalence. Sub-Saharan Africa has a high burden of stillbirths (SB), most of which are late preterm, term, and intrapartum deaths , 2. No dPeriodic enquiry into causes of SB and successful implementation of intervention strategies have allowed the developed nations to make giant strides in curbing needless fetal deaths but this has not been the case in Africa . KnowledWhat is the current situation now? Is there any departure from what it has been before? What factors presently contribute to SB in our setting and how well can we modify them? Where knowledge of the actual burden and causes of SB is deficient, expectations of preventability will be low and this will negatively impact the level of priority accorded to SB reduction . TherefoThus, the focus of this study is to identify the triggers for SB in a Nigerian population with the aim of making recommendations to reduce them.The setting for this study was the maternity unit of the Ekiti State University Teaching Hospital (EKSUTH), located in the semiurban capital city of Ekiti State, south-western Nigeria. EKSUTH was created on April 1, 2008, from the erstwhile State Specialist Hospital, Ado-Ekiti, and it is the apex health facility in the state serving a population of about 2,398,957 [A 3-year review of obstetric records was done from January 2012 to December 2014 and file numbers of patients with SB were identified. The files were subsequently retrieved from the hospital's health information management department. SB was defined as the birth of a baby with a birth-weight of 1000 g or more, 28 weeks' gestation or more, or a body length of 35 cm or more, who died before or during labour . Those wUsing a proforma, data were obtained from the SB case files about the maternal age, parity, probable cause of SB based on Baird-Pattinson's classification system , documenFor the purpose of this study, we defined delay in seeking help as not asking for medical assistance >24 hours after first symptom of pregnancy/labour complications. Delay in transfer from referring hospital was defined as not leaving the referring hospital/mission house for the tertiary hospital >1 hour after referral while delay in receiving treatment was defined as not receiving any medical attention at the tertiary hospital >30 mins after presentation.t-test or χ2 test as appropriate. The level of significance was set at p < 0.05.The extracted data were analysed using the Statistical Software for the Social Sciences (SPSS) package version 17. Frequency tables were generated and statistical comparison of the cases and controls was done using Student's Approval for the study was given by the Ethics and Research Committee of Ekiti State University Teaching Hospital.In the 3-year period, there were 5408 deliveries and 178 SB, giving a crude SB rate of 33 per 1,000 births. Out of the 178 SB cases, 138 (77.5%) were “unplanned transfers” from lower levels of healthcare and mission houses after onset of pregnancy and/or labour complications. However, from the 4467 patients that obtained antenatal care at the study centre, 40 had SB giving a corrected SB rate of 9 per 1,000.p = 0.031), grand-multiparous women have increased likelihood of SB .Based on Baird-Pattinson classification of causes of fetal deaths , intrapap = 0.001) in contributing to SB.As shown in Following presentation at the tertiary hospital, 26 (14.6%) women in the SB group did not receive any medical assistance for more than 30 minutes after arrival. Although further enquiry showed that 18 out of the 26 already had fetal demise on arrival, 8 patients with delayed intervention had a live baby at presentation.p = 0.001), wrong diagnosis , inadequate intrapartum monitoring , and inappropriate clinical management , significantly contributed to SB in the study group.Ten (5.6%) patients had an initial wrong diagnosis, clinical management was inappropriate for 18 (10.1%) patients, and in another 20 (11.2%) intrapartum monitoring was poor. When compared with the control group, these factors, delay in receiving treatment  . The figAlthough various researches have shown increased risks of SB at extremes of parity –15, thisOur analysis indicated that intrapartum-related factors were the commonest cause that led to fetal deaths in the population studied. Ezugwu et al.  and LawnAs found in the index study, the World Health Organization (WHO) identified hypertensive disorder as a leading cause of fetal deaths in developing countries . Though More than a tenth of SB was unexplained because specific cause could not be found. Although this appears to be due to absent or inadequate investigations, unknown causes of SB might lead to superstition and speculation. Globally, one in three SB is attributed to the mother's sins and faults, bad luck, or the work of evil spirits . Better The contribution of delay in seeking care to SB reached significant level in this study. More women with SB failed to ask for medical help early. This possibly found root in poverty, low level of literacy, and failure to recognize warning signs of imminent danger –25. TherThough sad, the fact remains that despite scaling many hurdles to access quality healthcare, some of the women still experienced delay in receiving medical intervention on arrival at the tertiary centre. Factors contributing to delays in the timely provision of needed care have been frequently mentioned in the literature . These iShortage of trained personnel and dilapidated health facilities coupled with lack of commitment on the part of health workers make poor clinical management and defective intrapartum monitoring significant triggers for SB. Other studies have reported associations between cases of clinical mismanagement and adverse pregnancy outcomes –28. HoweThe use of a standard classification system for the causes of SB and a detailed review of the case records to identify prevailing events that contributed to the fetal deaths lend credence to this research. Although the extent of information retrieval is limited in a retrospective study, its adoption in our review is appropriate.In conclusion, the SB rate in our environment remains high. Grand multiparity, hypertensive disease, intrapartum-related events, and delays in seeking and/or accessing care were major contributing factors. It is essential to reinforce the gains of antenatal care irrespective of a woman's parity and/or previous pregnancy experience. Implementing routine calcium supplementation in our setting may assist in reducing fetal mortality associated with hypertensive disorders in pregnancy. Furthermore, updated health facilities, locality-specific birth preparedness scheme, improved dedication of health workers to duty, and regular retraining of maternity care providers will go a long way to reduce SB in our society.


Although adult asthma is attributable to occupational factors, few reports are available on asthma prevalence among health care workers in Japan. The objective of this study was to estimate the prevalence of asthma and wheeze among Japanese nursing professionals. A cross-sectional study was conducted by postal survey using a translated version of the European Community Respiratory Health Survey questionnaire from April to June 2013. The analysis included 4634 nursing professionals (257 men and 4377 women) and the overall response rate was 84.8%. The prevalence of current asthma and wheeze were 10.7% , 9.9%–11.7%) and 15.6% , respectively. More than one year of work experience as a nursing professional and more than one year of experience with bed-making tasks were associated with odds ratios (ORs) of 1.95  and 1.64  for wheeze, respectively. Current smoking was significantly associated with the presence of wheeze, with ORs of 2.27 for men  and 2.01 for women . Among female nurses, latex allergy was associated with wheeze , as was body mass index ≥30 . This study has provided the prevalence of asthma and wheeze among Japanese nursing professionals. Employment period, bed-making tasks, latex allergy, obesity, and smoking may be risk factors for prevalent wheeze among nursing professionals. Occupational exposures account for a substantial proportion of adverse respiratory health effects. Asthma has increased worldwide  and it hPrevious studies of occupational exposures among various groups of workers have suggested that asthma prevalence may be notably high among nursing professionals ,6. The lA recent nationwide cross-sectional study provided estimates of asthma prevalence and asthma symptom prevalence among Japanese adults . However2 and 103.9/km2, respectively. We asked the Nursing Association for assistance and received approval to submit the survey to the hospitals, clinics, and health care centers in Tottori and Shimane. Forty-five hospitals, 10 clinics, and 28 health care centers approved the survey. The nursing staffs at these hospitals, clinics, and health care homes were asked to participate in the study. If they provided written consent, a postal survey was performed. This study was conducted from October to December 2013. The study was approved by the institutional ethics committee of Tottori University .The primary outcome variable was the prevalence of asthma and wheeze among nursing professionals. Using the European Community Respiratory Health Survey (ECRHS) questionnaire, a cross-sectional study was conducted in the neighboring Tottori and Shimane Prefectures, which are located in Southwest Japan. The population densities of Tottori and Shimane were 163.4/kmhttp://www.ecrhs.org [To evaluate asthma symptoms, we asked the same questions that had been included in the ECRHS. The Japanese version of the questionnaire was prepared based on the one-page ECRHS questionnaire, as well as page one of the two-page questionnaire that had been prepared for a stage one repeat study ,12. The crhs.org . The queA history of asthma as confirmed by a doctor was defined as an affirmative response to the question, “Have you ever had asthma?” (Q5), followed by an affirmative response to the question, “Was this confirmed by a doctor?” (Q5.1). Current asthma was defined as affirmative responses to each of the following questions: “Have you ever had asthma?” (Q5), followed by, “Was this confirmed by a doctor?” (Q5.1), and “Have you had at least one asthma-related symptom in the last 12 months?” . If a reResults are shown as means ± standard deviations (SDs). SPSS Statistical Software  was used for all statistical analyses. The prevalence of current asthma and the associated 95% CI were estimated for all participants aged 20–69 years. The Clopper–Pearson method was used to obtain the exact CI . Fisher’A total number of 5463 nursing professionals provided written content and 4761 nursing professionals answered the questionnaire before the deadline for submission. Fifty-five out of 4761 subjects were excluded because of inadequate responses to Q1 of the questionnaire. Therefore, a total of 4634 subjects were included in the analysis, amounting to an overall response rate of 84.8%. Data on gender and age were not missing for any of these 4634 subjects. OA has become one of the most common forms of occupational lung disease in many industrialized countries ,18. A hiet al. used the ECRHS questionnaire to conduct a population-based cross-sectional study of the prevalence of asthma and wheeze in Japanese adults [Relatively few studies have used standardized questionnaires to investigate the prevalence of asthma and asthma symptoms in Asian countries. Recently, Fukutomi e adults . They foe adults ,7,8,9,10More than 300 natural and synthetic chemicals have been reported to cause OA (with latency) . The curMattresses can be a source of a range of chemicals, including volatile organic compounds, plasticizers, flame retardants, and unreacted isocyanates ,20. In aAlthough stress is a related factor in many explanations of the origins of asthma, the role of stress in the development and exacerbation of asthma remains poorly understood. Several studies have reported that stress has negative effects on the immune system, which may trigger asthma ,27. Sleeet al. reported that a changeover from powdered to non-powdered latex gloves can reduce latex-related symptoms. It may also be possible to reduce development of OA by using non-latex gloves [Various risk factors for OA have been established . Atopy ix gloves .et al. reported that 12% of work-related asthma cases were related to the use of cleaning products [et al. have also shown that, in comparison with other healthcare professionals, nursing professionals have an increased risk of developing new-onset asthma due to the chemicals and compounds that are used during patient care activities, medical instrument cleaning/disinfection, and general cleaning [Cleaning products and disinfectants are commonly used in both occupational and non-occupational settings. In medical settings, the many chemical products that are involved include topical cleansers and antiseptics that are applied to the patient’s skin, glutaraldehyde for cold sterilization of medical instruments, and all-purpose general cleaners, such as bleach . Rosenmaproducts . Arif etcleaning . Additiocleaning . In the cleaning .The present study evaluated the risks of wheeze that were associated with body mass index, smoking history, presence of latex allergy, total duration of employment as a nursing professional, total duration of shift work, and duration of employment involving bed-making tasks in a medical setting. The risks of wheeze differed significantly between men and women. It is possible that these differences resulted from the different numbers of men and women who were included in the study. On the other hand, a review of more than 60,000 subjects with asthma in a large healthcare organization showed that utilization of inhaled corticosteroids, routine hospital visits, emergency visits, and hospitalization appeared to be more common in women aged 23–64 years than in men . AdditioThe ECRHS questionnaire does not include a clear definition of current asthma. Previous studies using the ECRHS questionnaire employed various definitions of current asthma. Therefore, in this study, we estimated the associations between the prevalence of wheeze and body mass index, smoking history, presence of latex allergy, total duration of employment as a nursing professional, total duration of shift work, and duration of employment involving bed-making tasks in a medical setting. Our study was limited by its reliance on a questionnaire of symptoms to diagnose asthma and asthma-related symptoms. This approach may lead to an overestimation of asthma prevalence. Similarly, the diagnosis of latex allergy depended on self-reporting by respondents. Further investigation is needed, including skin-prick tests. One further limitation to this study is that we were unable to survey the number of employees in each hospital or clinic. Therefore, we were unable to investigate the effects on the prevalence of current levels of asthma and wheeze that resulted from differences in employment between hospitals, clinics, and health care centers.In conclusion, this cross-sectional study used a Japanese version of the ECRHS questionnaire to determine that the prevalence of current asthma and wheeze among Japanese nursing professionals, which were 10.7% and 15.6%, respectively. As compared with Japanese adults, Japanese nursing professionals have more than 1.5 times the risk of prevalent asthma. Further, durations of employment as a nursing professional, shift work, and employment involving bed-making tasks were each associated with the presence of wheeze.


Sex and eating may have behavioral and psychological relationships and have cortical regions in common. This research investigated the general relationship between sex and eating from a reward perspective among the general population. Two-hundred and sixty-one Chinese participants were recruited via the internet  to fill in questionnaires about wanting and liking for sex and eating. The results revealed that first, there was a positive correlation between wanting for sex and wanting to eat only for males. Second, the relationship between liking for sex and eating was also positive for males and not significant in females. Third, the correlation between sociosexual orientation and wanting to eat was significant only in females, and there was no significant correlation between sociosexual orientation and liking for eating. Fourth, emotional sex cravings  was positively correlated with emotional food cravings , with a higher magnitude correlation in males than females. Finally, analysis of wanting (liking) models of sex and eating for males and females revealed three models for wanting among females: high wanting, low wanting for eating, and low wanting for sex; and two models for wanting among males: high wanting and low wanting. Liking for sex and eating among females consisted of two types of model: high liking and low liking; whereas three type models existed for males: high liking for sex, high liking for eating, and low liking. In general, our research revealed that, as with other natural reward, sex and eating have considerable commonality and are related in numerous ways. In Chinese culture, the concepts of food and sex are traditionally linked, and many expressions describe food and sex in terms of each other, such as “a beauty to feast one’s eyes on” and “when the belly is full, the mind is among the maids.” There is also the saying that people who like eating have a high sex drive; or, conversely, people who have little desire to eat have little desire for sex. Sex and eating are natural, instinctive needs: the former encourages reproduction, ensuring continuation of the species, whereas the latter is required for individual survival.Existing research has illuminated the relationship between eating and sex. For example, Both life experiences and scientific research have indicated a link between sex and eating. However, little research has directly explored this relationship. Although the correlation between sex and eating can be inferred from studies focusing on eating disorders and sexuality, whether there exists any general relationship between sex and eating in a community sample remains unclear. Therefore, in this study we explored this possibility.According to incentive salience theory, reward consists of two components, i.e., wanting and liking. Wanting is the motivation to approach stimuli, whereas liking refers to the pleasure derived from stimuli . The twoWe first asked whether there is a correlation between wanting for sex and wanting for eating, between liking for sex and liking for eating, and whether there exist gender differences in these relationships. We also analyzed the relationships between sociosexual orientation and wanting/liking for eating. Second, as mentioned above, much prior research has found a correlation between eating disorders and non-traditional sex roles, and non-heterosexual orientation. Therefore, we investigated the relationship between sex and eating during a negative emotional state. Sex and eating both can be influenced by negative mood or stress , but theOnly volunteer participants who were 18 years or older were recruited and completed an internet questionnaire via the professional survey website, Wenjuan xing. Respondents were told that the questionnaire was about sex and eating, that it was entirely anonymous, and that they would receive feedback regarding their survey results. This study was approved by the Ethics Committee of Southwest University of China. All participants gave online informed consent before filling in the questionnaire.SD = 6.788) and ranged from 18 to 59 years old. Two-hundred and twenty-eight (87.4%) respondents were employed, 29 (11.1%) were students, and four (1.5%) were unemployed. Seven (2.7%) participants reported a junior high school education or less, 19 (7.3%) a senior high school education, 196 (75.1%) a college education, and 39 (14.9%) postgraduate education or higher. Twenty-two (8.4%) had never been in a relationship, 25 (9.6%) were currently single, 50 (19.2%) were unmarried but in a relationship, and 164 (62.8%) were married. Two-hundred and fifty-four (97.3%) participants reported they were heterosexual, six (2.3%) bisexual, and one (0.4%) respondent reported “other”; no one reported that they were homosexual. Regarding ethnicity, 256 (98.1%) were Han and 5 (1.9%) an ethnic minority. No religion was reported by 217 (83.1%) individuals, 33 (12.6%) reported Buddhism, eight (3.1%) Christianity, one (0.4%) Islam, and two (0.8%) reported other religions.The sample comprised two-hundred and sixty-one Chinese people  from 88 provinces/regions of China. The mean age was 30.46 years  using the SOI-R , to analTwo scales were used to measure general wanting to eat. First, the RED scale was used to measure basic, non-pathological eating drive . This scIn addition, we used the 21-item FCQ-T to measure general, but not specific, food cravings . ParticiBoth liking for sex and eating were measured via one item each: participants rated to what extent they agreed with the statement “how much pleasantness can you can feel from eating/sex” using a 7-point Likert scale .One dimension of the FCQ-T  is emotiThe emotional eating scale of the Three-Factor Eating Questionnaire-R18  was usedThe above two scales were modified to measure emotional sex cravings and emotional sexual activity. The food items were replaced with sex-related items, while response and scoring methods remained the same. The total scores of the two questionnaires were used as an emotional sex craving measure and emotional sexual activity measure, respectively. The internal consistency for emotional food cravings was 0.935 , 0.844 for emotional eating behavior , 0.916 for emotional sex cravings , and 0.863 for emotional sexual activity .p-value for significance was adjusted to 0.00833 . Additionally, correlation coefficients were compared between sexes. All correlation coefficients were transformed into Fisher’s Z-values before comparison using SPSS syntax. Second, to explore models of wanting (liking) for sex and eating, LPA was used. LPA allows exploration of latent constructs underlying psychology and behavior, with advantages over other, traditional, techniques such as cluster analysis  and liking for eating . We investigated the plausibility of 2-, 3-, 4-, and 5-class solutions and determined the optimal model fit. Subsequently, MANOVA was used to explore the differences in demographic characteristics among different wanting (liking) groups.Initially, data were analyzed using SPSS version 16.0. We checked the data for normality and for outliers before analysis. We examined six correlations between sex and eating. After Bonferroni correction to control the risk of type I error, the threshold analysis . In thisr = 0.151, p = 0.014), and were correlated for males but not females . Total scores of the sex drive scale and FCQ-T were also not significantly correlated overall , with a significant correlation for males  but not females .We tested the correlations between the total scores of the sex drive scale and RED scale and between the total scores of the sex drive scale and FCQ-T to explore the relationship between wanting sex and wanting to eat. There were significant positive correlations only for males. Total scores of the sex drive scale and the RED scale were not significantly correlated overall , and this correlation was significant only in males .Scores for liking for sex were significant positively related to scores for liking eating overall (p = 0.006), while total scores of SOI-R were not significantly correlated with total scores of FCQ-T . Correlations between total scores of SOI-R and RED scale or FCQ-T were significant only in females .The correlation between sociosexual orientation and wanting to eat varied according to the different scales. There was a significant positive correlation between total scores of SOI-R and RED scale .There were no significant correlations between total scores of SOI-R and liking eating , and the two sexes exhibited significant correlations . This correlation was stronger for males than for females (p = 0.03). There was also an overall significant positive correlation between emotional sexual activity and emotional eating behavior , with significant correlations for both males and females . The correlation coefficient for males was greater than for females and this difference approached significance .Overall, there was a significant positive correlation between emotional sex craving scores and emotional food craving scores (p > 0.05), which indicates that the 4-class solution was not better than the 3-class solution. The 3-class solution was better than the 2-class solution according to the LMRT value . Although the 3-class solution had smaller entropy than the 2-class solution, both AIC and aBIC were smaller than the 2-class solution. Taken together, these results suggest that the 3-class solution was optimal (Table 2).For females, the LMRT was not significant for the first time for the 4-class solution  consisted predominantly of individuals who had the highest level of wanting for both sex and eating. Therefore, this group was named the high wanting group. Class 3 (25.6%) primarily included low levels of wanting to eat and moderate levels of sexual desire. This group was named the low wanting for eating group (Table 3).Class 1 (45.6%) was typified by individuals with the lowest level of wanting sex and moderate levels of want to eat. This subgroup we named the p > 0.05), indicating that the 3-class solution was no better than the 2-class solution. Additionally, entropy began to decrease for the 3-class solution. Taken together, these results led us to consider the 2-class solution the best model fit (Table 4).For males, the LMRT was not significant for the 3-class solution  consisted predominantly of individuals with higher levels of wanting for both sex and eating, leading us to assign name this class the high wanting group (Table 3).Class 1 (52.9%) was typified by individuals having lower level of wanting for sex and eating. This subgroup was named the ps > 0.05). For males, there was a significant difference in age between the two groups : the low wanting group  was younger than the high wanting group . Additionally, the low wanting group  was shorter than the high wanting group , a difference which approached significance .In addition, MANOVA was conducted to test whether there were differences in demographic characteristics among these groups. We tested the effect of class on age, height, weight, and BMI. For females, there were no significant differences in demographic characteristics among the three groups .For females, non-significant LMRT occurred for the first time for the 3-class solution, indicating that the 3-class solution was no better than the 2-class solution. Further, the 2-class solution had the greatest entropy. As such, the 2-class solution was considered optimal (high liking group (88%) and the latter the low liking group .Class 1 had a greater level of liking for sex and eating than class 2, so the former was named the p > 0.05), signifying that this model was no better than the 3-class solution. LMRT was significant for the 3-class solution , denoting that the 3-class solution was better than the 2-class solution. In addition, the 3-class model had the smallest AIC, relatively small aBIC, and the largest entropy. Overall, these results indicated the 3-class solution was the best model (Table 6).For males, LMRT was not significant for the 4-class solution  consisted predominantly of individuals who had the highest level of liking for sex and the lowest level of liking for eating. Therefore, this group was named the high liking for sex group. Class 3 (72.8%) primarily included the highest level of liking for eating and moderate levels of liking for sex. As such, this named the high liking for eating group (Table 7).Class 1 (16.9%) had a low level of liking for sex and eating and this group was named the ps > 0.05). For males, there was a significant difference in height among these three groups . The low liking group  was shorter than the high liking for sex group .A MANOVA was again conducted to test whether there were demographic characteristic differences among these groups. For females, there were no significant differences in these demographic characteristics  there were significant positive correlations between wanting (and liking) for sex and eating only in males; (2) sociosexual orientation was positively correlated with females’ wanting to eat; (3) emotional sex cravings  were significantly related to emotional food cravings (or eating behavior), and the relationship was stronger in males than in females; (4) each sex had a different wanting (liking) model.That significant correlations between wanting (and liking) for sex and eating were present only in males indicates that sex and eating might be more consistently comparable in males than in females. That is, it is possible that sex and eating play a more equal role in males than in females. Sex and eating are related to reproduction and personal survival; can we thus conclude that these two primary needs are more equivalently important to males than females? Currently, we cannot answer this question; future research is needed. However, of relevance is the work of There was a significant positive correlation between sociosexual orientation and wanting to eat only in females. This indicates that more sexually unrestricted female individuals may have a stronger desire to eat. Existing studies have found that females with bulimia nervosa tend to exhibit promiscuous sexual behaviors, have more sexual activity, and engage in more sexual intercourse than controls . AlthougEating disorders are frequently accompanied by abnormal sexuality, non-traditional sex roles, and non-heterosexual orientation. Accordingly, we explored the relationship between eating and sex under emotional stress. We found a positive correlation between general emotional sex cravings  and general emotional food cravings (or eating behavior). To manage negative mood or release stress, sex and eating may play the same role for some individuals. In addition, the correlation with emotional cravings was of higher magnitude in males than in females, while the correlation with emotional behavior in males was higher than in females, albeit falling just outside significance. This indicates that males’ emotional cravings for sex and food, but not emotional behaviors, were more comparable and consistent than in females. However, because we did not assess individuals’ actual behaviors, this almost significant result remains to be tested further via additional experiments that directly measure behavior. As mentioned above, males with anorexia and bulimia are more likely than their female counterparts to report sexual isolation, sexual inactivity, and conflicted homosexuality . In our The wanting model in females had three types: high wanting, low wanting for eating, and low wanting for sex. The wanting model in males had two types: high wanting and low wanting. For males, the statement “people who like eating may have a high sex drive” may be reasonable, and males who have a limited desire to eat may also have little desire for sex. However, this is not the case for females. Females with moderate levels of wanting to eat may have the lowest levels of sexual desire. There were two liking models in females: high liking and low liking; whereas there were three liking models in males: high liking for sex, high liking for eating, and low liking. A woman who receives little pleasure from eating may also receive little pleasure from sex. In contrast, a man who receives little pleasure from eating may receive little pleasure from sex, or considerable pleasure from sex. The pleasure received from sex will not be low for individuals who receive great pleasure from eating: females receive considerable sexual pleasure, and males, moderate pleasure. Both sex and eating are important in life; eating is more vital than sex for individuals  while sex is more necessary than eating for the species (reproduction and continuation of the species). Although both sex and eating are important, our results indicate that one model cannot describe all individuals. For example, some people have high level of desire to eat but low desire for sex, some have a high level of desire for sex and eating, while others may want sex and food relatively little. Is the individual survival motivation more important than the reproduction motivation for some people, while the opposite is true for others? Is this difference displayed in individuals’ mating motives or behaviors related to individual survival? We found that the high wanting group was older and taller than the low wanting group in males, and the high liking for sex group was taller than the low liking group in males. It seems that females prefer old and tall males rather than young and short males . TherefoThe primary shortcoming of our research was that all correlation coefficients were relatively modest. The measures used might underlie this result: questionnaires and online surveys have limitations that could be addressed via future laboratory-based research. However, given that our objective was to provide a novel, preliminary analysis of the general relationship between sex and eating, that we found any relationships is consequential. Second, The correlation between sex and eating has received some recent attention, including a realization of the many similarities between sex and eating. For instance, sex and eating are both consummatory behaviors that have rhythmicity; for both, novelty is motivating; and, learning and prediction are important in both behaviors . Given tYK carried out the experimental work and the data collection, interpretation and drafted the manuscript. LZ and YZ participated in the design and coordination of experimental work and interpretation, and revised the manuscript. All authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The resilience subscales of perception of self, perception of future, social competence, and social resources, but not family cohesion, significantly predicted total MT (R2 = 0.35). Both total resilience and total MT significantly predicted total stress (R2 = 0.21). Based on the findings, interrelations between MT and resilience are explored, implications outlined, and additional research is suggested to ascertain the contextual relevance and outcomes associated with each construct in sport.The present study investigated the relationships between mental toughness (MT), resilience, and stress among competitive South African tennis players. A total of 351 tennis players participating at various competitive standards completed the Sports Mental Toughness Questionnaire, the Resilience Scale for Adults, and a modified version of the Recovery-Stress Questionnaire for Athletes. The results indicated that total MT was positively associated with total resilience ( With success often bestowed solely upon winners or champions, the pursuit of sporting achievement has generated interest in determining the underlying characteristics of successful athletes  as well as playing surfaces . Contrasting other sports , tennis players are restricted from communicating, interacting, or seeking guidance from their coaching or support personnel during competition . Also, tCollectively, the aforementioned issues have contributed to critical debates on the conceptual make-up and measurement of MT e.g., . Notwithconfidence (as a component of MT) is the distinguishing attribute between the two. Along similar lines, Conceptual disparities also appear to relate to the similarities between MT and other related constructs that may have been appropriated into the underpinning of MT. For instance, Resilience is another construct that is noticeably similar to MT. Like MT, the definition of resilience remains a contentious area . ConceptThe notion of effectively overcoming and dealing with pressure, challenges, and stressors has been explicated in several descriptions of MT e.g., , which iemotional resilience as an aspect of MT and recent qualitative investigations have asserted resilience as a subcomponent of MT in sport  and social resources required following a disappointing loss in order to rebound quickly.During exposure to internal and external demands to which consequences are ascribed, the concept of stress refers to disequilibrium between such demands  and the ability to successfully meet them . AcknowlAlthough few quantitative studies involving resilience and stress in sport have been conducted, MT has received some attention in relation to stress. Mentally tougher individuals tend to report stressors as being less intense, perceive greater control over the stressors they are confronted with , and repThe purpose of the present study, therefore, was to explore the relationships between MT and resilience, MT and stress, and the role of resilience and MT in relation to stress. In particular, the following hypotheses were tested: (a) MT would be positively related to resilience, (b) MT would be predicted by the resilience resource domains , (c) MT would be negatively related to stress, and (d) MT and resilience would both be predictors of stress.M age = 28.91 years, SD = 13.87). The participants had played tennis for a minimum of 5 years  and had competed in a competitive tennis event within the last 2 weeks prior to participation in the study. The participants were purposively recruited through local and national South African tennis organizations, universities, and tournaments. The participants competed at international (N = 33), national (N = 78), university team/league (N = 156), local county (N = 23), and county club (N = 61) tournament levels.The sample included 185 male and 166 female competitive South African tennis players ranging from 18 to 84 years of age (r = 0.72), constancy (r = 0.71), and control (r = 0.66) were considered acceptable. Correlations between confidence and control, confidence and constancy, and constancy and control were 0.28, 0.31, and 0.31, respectively  and 6  and address the degree to which the participants experienced the item in the past 3 days/nights. The items comprise 10 dimensions of stress (four items for each factor), which permits the assessment of the stress experienced by athletes in a broad range of aspects inside and outside of sport.A modified version of the Recovery-Stress Questionnaire for Athletes RESTQ;  was usedSeven of the scales measure a general stress domain, comprising the subscales of general stress , emotional stress , social stress , conflicts/pressure , fatigue , lack of energy , and somatic complaints . Three subscales measure sport stress, which are labeled disturbed breaks , burnout/exhaustion , and fitness/injury .The inventory has been validated using PCA , a findicompetitive tennis. The inventories required approximately 20 min to complete.Following the attainment of relevant gatekeeper permission and Ethical Clearance from the University of KwaZulu-Natal’s Human and Social Sciences Research Ethics Committee, various tournament, university, and tennis organization directors were approached to obtain permission to access the participants. Based on athletes’ availability, the self-completed questionnaires were administered in groups of 5–10 players. The purpose of the study was explained to the participants, informed consent was outlined, and each participant completed an informed consent document prior to his or her participation. For each instrument, the athletes were prompted to consider and respond to the items according to the extent to which each item applied to them in relation to their involvement in Table 1. Multiple linear regression analyses, using the stepwise forward selection method , are presented in Table 2. An alpha level of 0.05 was used for all statistical tests. For each variable, greater scores are associated with higher levels of the characteristic.The Statistical Package for Social Sciences (SPSS 23) was used to conduct all statistical tests. Prior to proceeding with statistical analyses, the hypothesis testing assumptions, including normality and homoscedasticity, were performed. The descriptive statistics and Pearson correlations (one-tailed) that were used to examine the relationships between the MT, resilience, and stress scales are reported in r = 0.59) and the subscales of resilience (r = 0.35–0.53), which, according to r = -0.44), general stress (r = -0.46), and sport stress (r = -0.32), which were medium and medium-to-large in effect size , social resources , perception of future , and social competence  were statistically significant predictors of MT . The family cohesion (p = 0.218) subscale was not a statistically significant predictor of total MT.Multiple linear regression was used to determine the extent to which the five subcomponents of resilience  predicted total MT. Perception of self  and total resilience  were both significant predictors of total stress .Multiple linear regression was computed with total stress as the dependent variable and total MT and total resilience as the predictors. The results indicated that total MT  MT and resilience would be positively related, (c) MT would be negatively associated with stress, and (d) both MT and resilience would significantly predict stress were all supported. The hypothesis that (b) MT would be significantly predicted by each of the resilience subdomains was partially supported, with one subscale (family cohesion) not found to be a significant predictor of MT.The strong positive association between MT and resilience may demonstrate the conceptual parallels between the two constructs. That is, both resilience and MT are associated with effective adaptation, coping, maintaining functioning or performance, and achieving despite experiencing adversity, pressure, setbacks, or stress . In factThe finding that resilience resources did not account for approximately 65% of the variability in MT may support the contention of resilience as a component of MT . That isThere may also be theoretical and conceptual distinctions between MT and resilience. For instance, Mental toughness, on the other hand, may apply more specifically to stressors and the resultant stress that athletes experience during sport training, competition, and post-competition. Thus, although resilience may have a role in relation to overcoming stress, MT might be more important for negating or avoiding the detrimental effects of stress among athletes in sporting contexts, whereas resilience may be relevant primarily when experiencing more severe adversities that are likely to occur outside of sport participation.The finding that MT is related to lower levels of stress corresponds with the assertion that MT is associated with positively adapting to stress e.g., . The resThe findings in this study offer some key prospective directions for MT research. Specifically, a number of external resilience protective factors  were associated with greater MT, suggesting that a strong social support system, social interconnectedness, and interpersonal skills may be beneficial to MT. Similar types of external factors have been identified as important to the development of MT, including various interpersonal relationships . FosteriBased on the negative relationship between MT and stress found in this study, identifying sources of stress as well as an athlete’s psychophysiological reactions to such may enable the alteration of debilitative perceptions and responses. Initial evidence suggests that mentally tough athletes’ more opportunistic or facilitative appraisal of stressors assists them to experience lower stress responses . AccordiAnother method through which negative stress responses may be avoided is through mentally tough athletes’ apparent attentional control abilities . With thFuture research is also necessary to determine mentally tough outcomes or indicators  as a function of sport type and situations that require MT in sport. Research differentiating MT and resilience is also warranted, including distinctions along the lines of the relevance, application, and outcomes associated with each construct in varied sport and non-sport contexts.There are selected limitations associated with the present study. Specifically, the cross-sectional design restricts conclusions of causality between the variables. Attempts to differentiate MT and resilience may require delineating the divergent circumstances in which the constructs may be relevant. Accompanying this is the necessity to generate consensus on the conceptualization of each construct as well as key definitions of the antecedents and consequences linked to both constructs . The sport specific focus of this study , as well as the inclusion of competitive tennis participants from South Africa, limits the ability to generalize the findings to other population groups. However, with sport-specific MT studies recommended e.g.,  and indiIn addition, although the RSA and SMTQ have been validated previously, the internal consistency of one subscale from each instrument was particularly low (<0.60), which limited the application of these subscales in this study. With prior studies raising internal consistency concerns over selected SMTQ subscales c.f.  and receThe current study offers preliminary quantitative support for the interrelatedness between resilience and MT and extends the negative association between MT and stress to competitive tennis players, an athletic domain in which MT has been underexplored. The findings also offer initial evidence to suggest the distinct roles of resilience and MT in avoiding or alleviating stress, at least in competitive tennis. Additional research in this area is needed, especially along the lines of discerning MT from resilience and determining the contextual relevance of each construct in sport.All authors listed, have made substantial, direct and intellectual contribution to the work, and approved it for publication.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.


The goal of the present study was to take a new look at the relationship between creativity and cognitive functioning. Based on models that have postulated domain- and sub-domain-structures for different forms of creativity, like scientific, technical or artistic creativity with cognitive functions as important basis, we developed a new questionnaire. The Artistic Creativity Domains Compendium (ACDC) assesses interest, ability and performance in a distinct way for different domains of artistic creativity. We present the data of 270 adults tested with the ACDC, standard tests of divergent and convergent thinking, and tests of cognitive functions. We present fine-grained analyses on the internal and external validity of the ACDC and on the relationships between creativity, working memory, attention, and intelligence. Our results indicate domain-specific associations between creativity and attention as well as working memory. We conclude that the ACDC is a valid instrument to assess artistic creativity and that a fine-grained analysis reveals distinct patterns of relationships between separate domains of creativity and cognition. Artistic Creativity Domains Compendium (ACDC), a new self-report-measure for artistic creativity. It separately assesses the four domains visual arts, literature, music and performing arts and 18 according sub-domains such as painting, ballet-dancing or acting on three levels of involvement, that is, interest, ability, and performance. We present data of a norm-sample of 270 adults and relate artistic creativity to measures of divergent and convergent thinking, working memory, attention, and intelligence.“Creativity is intelligence having fun” says a quote alleged to Albert Einstein, suggesting that creativity and cognition are closely linked together. Often in contemporary research, however, the relationship between creativity and intelligence has been discussed controversially. While some researchers have distinguished the constructs from each other, others have described them as complements . DiffereCreativity can be defined as the ability to generate new and adaptive ideas or novel solutions to problems and it is thus considered as fundamental for human civilization . It can Beyond the general definition, creativity is a versatile construct that can be expressed in many forms, domains and facets. Artistic, scientific, and technical creativity have been proposed as specific forms in previous research . MoreoveFirst, as the process of artistic creativity is likely to be more time-consuming than stimulus triggered divergent or convergent thinking due to domain specific stages, self-report questionnaires provide the opportunity to report past achievements specific for artistic creativity, instead of pressing the participants to produce creative solutions under non-ecological time pressure. Thus, we decided to develop a questionnaire that protocols artistic creativity completely independent of time pressure.Second, artistic creative thinking is not limited to figural and verbal modes of expression. While painting, sculpting and designing can be easily described as figural expressions, and writing certainly is a verbal form of expression, singing, dancing, and acting cannot be sufficiently characterized by only these two modes. Thus, it is important to cover a wide range of different domains and sub-domains as proposed by visual arts, literature, music and performing arts separately. Moreover, for each domain related sub-domains are included. For visual arts, they include painting, sculpting, photography, and graphic design; for literature, they include fictional writing, poetry, play writing, and journalism; for music they include, classical music, jazz music, rock music, and folk music and for performing arts, they include dancing, ballet, and acting in movies, theaters and musicals. Thus, it is possible to investigate the relationships among the several domains, sub-domains and their superordinate modes of creative expression and differences in their relationships to cognitive functions with the ACDC.To take this into account, the ACDC addresses the four main artistic domains of interest, ability, and performance. These can be assessed independently. The first level refers to the mere interest in a domain and sub-domain. The second level refers to past completion of creative accomplishments. The third level refers to publication of completed artworks. This differentiation of levels of involvement enables to assess the specificity of a certain degree of involvement for each (sub-) domain separately. It also provides for the possibility to assess the development of creative profiles over time. This may be particularly useful to assess progresses in development, to test the effectiveness of creativity training, and for the assessment of pathological changes related to neurodegenerative and/or psychological disorders . In sum, the ACDC is a self-report questionnaire to assess artistic creativity with its domains and subdomains on three levels of involvement .Third, one can be interested in different domains, in each domain the level of ability can vary, and making the creative achievement available for others reflects creative performance. That is, the quality of artistic creative products is influenced by knowledge and technical expertise. Beyond coming up with creative ideas, creativity also involves the creation of an artistic output expressed in a specific domain. The individual either has the aim and ability to do so or not. If the ability is present, the production on a subsequent level can be more or less skilled. Ideally, it will then be judged in an appropriate frame of reference . Levels In differentiating several forms and levels of involvement of artistic creativity, it is an interesting question how they further relate to cognitive functions. For divergent and convergent creativity, contradictory results between creativity and cognitive functioning have been found which have been explained as a function of overlaps in the assessment of the different constructs . KaufmanSeveral studies support this position. For example, interest, ability, and performance in artistic domains and sub-domains of different modes of creative expression. The second goal was to test the relationship between artistic creativity and common tests of figural and verbal, divergent and convergent thinking, in order to test the external validity of the ACDC. The third goal was to relate artistic creativity and divergent and convergent thinking to cognitive functions such as working memory, attention, and intelligence. This enables us to generate new insights into the relationships between domain-specific artistic creativity, typical measures of creativity (such as convergent and divergent thinking) and cognitive functions more generally.The first goal of this study was to validate a new self-report-questionnaire that assesses artistic creativity. The ACDC covers In line with the suggestion that creativity is domain-specific e.g., , we expeliterature, visual arts, performing arts, and music as separate domains. For each domain, it includes three levels of involvement as described above . For each sub-domain four questions were constructed. The first two questions refer to interest in a certain sub-domain. For example, for the “painting” sub-domain, “I have a strong interest in painting” and “I visit painting exhibitions.” The third question refers to ability, for example, “I paint pictures,” and the forth question refers to performance, for example, “I have already exhibited my pictures publicly” .The ACDC includes interest in visual arts/literature/music/performing arts, ability in visual arts/literature/music/performing arts and performance in visual arts/literature/music/performing arts . Figure 1 shows the hypothesized scale structure.For each scale mean scores were computed to provide a profile of the four domain-scales visual arts, literature, music and performing arts, the three levels of involvement and further the 12 scales of domain differentiated by level of involvement M = 26.19, SD = 8.52) were recruited from the general public. Approximately half of them were students, the other half had already completed their professional education. The study was approved by the institutional ethical review committee of the University of Bern. Participants signed written informed consent before data collection. They did not receive a reward for participation. Due to missing data, we had to eliminate 50 data sets. Thus, the final sample consisted of 270 participants.A total of 320 German speaking, healthy participants, 160 women and 160 men, aged 18–53 years , across levels of involvement , and across both domains and levels of involvement . It is available in German and in English, the present study was conducted with the German version.The ACDC consists of 72 questions about interest, ability and performance in four artistic domains  and 18 corresponding sub-domains . The full questionnaire is presented in Remote Associates Test (RAT) by The Abbreviated Torrance Test for Adults translated to German . Interrater-reliability for the present sample was The ASK, consists of the presentation of four capital letters. Participants are instructed to construct four-word sentences with these letters as the initial letters. A sum score of all countable sentences in both trials was calculated and ranked according to the manual.figural divergent thinking score was calculated as the mean of all figural scales of the ATTA and a verbal divergent thinking score was calculated as the mean of all verbal scales of the ATTA and the sum score of the ASK.A Wortschatztest (WST), a German vocabulary test was used to assess verbal intelligence  with a mean word length of 6.25 (SD: 0.81). Reading-span is scored as the set-size of the block in which all words of at least three sets can be remembered correctly or the block in which at least two sets were remembered minus 0.5.Working memory was tested with a German version of the ask RST; . It consTable 1.After signing written informed consent, participants were tested individually. The study consisted of the ACDC, tests of divergent and convergent thinking, intelligence, working memory, and attention. The ordering of the tests is displayed in d-target-stimuli combined with two dashes, distributed in an exercise-line including 26 target-stimuli and 31 distractor-stimuli. The test consisted of 14 lines, which had to be filled out successively without break. Participants had to start a new line every 20 s. Next, the RAT was administered. Participants were instructed to find the single fourth word that could possibly connect the three former unrelated words of each triad. They solved the 30 word triads of the RAT, presented on one sheet, within 5 min . This allows investigating artistic creativity from two view-points, the four different domains and the three different levels of involvement  = 55.75, p < 0.05, Comparative Fit Index (CFI) = 0.96, Tucker Lewis Coefficient (TLI) = 0.94, and a root mean square error (RMSEA) of 0.04. The indicator-reliabilities of the domains by levels of involvement were all above 0.4, indicating good convergent validity and implying that all 12 scales can be maintained as constructed. The complete model with standardized correlations and factor-loadings is presented in Figure 2.We generated an MTMM-model with 200 bootstraps according to the structure of the ACDC, that is, 72 items in four domains separated by level of involvement . The fit was good with χvisual arts, α = 0.80 for literature, α = 0.84 for music and α = 0.87 for performing arts.Internal consistency was high, with Cronbach’s alpha of α = 0.93 for the 72 items as a whole. For the four domains, internal reliability was α = 0.88 for interest, α = 0.77 for ability and α = 0.68 for performance. Further differentiation of levels of involvement for each domain resulted in α = 0.84 for interest in visual arts, α = 0.71 for ability in visual arts, α = 0.57 for performance in visual arts. For literature resulted α = 0.77 for interest, α = 0.37 for ability and α = 0.25 for performance. For interest in music α = 0.75 was obtained, for ability in music resulted α = 0.75 and for performance in music α = 0.31. For performing arts resulted α = 0.83 for interest, α = 0.52 for ability and α = 0.59 for performance.For the levels of involvement resulted α = 0.91 for figural divergent thinking was computed as a mean from the scores ATTA Mean Figural 1 and 2, and verbal divergent thinking was computed from ATTA Mean Verbal Score 1 and 2 and ASK (cf. Table 2). The mean score of the ACDC correlated significantly with the figural divergent thinking score and the verbal divergent thinking score. The correlation with the convergent thinking score was not significant.In order to test the external validity of the ACDC, we assessed its relation to divergent and convergent thinking. The involvement in art, the figural divergent thinking score correlated with interest, ability, and performance. The verbal divergent thinking score also correlated significantly with interest, ability, and performance. Results for the convergent score of the RAT were not significant. These correlations are presented in Table 3.On the level of art domains, the divergent figural mean-score was significantly correlated with visual arts and performing arts. The divergent verbal mean-score correlated significantly with visual arts, literature, music and performing arts. The convergent score of the RAT correlated with none of the domain scores of the ACDC. These correlations are likewise presented in Table 3.On the level of Table 4. They showed a significant correlation for the figural divergent thinking score with interest in visual arts, ability in visual arts, interest in performing arts, ability in performing arts, and performance in performing arts. The verbal divergent thinking score correlated significantly with interest in visual arts, ability in visual arts, interest in literature, ability in literature, performance in literature, ability in music, interest in performing arts, ability in performing arts, and performance in performing arts. Convergent thinking correlated with none of the domain scores divided by levels of involvement of the ACDC.The correlations between artistic domains divided further by levels of involvement are presented in verbal intelligence. On level of involvement, verbal intelligence correlated with interest, and ability. Attention and working memory did not correlate with any of the levels of involvement. Correlations are presented in Table 5.The total score of the ACDC correlated with verbal intelligence correlated with visual arts, literature, music and performing arts. Attention correlated with performing arts. Working memory did correlate with literature. All correlations are likewise shown in Table 5.We also explored the relation between specific artistic domains and intelligence, attention, and working memory. On level of domains, Ability in performing arts correlated positively with attention. Interest in visual arts, interest in literature, interest in music, interest in performance and ability in literature, ability in music and performance in music correlated with verbal intelligence. Interest in literature and ability in literature and performance in music correlated with working memory.Table 6 shows all correlations.Further, for the artistic domains of the ACDC divided by levels of involvement divergent and convergent thinking, verbal intelligence, attention, and working memory. The figural divergent thinking score correlated with attention. The verbal divergent thinking score correlated with verbal intelligence and working memory. The convergent thinking score correlated significantly with verbal intelligence. These correlations are shown in Table 7.Finally, we also analyzed the relationship between visual arts, literature, music and performing arts) on different levels of involvement . We used the ACDC to investigate the relation between domains, sub-domains and levels of involvement and cognitive functions in a differentiated way. Internal consistency among the four domains as well as the levels of involvement was very good. The MTMM-model that was used to separate the domains and levels of involvement showed a good fit. It supports a model of artistic creativity that differentiates levels of involvement for each sub-domain. Moreover, the good fit of the model structure with uncorrelated domains of artistic creativity suggests a clear specificity of the scales. The indicator-reliabilities of the sub-scales were high and the factor loadings for subordinate scales were mostly high, supporting the scale-construction of the questionnaire. However, lower loadings on some sub-scales in the domains of literature and music, for instance, may reflect the skewed distribution that is typical for this kind of non-expert population (literature are supposedly due to low variance in that particular scale. The correlations between levels of involvement are very high. However, the by far lowest correlation between interest and performance still supports our suggestion to observe the scales separately.We present the ACDC, a new questionnaire that covers artistic creativity in different domains (pulation . In anotIn the external validation of the ACDC the correlations support the hypothesis that it indeed measures forms of divergent creativity. The non-significant correlation between the ACDC and convergent thinking might suggest that artistic creativity is rather related to divergent than to convergent thinking. In future studies, tests of figural convergent creativity should be included to see if the results are similar.visual arts and performing arts correlate significantly with the divergent figural mean-score whereas music and literature did not. These results demonstrate that the ACDC does not only assess general divergent thinking but also shows differences between the domains. Moreover, the higher correlation with performing arts indicates that this domain shares a higher portion of divergent figural creativity. This complements earlier findings in which physical activity was strongly correlated with higher divergent creativity (performing arts, it is therefore important to control for an influence of general physical activity.On the level of artistic domains, eativity . To exclvisual arts, music, literature, and performing arts of the ACDC and the divergent verbal mean-score, with literature correlating highest, suggests that the domain literature might share the highest portion of verbal divergent thinking. On level of involvement, the ACDC levels interest, ability, and performance correlated significantly with figural and verbal divergent thinking. For verbal divergent thinking, ability, as assessed with the ACDC, showed a higher correlation. This result indicates that the divergent verbal tests represent divergent creative thinking best on the medium level of involvement.The significant correlation between each of the domains In sum, the external validation of the ACDC with divergent and convergent tests indicates that the questionnaire measures the construct “artistic creativity” that correlates with divergent creativity and does not overlap with convergent creativity. Moreover, the differing results among domains and levels of involvement concerning figural and verbal scores support the expected separation of domains and levels of involvement.verbal intelligence correlated significantly with the ACDC sum score together with all four domains visual arts, literature, music and performing arts on domain-level. These results indicate a relation between artistic creativity and intelligence that is not domain specific. A relationship between musicality and intelligence has been investigated by previous studies (ability or performance only ability in music and literature and performance in music correlate significantly with verbal intelligence. On level of involvement interest and ability correlated significantly with the verbal intelligence, with interest correlating higher than ability. On level of interest, interest in visual arts, literature, music and performing arts correlated with verbal intelligence. These results, showing that interest in several domains is related to verbal intelligence, complement findings that people scoring high on openness to experience also show higher intelligence scores (Further, the analysis of the correlations between the ACDC, intelligence, attention and working memory also showed interesting results. Only  studies . The dive scores .Attention correlated significantly positive with performing arts overall as well as ability in performing arts. This indicates the importance of a differentiated assessment of forms, domains and sub-domains of creativity and anticipate different processes for them. The fact that ability in performing arts correlated significantly with attention gives interesting insights into potential mechanisms of this domain. Here, action taking might be important. Attention could play a crucial role in the execution of performing arts like dance and play. It remains to clarify if the effects arise from a higher proportion of physical activity in general as described before concerning performing arts and divergent creativity (visual arts with attention sheds further light on the differing former results concerning its relation with divergent verbal and figural and artistic thinking.eativity . Future literature overall and with interest and ability in literature. As the RST is a verbal working memory task future studies should relate the ACDC to non-verbal tests of working memory.Working memory correlated with performing arts, lead to hypothesize a domain specific positive relation between divergent figural creativity and attention, specifically triggered by performing arts. Only the divergent verbal task on the other hand, correlated with verbal intelligence and the working memory task. This seems to provide evidence that divergent verbal and figural creative tasks and the different ACDC scales do not exclusively measure the same share of creativity. Moreover, it leads to the question if other forms of creativity, for example scientific creativity, would correlate differently with measures of working memory. Future studies that aim to investigate other forms of creativity could shed light on this question. As the RST is a verbal measurement of working memory, a different pattern of relationships may emerge for figural or numerical working memory tasks. Same applies for measures of intelligence. In future studies, figural intelligence tests could also be included to clarify if the relation between artistic creativity and intelligence is specific for verbal intelligence.To further analyze the correlations between artistic creativity and cognitive functioning we compared them to the correlations obtained between divergent and convergent tests and cognitive functioning. The divergent figural creative test correlated positively with attention whereas the verbal test did not. The fact that both parties also significantly correlate with verbal intelligence, than to basic cognitive functions like attention. This is important for future research in order to disentangle the relationships between different domains of creativity and general aspects of cognition.The ACDC is a new easy to use questionnaire that enables to assess artistic creativity in several domains and sub-domains. It provides separate scales for interest, ability, and performance, providing for fine-grained results. Moreover, the ACDC offers the possibility to study changes across development, in training studies, or to follow up on pathological changes. It also gives the opportunity to investigate relationships between different aspects of artistic creativity and personality traits, affective, or cognitive style in a straight-forward way. Further, our results show that relationships between creativity and cognitive functioning are most pronounced within domains and at the level of interest and ability. They show that different domains and sub-domains build on different cognitive functions. Interestingly all four domains of artistic creativity, on a level of interest, rather relate to more complex cognitive functions like All authors listed, have made substantial, direct and intellectual contribution to the work, and approved it for publication.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.