Central nervous systems receive and process information from the internal and external environment to maintain homeostasis. This includes interoceptive awareness of the organism’s nutritional state. Whenever food supply is required, feelings of hunger initiate the search for and the consumption of appropriate amounts of nutrients. How this is physiologically regulated in humans has been subjected to research into interoceptive awareness of body states during fasting and food consumption. However, there is no research on the distinct effects of carbohydrate or protein intake on interoception. Therefore, we aimed to investigate the impact of fasting and consumption of standardized carbohydrate and protein shakes on interoception in a repeated-measures cross-over design in a sample of 37 healthy, normal weight males. As a physiological correlate of interoception, we measured heartbeat-evoked potentials (HEPs), which are suggested to reflect the cortical representation of cardiac signals, during eight-minutes resting state EEG-recordings. After a 16-hour fasting period, the HEP amplitudes were lower over right central and parietal electrodes and increased after ingestion of the nutritional shake. Exploratory analyses indicated that the difference between fasting and satiety was more prominent at carbohydrate compared protein testing days. Correlation analyses with heart rate variability (HRV) suggested that high cardiac sympathetic activity is related to lower HEP amplitudes. Furthermore, cardiac sympathetic activity and stress indices decreased from before to after the intervention, whereas HRV increased. Together, this study shows for the first time that fasting and the intake of a nutritional shake affects cardiac measures of autonomic nervous system functioning and the neural correlates of cardiac interoception. These findings could be relevant for diets and psychosomatic disorders, including eating disorders. Central nervous systems receive and process information from the internal and external environment to maintain homeostasis. This includes interoceptive awareness of the organism’s nutritional state. In general, interoception refers to the awareness of internal states, in terms of visceral sensations, including cardiovascular and gastrointestinal signals, hunger and thirst, and tactile aspects comprising pain, pressure, and temperature perception . InterocExperimentally, interoception has mainly been investigated by subjective heartbeat detection and perception tasks. Neuroimaging has shown that interoception is associated with activation of prefrontal brain regions, the somatosensory and anterior cingulate cortices, and the insula . An alteAside from interoceptive awareness of cardiac signals, previous research has examined the association of cardiac interoception with interoception of other visceral signals, as for example the perception of satiety, thirst, and gastric contractions e.g., . Along tAs regards healthy individuals, Similarly, studies on HEPs demonstrated a link between HEP amplitudes and ANS functioning . In factWhile most of the above mentioned studies combined the analysis of interoception measured by heartbeat detection tasks with the assessment of other internal signals such as hunger, thirst, and satiety, little is known about the associations of physiological measures, i.e., cortical representations with gastrointestinal states. Previous work has examined gastrointestinal interoception by a two-step Water Load Test, in which non-caloric water is ingested until perceived satiation (step one) and maximum subjective fullness (step two). The volume of ingested water during both steps correlated inversely with cardiac accuracy during a heartbeat perception task in healthy participants , whereasTo the best of our knowledge, no study has assessed the specific impact of carbohydrates and proteins on the electrophysiological correlates of interoceptive awareness of cardiac signals and subjective feelings of hunger. Since carbohydrates and proteins are metabolized differently , and non-smokers. The mean age was 25.81 years (SD = 3.67). Further exclusion criteria were hearing loss and substance dependence. The existence of any psychiatric disorders, including eating disorders, was excluded by the Mini-DIPS Interview . As mentioned above, all participants were instructed the refrain from food and caloric drinks for 16 h. We additionally asked participants at what time they had eaten their last meal before the testing day and recorded the time of shake intake. For three participants the data regarding the time point of the last meal was incomplete. On average, the time differences between the last meal and time of appointment  did not differ between carbohydrate and protein testing days . Also, there was no difference between the time differences between the last meal and shake intake at carbohydrate and protein testing days . The participants and the experimenter were blind to the content of the drink and the results of blood glucose measurements.Thirty-seven participants were recruited for the study and were asked to refrain from food, alcohol, caffeine, and caloric drinks for 16 h prior to the appointment at the study day. All study days commenced between 08:30 and 11:00 AM. At the beginning, the hearing-ability was tested and psychopathology was ruled-out by a Mini-DIPS interview. After application of the EEG-cap and placement of ECG electrodes, all subjects completed hunger and mood surveys  and a me® Cool Mint). After this procedure, they removed the nose clip.For the carbohydrate and protein shakes, 80 g of whey-protein or maltodextrin powder were solved in 400 ml of water, respectively. Both shakes were prepared in an opaque, sealed containers. The carbohydrate maltodextrin 6 was produced by Berco Arzneimittel Gottfried Herzberg GmbH . The protein (whey-protein) powder contained a mixture of amino acids and was purchased from Fitmart GmbH & Co. KG . The participants were informed that they will receive a carbohydrate shake at one day and a protein shake the other day, but they did not know the order. Although we chose the taste “neutral” for the drinks, they still differed slightly in taste. Thus, we asked the participants to wear a swimming nose clip during drinking of shakes, which reduced the identifiability of the shake. When finished, participants drank a glass of water and rinsed the mouth with Listerine , were mounted on an elastic cap  according to the 10–20 system. Twenty-nine of these channels were used for EEG recordings, whereas an electrode placed at FPz was used as a ground electrode, and another one placed at FCz was used as the reference electrode. Two electrodes were used as EOG electrodes and two (bipolar) single-use silver and silver-chloride electrodes  were placed on each forearm close to the wrist for ECG recording. The data was amplified by a Neuvo 64 amplifier  and recorded with a sampling rate of 500, 200 Hz low pass filter, using the software Curry 8 (Neuroscan Compumedics). The impedances of the electrodes were kept at 10 or below throughout the recording. From one participants, problems with ECG recording occurred, wherefore only one testing session could be analyzed for HEP and heart rate variability measures.eyes open and eyes closed segments. The data was further re-referenced to the mastoid electrodes and filtered . The Fp1 electrode was used for automatic detection of eye movements by using a threshold of ±80 μV. The marked artifacts due to eye-movements were reduced by PCA including ±200 ms before and after the artifact. Further artifacts  were manually marked and were omitted from the HEP analysis. The semiautomatic QRS detection, a Curry 8 feature, was used to detect R-waves in the ECG channel and to mark the R-waves in the EEG channels. The EEG data was segmented afterward according to the R-wave with −200 ms before and 800 ms after the wave. The resulting segments were averaged, corrected for the baseline (−200 ms) and HEP mean amplitudes were extracted from the timeframe 456–596 ms after the R-wave for all electrodes, as frequently done in HEP analyses  and 206.2 segments (SD = 33.3) for eyes closed sections were averaged for the recording before shake intake, and 211.0 segments (SD = 29.0) for eyes open conditions and 210.8 segments (SD = 30.1) for eyes closed epochs were extracted for the post-shake HEP analysis. For the protein testing day, 211.4 segments (SD = 34.6) for eyes open and 211.4 segments (SD = 41.6) for eyes closed sections were averaged for the first measurement. After consumption of the protein shake, 206.8 segments (SD = 34.2) for eyes open and 215.9 segments (SD = 33.6) for eyes closed conditions were averaged. We selected HEP amplitudes over frontal , central , and parietal  electrodes for statistical analyses. These electrodes were selected analogous to previous studies focusing on frontal, central, and parietal regions . First, the recordings were down sampled to 250 Hz and segmented into es e.g., . We selees e.g., . The HEPns e.g., . The datFor additional control analyses, the ECG signal (amplitude) was also exported and the effect of the nutritional intervention on the ECG signal was investigated. Moreover, in order to control whether fasting and intake of caloric drinks would affect any ERP signal selected, we conducted the same analyses as reported for the HEP data, but for random events. Accordingly, we picked approximately (±20 events) as many events as detected by QRS detection for each participant, that is, approximately 200 segments were exported for each condition . All events were corrected for baseline, averaged, and mean amplitudes were extracted from the same timeframe. Again, outliers were removed and missing values were replaced by the mean. Five participants with several outliers were excluded from the analysis. All further statistical analyses were conducted in the same way the HEP analyses were performed.Mo), the height of the normalized RR interval histogram (AMo), as well as the difference between the longest and shortest interval between R-peaks (MxDMn). The square-root was taken so that the SI was less sensitive to extreme values  was applied on the raw signal and data was further analyzed with the software Kubios HRV Premium . We analyzed the data of the mean heart rate (HR), the mean RR interval, the standard deviation of NN intervals (SDNN), the root mean square of the successive differences (RMSSD), and the low-frequency (LF)/high-frequency (HF) ratio (computed by Fast Fourier Transformation). Kubios software also provides a general stress index (SI), an index for the activation of the parasympathetic ANS (PNS index), and an index reflecting the activation of the sympathetic ANS (SNS index). The stress-Index calculation (Eq. 1) is based on the median of RR intervals , were deleted, participants with more than three outlying data points were excluded from the analysis (n = 3). These participants were also excluded from correlation analyses.The PNS index was based on the mean RR, the RMSSD, and the HF power. The SNS index computation was based on the mean HR, the SI, and LF power. Both indices were computed as mean deviations from normal values . Thus, Pt-tests. For analyses of the HEP data, repeated measures ANOVA was calculated with the factors time point (before the drink vs. after the drink), nutrition (carbohydrate testing day or protein testing day) and eyes , frontal–parietal position , and hemisphere . Greenhouser–Geisser corrected values are reported. Post-hoc tests were performed by using Bonferroni corrected t-tests. We carried out exploratory analyses for comparisons of HEP amplitudes over C4 and P4 electrodes between the time points for the separated nutritional conditions by dependent t-tests. For control analyses, repeated measures ANOVA were further calculated with the factors time point (before the drink vs. after the drink), nutrition (carbohydrate testing day or protein testing day), and eyes  for the ECG signal. In addition, the same ANOVA and post-hoc tests as mentioned above for HEP data were conducted for random events of EEG data. For comparison of HRV measures before and after the shake intake and the hunger rating, dependent t-tests were used. Bonferroni correction was applied for comparison of heart rate variability measures due to multiple testing (significance level for the t-tests was set to 0.05/8 = 0.006). Effect sizes are reported as partial η2 and Cohen’s d for ANOVA and t-test comparisons, respectively. Pearson correlation coefficients were calculated for the associations of HEP amplitudes (for eyes and type of nutrition pooled) over central and parietal electrodes with HRV measures for pre and post data separately. We focused only on C4 and P4 electrodes, because the other electrodes seemed to be robust against the nutritional intervention. For HRV measures, the SNS and Stress indices were included into the correlation analyses. For further analyses, the differences between pre and post data  for SNS and Stress indices and HEP amplitudes over C4 and P4 electrodes were calculated. Afterward, correlations were calculated between Δ-HRV and Δ-HEP variables. Bonferroni corrections were applied for pre, post, and Δ correlations, resulting in a significance threshold of p < 0.0042 (0.05/12). We calculated additional partial correlation analyses for the hunger ratings and the blood-glucose levels and HEP data over C4 and P4, again for pre, post, and Δ-data controlling for the BMI. Bonferroni correction was applied for pre, post, and Δ correlations for hunger and blood-glucose correlations, resulting in the significance threshold of p < 0.0083 (0.05/6). For all initial tests, a significance level of 0.05 was chosen.All statistical analyses were performed using IBM SPSS Statistics for Windows, version 26 . The hypotheses tested were specified before the data were collected. Because the time differences between the last meals and the appointment time as well as shake intake time were not normally distributed, non-parametric Wilcoxon tests were used for comparisons of fasting times between the carbohydrate and protein testing days (results in section “Design and Procedure”). The self-reported hunger rating was compared between time points with nutrition conditions pooled and separated by means of dependent SD = 1.96) to 4.496 , with no difference between the type of nutrition .The self-reported hunger decreased significantly after consumption of the drink from 5.249  = 21.34, p < 0.001; partial η2 = 0.400] and a main effect of hemisphere . The main effect frontal–parietal position indicated that HEP amplitudes were higher over central electrodes  compared to frontal electrodes  and higher over parietal electrodes  compared to frontal electrodes , whereas no difference emerged between central and parietal electrodes . In addition, midline electrodes also showed higher amplitudes compared to electrodes over the left hemisphere . No difference occurred between midline and right electrodes .As shown in time point with frontal–parietal position  and an interaction of time point with hemisphere . Post-hoc tests for the interaction of time point with frontal–parietal position indicated a difference between the pre and post conditions over parietal electrodes . No differences between conditions occurred for frontal and central electrodes . The interaction of time point with hemisphere revealed a difference between the conditions (fasting vs. satiety) for the right hemisphere . In contrast, no differences between conditions were found for the left and midline electrodes . Grand-averaged waveforms for both time points and all selected electrodes are shown in Most interestingly, the ANOVA further revealed an interaction of time point with frontal–parietal position and with hemisphere indicated a significant difference between the HEP amplitudes recorded before and after shake ingestion for the right central and parietal electrodes . No differences between the conditions occurred for frontal electrodes as well as for other midline and left electrodes  = 2.246, p = 0.088; partial η2 = 0.066]. Moreover, the interaction of nutrition, time point, frontal–parietal position, and hemisphere was not significant . Nevertheless, we conducted further exploratory analyses concerning the impact of nutrition and fasting on HEP amplitudes over C4 and P4 electrodes, since these electrodes have been shown to be sensitive to the time point, i.e., fasting and satiety states. T-tests between pre and post conditions for the carbohydrate and protein testing days separately showed that differences between time points were more prominent for carbohydrate testing days than for protein testing days . Comparisons of time points for the protein testing day showed no statistical significant differences .Whereas no main effect of Finally, as multiple-comparisons by ANOVA are fraught with the problem of inflated Type I error , we noteThe comparison of HRV measures between before and after consumption of the shakes revealed significant differences for the SNS index, SI, SDNN, and LF/HF ratio see . The SNSSignificant correlations between the HEP amplitudes and HRV measures were found during the satiety conditions. In detail, the Stress and SNS indices were negatively associated with HEP amplitudes over the P4 electrode, which suggest lower amplitudes during high SNS activity . The cornutrition, time point, and eyes for the ECG amplitudes. Here, neither main effects of nutrition, time point, and eyes occurred, nor interactions with time point were found, as observed for HEP data . One significant interaction of nutrition with eyes occurred, whereas post-hoc test between nutritional interventions and eyes open/closed conditions failed to reach significance . For another control analysis, random ERP events were created and the analysis conducted for HEP data was repeated. Here, only a main effect of eyes occurred  indicating lower amplitudes when eyes were open compared to eyes closed recordings . In addition, an interaction of eyes with frontal–parietal position was observed , which indicated a difference between eyes open and closed recordings only over frontal electrodes  and a differences between frontal and parietal during the eyes open condition . An interaction of nutrition with frontal–parietal position further occurred , whereas no significant effect surviving Bonferroni correction (p < 0.006) was found. The same applies for the interaction time point with frontal–parietal position and hemisphere , where no post-hoc test reached significance .In order to check whether differences in HEP amplitudes could be simply related to differences in ECG signals during the selected time window, we calculated repeated-measures ANOVA with the factors Finally, we calculated correlation coefficients between HEP data and the subjective rating and blood-glucose levels. Here, only the correlation between blood-glucose level and HEP over P4 during fasting reached significance .The present study aimed to characterize the effect of fasting and selective intake of carbohydrates and proteins on the electrophysiological correlate of cardiac interoception, namely HEP in a sample comprising healthy, male participants. We found higher HEP amplitudes during the satiety condition compared to the fasting condition over right central and parietal electrodes, whereas in the initial analyses, no effect of the type of nutrition occurred. This findings are in contrast to the study of In our study, we did not assess interoceptive accuracy, which is why the results of our study using HEPs are difficult to compare with behavioral studies. Therefore, based on our data, we cannot conclude that HEP changes reflect changes in visceral interoception. In fact, hunger rating did not correlate with HEP amplitudes. In contrast, the blood-glucose level correlated inversely with HEP amplitudes during fasting. This could suggest that subjective interoceptive accuracy and objective measures such as HEP are not that tightly correlated as predicted . FurtherIndeed, the nutritional composition has been shown to selectively affect another electrophysiological marker, the LDAEP, which has been proposed to be related to the activity of the neurotransmitter serotonin in the brain, as suggested based on additional data of the present study. More detailed, the marker for central serotonergic activity was increased after food intake compared to fasting conditions, whereas this effect was more prominent for the carbohydrate consumption than after proteins . Thus, tIn our study, the effects observed in our HEP analyses occurred mainly over the C4 and P4 electrodes, i.e., the right central brain region. The localization of maximal HEP amplitudes over frontal and central electrodes has been reported frequently and is in accordance with the idea of the anterior cingulate cortex, insular, parietal, somatosensory, and somatomotor cortices being involved in interoception . A higheThis is the first study showing that fasting and intake of carbohydrates and proteins affect HEP amplitudes, whereas this effect was more prominent during the carbohydrate testing days, as shown by exploratory analyses. These results are restricted to a sample of male, normal weight, young participants. The electrophysiological marker was further associated with HRV measures indicating that low sympathetic activity is related to high cortical representations of cardiac signals under satiated states.The data will be made available by the corresponding author upon request.The studies involving human participants were reviewed and approved by Ethics Committee of the Medical Faculty of the Ruhr-University Bochum. The patients/participants provided their written informed consent to participate in this study.VF: acquisition, analysis, interpretation of data for the work, and drafting the work. CB: acquisition and revising the manuscript critically for important intellectual content. MB: interpretation of data for the work and revising the manuscript critically for important intellectual content. All authors: substantial contributions to the conception or design of the work, final approval of the version to be published, and agreement to be accountable for all aspects of the work.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.


To investigate the risk factors and the outcomes of extracorporeal membrane oxygenation (ECMO) in pediatric patients treated at the University Hospital Center Zagreb, the largest center in Croatia providing pediatric ECMO.This retrospective study enrolled all the pediatric patients who required E-CPR from 2011 to 2019. Demographic data, cardiac anatomy, ECMO indications, ECMO complications, and neurodevelopmental status at hospital discharge were analyzed.In the investigated period, E-CPR was used in 16 children, and the overall survival rate was 37.5%. Six patients were in the neonatal age group, 5 in the infant group, and 5 in the “older” group. There was no significant difference between the sexes. Four patients had an out-of-hospital arrest and 12 had an in-hospital arrest. Twelve out of 16 patients experienced renal failure and needed hemodialysis, with 4 out of 6 patients in the survivor group and 8 out of 10 in the non-survivor group. Survivors and non-survivors did not differ in E-CPR duration time, lactate levels before ECMO, time for lactate normalization, and pH levels before and after the start of ECMO.The similarity of our results to those obtained by other studies indicates that the ECMO program in our hospital should be maintained and improved. The use of extracorporeal cardiopulmonary resuscitation (E-CPR) is increasing . E-CPR iThe most recent systematic review by the International Liaison Committee on Resuscitation from 2015 recommended that E-CPR should be considered for children with underlying cardiac conditions who have an in-hospital cardiac arrest when appropriate protocols, expertise, and equipment are available . AccordiThis study assessed the risk factors and the outcomes of ECMO in the largest Croatian center providing pediatric E-CPR experience over nine years and compared the survivor and the non-survivor group.This retrospective study enrolled all the children with sudden and refractory cardiac arrest who were treated with E-CPR at the University Hospital Center Zagreb between January 2011 and June 2019. We retrospectively reviewed the records of 16 children and collected demographic data and data on the etiology and location of the arrest, setting of the ECMO run, ECMO type, time of support, and the use of hemodialysis. In Croatia, pediatric ECMO was also instituted in two other hospitals – UHC Rijeka, where it was used for acute respiratory distress syndrome in an 11-month old girl . Venoarterial (VA) ECMO was used in all patients. In two patients, a peripheral VA ECMO was instituted through the cannulation of femoral vessels, one patient underwent neck cannulation , and other patients underwent central cannulation of the carotid artery and internal jugular vein. None of the patients required the use of inhaled nitric oxygen. The amount of cardiovascular support for hemodynamic instability was calculated with vasoactive inotropic score (VIS). The score was dichotomized into normal (VIS<20) and high (VIS>20). The decision to start E-CPR was not standardized and was made by the patient’s primary bedside physician. We defined the E-CPR duration as the time between the start of the chest compressions and the ECMO flow initiation. Laboratory data before and after ECMO cannulation were also obtained. In the pediatric intensive care unit (PICU), standard heart ultrasound was performed twice daily. Therapeutic hypothermia after CPR and during ECMO was not used, although hyperthermia was aggressively treated. Survival was defined as a survival to hospital discharge, or, where specified, as a survival to ECMO decannulation. Children who underwent E-CPR were neurologically evaluated by radiologic imaging: computed tomography, ultrasonography, and magnetic resonance. Neurological outcome was assessed by a pediatric neurologist using pediatric cerebral performance score. Concerning cardiac surgery, none of the patients were re-operated. The study was approved by the University Hospital Center Zagreb Institutional Review Board (02/21 AG).The criteria for choosing the patients for rescue ECMO were in- or out-of-hospital cardiac arrest, associated or not with congenital heart surgery, in which CPR (including bystander) started within 10 min after the arrest. We included the patients with CHD both before and after cardiac surgery. All the patients were aged from 0 to 18 years. CPR was defined as a procedure that requires chest compressions, not only rescue breaths. The ECMO team was activated by the pediatrician in charge of the resuscitation. The study did not include a neonate with congenital diaphragmatic hernia in whom CPR had started and ECMO had been indicated but not deployed because of technical problems.2 test were used to compare categorical and numerical variables, while some data were analyzed descriptively. A P value <0.05 was considered significant. The analyses were performed with the SPSS, version 20.0 .Descriptive statistics were summarized as counts and percentages for categorical variables and as median and interquartile range (IQR) for continuous variables. The Fisher exact, Mann-Whitney, and Pearson χ2 (IQR 0.22-0.63 m2). Cardiorespiratory arrest was caused by circulatory insufficiency in 15 out of 16 patients (94%) and by a respiratory cause in one patient, a neonate with diaphragmatic hernia. In this patient, CPR lasted 160 minutes, and ECMO lasted only 8 hours, due to the unfavorable disease course.From January 2011 to June 2019, ECMO support during CPR was initiated in 16 patients. Four of them had an OHCA and 12 had an IHCA. Six patients were neonates, 5 were infants, and 5 belonged to the “older” group, encompassing all the children up to 18 years. The average age for starting CPR was 5 months . Six patients were female (37.5%). The average weight was 4.7 kg (IQR 3.225-14.58 kg), height 57 cm (IQR 52-95.5 cm), and body surface area 0.275 mP > 0.05), and the initial flow was somewhat higher . No significant difference in lactate levels was found before or during lactate normalization after starting ECMO. Moreover, survivors and non-survivors did not differ in pH, BE, and pCO2 levels before and after starting the ECMO procedure , while the other causes included myocarditis, cardiomyopathies, and sodium valproate intoxication. ECMO treatment was performed after cardiac surgery in patients with tetralogy of Fallot (one patient), coarctation of the aorta with ventricular septal defect, patent foramen ovale, and patent arterial duct (three patients), total anomalous pulmonary venous return (TAPVR) – infradiaphragmatic type, univentricular heart, and transposition of the great arteries (one patient), complete atrioventricular canal (one patient), and TAPVR as a part of a heterotaxy syndrome and with double inlet left ventricle and pulmonary atresia (one patient). In conclusion, five patients had RACHS score 2, two patients RACHS had score 3, one patient had RACHS score 4, and one patient had RACHS score 5. One patient had severe aortic valve stenosis but cardiac surgery was not performed. Male and female groups did not significantly differ in any of the parameters . Two patrocedure . The mosrocedure . In the In our study, survival to hospital discharge after E-CPR was 37.5%. The first pediatric ECMO in Croatia was performed in November 2009, and up to early 2020 there were 48 ECMO runs. Since the first successful case, more than a year passed before the second ECMO run, which was our first pediatric ECMO after providing CPR. In the last decade, an increasing trend of pediatric E-CPR use was observed, with three patients from 2011 to 2013 and nine patients from 2017 to 2019. Barbaro et al ,22. MostUnlike other studies, we found no significant difference between survivors and non-survivors in E-CPR duration time, lactate levels before ECMO, time for lactate normalization, and pH levels -24. A poThe small sample size prevented us from investigating the complexity of cardiac lesions and their effect on mortality and morbidity. Other studies reported the effect of the type and complexity of congenital heart defects on ECMO outcomes. The mortality rate increased with a higher RACHS score . As we aLonger CPR time in our study can be partly explained by a lack of local guidelines for activating the ECMO team. In all of the cases, the ECMO team was activated by the pediatrician in charge of resuscitation. A particular problem are the night shifts, when only one pediatrician is in charge, very often directly involved in CPR. Problems are also present during the transport from the emergency department to PICU, where special attention needs to be placed on the compression depth and rate . In the Twelve out of 16 patients experienced renal failure and needed hemodialysis, with 4 out of 6 patients in the survivor group and 8 out of 10 in the non-survivor group. The remaining two patients in the non-survivor group did not undergo hemodialysis because the ECMO run lasted for only 7 minutes in one patient and 47 minutes in the other. This and the small sample size are probably the reasons why the difference between survivors and no survivors in the need for hemodialysis did not reach significance. Consequently, the results are different from other studies, where both kidney injury and renal replacement therapy were independent predictors of mortality .Regarding the associated malformations, patients with trisomy 21 make up to 20% of syndromic patients needing ECMO treatment . FurtherThe use of pediatric ECMO in our hospital is increasing. A total of 16 E-CPR runs were performed in last nine years, but the number was disproportional during the years. In the first four years, 5 ECMO runs were performed after CPR, and 11 in the last four years. The number is still too low to allow making a definite conclusion, but an increased number of ECMO runs after CPR in the last few years encourages us to develop our local guidelines. Finally, our overall results are similar to other published studies, which is a reason to maintain the ECMO program in our hospital with an aim to improve the outcome of every new patient.This study has some important limitations. First, it is a single-center study with a relatively small sample size, which is understandable as cardiac arrest in children is not as common as in the adult population. Furthermore, as the number of patients is limited, the number of events is also low, meaning that the outcome is affected by several factors, which cannot be included in a multi-variable analysis. Second, the absence of some data in patients' histories due to the retrospective nature of the study can be an important confounder. We hope that a prospective database, which is currently being instituted, will help us more accurately analyze prognostic factors. Finally, the neurodevelopmental outcome was assessed with a simple scoring system, without uniform criteria on imaging studies.In conclusion, E-CPR should be used as a rescue treatment for in- and out-of-hospital pediatric cardiac arrest refractory to initial procedures. If not on standby already, ECMO team should be immediately activated when an IHCA occurs. Although derived from a small sample, the results of OHCA patients are encouraging for the implementation of an ECMO protocol in as many regional hospital centers as possible.


N = 31,621). National Sleep Foundation (NSF) age-specific sleep recommendations were used to define recommended  sleep duration. The balanced, repeated, replicate variance estimation method was applied to the ATUS data to calculate weighted estimates. Less than half of the US population had a sleep duration that mapped onto the NSF recommendations, and alignment was higher on weekdays (45%) than at weekends (33%). The proportion sleeping longer than the recommended duration was higher than those sleeping shorter on both weekdays and weekends (p < 0.001). Time spent on work, personal care, socialising, travel, TV watching, education, and total screen time was associated with nonalignment to the sleep recommendations. In comparison to the appropriate recommended sleep group, those with a too-short sleep duration spent more time on work, travel, socialising, relaxing, and leisure. By contrast, those who slept too long spent relatively less time on each of these activities. The findings indicate that sleep duration among the US population does not map onto the NSF sleep recommendations, mostly because of a higher proportion of long sleepers compared to short sleepers. More time spent on work, travel, and socialising and relaxing activities is strongly associated with an increased risk of nonalignment to NSF sleep duration recommendations.The objective was to investigate the association between time spent on waking activities and nonaligned sleep duration in a representative sample of the US population. We analysed time use data from the American Time Use Survey (ATUS), 2015–2017 ( Optimal sleep duration is crucial as both short and long sleep duration are associated with physical and mental health problems ,2,3. ForHere, we use these recommended guidelines to study sleep patterns in a population-based sample of over 31,000 US residents from the American Time Use Survey (ATUS) from 2015 to 2017 . As prevPrevious work using the ATUS examined sleep–wake time; however, the authors could not compare the prevalence of sleep duration to the NSF guidelines as these were published eight years later. Because waking activities are likely to have changed since the original report was published in 2007 , we provThe ATUS is a federally administered annual survey sponsored by the Bureau of Labor Statistics and conducted by the US Census Bureau. The survey includes a nationally representative sample of US residents, aged 15 years and over, who are neither residents of nursing homes or prisons nor in active military duty. The sample frame for the ATUS is provided by the Current Population Survey (CPS), a continuous survey of representative sample households. All members of an eligible household have equal probability of being selected into an ATUS household if they meet the eligibility criteria. To ensure adequate representation, the ATUS oversamples eligible households with Hispanics and non-Hispanic Black people, households with children, and weekend data collection. The primary objective of the ATUS is to measure how US residents spend their time on a typical day. The ATUS therefore captures a 24 h time activity diary recall, to 1 min resolution, of eligible respondents starting at 4 a.m. the previous day and ending at 4 a.m. on the interview day via a computer-assisted telephone interview lasting between 15 and 20 min per respondent . The desDetailed activities are coded and classified into 17 major categories labelled from 01 to 17. Each category is further classified into two-tiered subcategories, each labelled with two digits. For example, time spent sleeping (t010101) is a subcategory of sleeping-related activities (0101), which is also a subcategory of personal care activities, a major category (01). Thus, each pair of digits indicates the first, second, and third tiers in order. Due to the complexity of coding daily activities, coders follow a strict flowchart to help to categorise an activity into this three-tier coding system. Detailed information about coding, categorisation, verification, and adjudication of activities is available in the ATUS User’s Guide .The ATUS has been continuously run since 2003. For this article, only pooled data from 2015 to 2017 comprising 31,621 respondents from a designated sample of 69,838 were used. The configuration of the ATUS database and corresponding survey response rates from 2015 to 2017 is presented in First, we focused on sleep duration and waking activities and mapped these to the NSF sleep guidelines in the population. An adjusted Wald test was used to compare average sleep duration between groups of categorical variables. For this part of the analysis, we generated 4 age categories to reflect age groups with different NSF sleep recommendations, i.e., <18 years, 18 to 25 years, 26 to 64 years, and ≥65 years see . We thenp-values [We used the chi-square test of independence to compare the weighted proportion of the five alignment categories by sociodemographic variables. To account for the survey nature of the data, a second-order Rao and Scott correction was used to generate non-integer degrees of freedom, which were then used to compute the corrected F-statistic and corresponding p-values . The socp-values [We used the chi-square test of independence to compare the weighted proportion of the five alignment categories by sociodemographic variables. To account for the survey nature of the data, a second-order Rao and Scott correction was used to generate non-integer degrees of freedom, which were then used to compute the corrected F-statistic and corresponding p-values . The socp < 0.05. To correct oversampling in the ATUS dataset, representative estimates of time spent on different activities were calculated using sampling and replicate weights provided by the ATUS. Representative average estimates were calculated by making the survey design variables identifiable  and using the balanced repeated replicate (BRR) weights and a Fay’s adjustment of 0.5 [N = 456).All analyses were performed using Stata/SE 15.1 for Windows . Statistical significance was defined as t of 0.5 . For thiThe sociodemographic characteristics of the ATUS respondents are presented in M = 9.3 h, SE = 0.02 h) than on weekdays . The adjusted Wald test showed that the difference between average weekend and weekday sleep duration was significant, F = 875.4, p < 0.001). However, there was no difference in average sleep duration, either on weekdays, at weekends, or in total, across the ATUS recruitment years 2015–2017. When comparing average sleep duration by sex, we observed that, in general, women had 9 min longer average sleep duration than men, F = 24.5, p< 0.001). After stratifying the analysis by weekday/weekend, this difference only remained for weekday sleep  = 20.7, p < 0.001)), but not weekend sleep.Weighted average sleep duration on weekdays and at weekends by sex from 2015 to 2017 is presented in M = 9.8 h, SE = 0.08 h) and lowest among the adult group . The difference in sleep duration between age groups after pairwise comparison was consistently statistically significant among men  but not among women. For women, average sleep duration was significantly different between all the age groups pairs  except between teenagers and young adults. Likewise, weekday average sleep duration was significantly different between all the age groups pairs  except between teenagers and young adults  = 248.4, p < 0.001. Results for the weighted proportion of sleep duration on weekdays to weekends showed that sleeping duration was outside the recommended range and was too long (NRL) at weekends than on weekdays irrespective of the age category  (see g adults b. In totg adults . The pro001) see c. The we001) see d.ps < 0.001). Specifically, the likelihood of sleeping for an appropriate duration according to NSF recommendations increased with increasing educational attainment. This trend was also similar for increasing family income (y income . Sleep dps < 0.001). Conversely, those with longer sleep duration, whether within the recommendations or not (AL or NRL), respectively worked 94 min  and 142 min  less than those in the AR category (ps < 0.001). A similar pattern of association was observed for travel time, personal care, and education—the population in the NRS and AS sleep duration categories spent more time on these activities, whereas those in the AL and NRL categories spent significantly less time compared to the AR category. Participants in the NRS category consistently exchanged sleep time for each of the seven waking activities presented in ps < 0.05).We calculated the adjusted deviation in the duration of waking activities of respondents in each of the four nonaligned categories from the AR category in a weighted multiple linear regression. Regression models were adjusted for age, sex, ethnicity, educational attainment, children in household, marital status, family income, and employment status. When the multiple linear regression models were restricted to data collected on weekdays , change There was a significant adjusted change in the duration of sports, exercise, and recreation between different sleep duration categories and the AR category. Specifically, respondents in the AS spent 10 min  more on sports, exercise, and recreation than the AR group, whereas those in the AL and NRL categories spent significantly less time  and -7 min , respectively) on sports, exercise, and recreation.Our findings show that less than half of the US population met the number of hours of sleep recommended in the NSF age-appropriate guidelines. Sleep duration among the US population mapped onto the NSF recommendations mostly on weekdays (among 45%) rather than at weekends (among 33%). Further, after controlling for sociodemographic variables, time spent on each of the following waking activities: work, personal care, socialising, relaxing, leisure, travel, TV watching, education, and screen time was inversely associated with sleeping the recommended number of hours, in general. These waking activities remained significantly associated with sleep duration when analysis was restricted to weekdays. At weekends, however, all but education remained significantly associated (by at least a 15 min difference) with sleep duration outside of the recommended number of hours. In addition, time spent on household activities at weekends was associated with sleep duration.To our knowledge, this is the largest study using time-use survey data from a population representative sample in the US to describe reported sleep duration in relation to NSF age-specific recommendations among adults. Sleep duration in relation to recommendations in adult populations is rather limited as the NSF guidelines were published only five years ago. We show that about 60% of the US adult population’s sleep duration does not map onto the NSF recommendations on sleep duration when age-specific thresholds are applied. Sleeping duration outside of the recommendations was more common on weekdays than at weekends. Adding to the debate about global decline in sleep duration ,24, thisIn the US population, time spent on waking activities—time spent on work, travel, personal care, socialising, relaxing, leisure, watching TV, and education—differed for those who slept the recommend number of hours and those who did not. Thus, the kinds of activities that are traded for sleep among the United States population have not changed over the past decade . Using AA strength of our study is that we directly mapped reported sleep duration to the NSF sleep recommendations using nationally representative data. The use of the age-specific sleep recommendation categories permitted the standardisation of sleep duration. In addition, we accounted for potential confounding variables in our regression analysis. The ATUS uses a probabilistic sampling technique in which every eligible individual has equal opportunity of being a participant, making the sample representative of the US teenage and adult population. Oversampling of minority ethnic groups and data collection during weekends were corrected with sampling weights provided by the ATUS. Further, the use of survey-specific statistical analysis permitted the estimation of population parameters rather than sampling statistics; thus, findings from this study can be extrapolated to the US population.A limitation of this study is the cross-sectional nature of the data which does not allow for temporal and causal associations to be made between adherence to sleep recommendation and time spent on waking activities. The 24 h recall method used in collecting activity data for the ATUS does not take into account any prior activities  that could have influenced the time spent on activities during the interview period, thus opening the possibility of reverse causation. Although relatively low, recall bias remains an issue in the retrospective data collection format used in the ATUS. Further, the response rate of eligible participants in the ATUS was low for all three years, although this is not different from the ATUS response rate in earlier years. Investigations conducted on earlier cohorts revealed that nonrespondents were more likely to be weakly integrated in their communities . A recenThe present study has implications in promoting a balance between time spent on waking activities, particularly work-related activities, and time spent sleeping. While management of sleep and waking activities will vary greatly across professions and age groups, the ability to maintain healthy levels of sleep remains a problem in the current 24 h society ,40,41.This study shows that on a typical day, people whose sleep is very short and below the NSF recommendations spend more time on work, socialising, relaxing and leisure, personal care, and travel, whereas those whose sleep is above the NSF recommendations spend less time on all these activities both on weekdays and at weekends. This study shows that less than half of the US population adheres to the recommended sleep duration for their age. A significant portion of the population “catch up” on sleep deficits at weekends, warranting further study of the potential health implications of this behaviour.


The purpose of the present study was to investigate whether there are associations between polyunsaturated fatty acid (PUFA) blood levels, reading/writing performance and performance in neuropsychological tasks. Moderate to strong correlations were found between PUFA levels (specific omega-6/omega-3 ratios) and reading/writing abilities, and the former and neuropsychological test scores. Mediation models analyzing the direct and indirect effects of PUFA on reading and writing scores showed that the effects of fatty acids on learning measures appear to be direct rather than mediated by the investigated visual and auditory neuropsychological mechanisms. The only significant indirect effect was found for the difference in accuracy between the left and right visual fields in visual-spatial cueing tasks, acting as a mediator for the effect of PUFA ratios on writing accuracy. Regression analyses, by contrast, confirmed the roles of phonological awareness and other visual attentional factors as predictors of reading and writing skills. Such results confirm the crucial role of visual-spatial attention mechanisms in reading and writing, and suggest that visual low-level mechanisms may be more sensitive to the effects of favorable conditions related to the presence of higher omega-3 blood levels. Developmental dyslexia (DD) is one of the most common learning disabilities. It is characterized by deficiencies in the acquisition of reading skills, despite there being no evidence of intellectual disability, or sensory or neurological deficiencies ,2. DD isOver the last few decades, indeed, deficits in reading were shown to be associated with phonological processing ,6 and peThe magnocellular system  can be described as a circuit, including different brain regions, which is dedicated to space perception, but also to the coding of visual information for action organization . Since tSeveral children with DD display reduced motion sensitivity and impaired focusing of visual or auditory attention ,19,20. TOmega-6 and omega-3 polyunsaturated fatty acids (PUFA) play an important role in physiological brain development and function ,23. PUFALong-chain omega-3 and omega-6 PUFA are synthesized from the essential fatty acids (EFA) α-linolenic acid  and linoleic acid , respectively . These aOmega-3 PUFA, in particular, have important roles in the brain beyond infancy  and possSeveral studies investigated the levels of blood fatty acids in children with DD, and it was found that children with the most severe fatty acid deficiencies had poorer reading, spelling and auditory working memory than children with milder PUFA deficiency . MoreoveThe aim of the present study was to investigate the correlations between PUFA blood levels, reading/writing performance and performance in neuropsychological tasks. More precisely, our aim was to test the hypothesis that the effect of PUFA on reading and writing skills is mediated by neuropsychological functions such as phonemic awareness, magnocellular-related visual perception, visual-spatial attention (VSA), and executive functions.Based on previous studies on PUFA and learning and neuropsychological abilities, our first hypothesis was that high levels of omega-6 and low levels of omega-3 and/or low omega-6 to omega-3 ratios would be associated with worse performance in reading and writing. Secondly, we expected that such associations could be explained (mediated) by the effects of PUFA levels on the neuropsychological functions for which speed of processing is more crucial, i.e., low-level perceptual functions . Our third hypothesis was that the influence of visual and auditory perception could be exerted at high levels of processing—not just basic perceptual tasks , but more complex tasks involving visual searching  and phonological awareness . Therefore, visual search tasks and phonological awareness were included in the neuropsychological battery to allow investigation of their possible roles as mediators. Indeed, phonological awareness is known to play an important role in reading and DD: some children with reading disabilities have difficulties in segmenting the phonemic constituents of words, or in matching speech sounds with the visual counterparts ,48,49. SThe study is situated in the context of a larger trial on the effects of PUFA supplementation during intervention for DD, which included assessments with further tasks that will not be considered in the present study.A total of 30 Italian students aged between 8 and 13 years  were involved in the study. The sample consisted of 15 children diagnosed with DD and 15 normally reading children. The recruitment took place between July 2020 and September 2021. Participants with reading disorders were selected among patients of the neuropsychiatry unit of IRCCS “Eugenio Medea” in Bosisio Parini, Northern Italy, and typically developing children (TD) were recruited in the same geographic area among the schoolmates and friends of the children with DD, through sport centers or through social media. The children and their families were contacted by the researchers, and the purpose and procedures of the study were explained. Written parental informed consent was obtained before the beginning of the study.Participants had to fulfil the following inclusion criteria: (a) between 7 and 15 years of age and attending at least the third class of primary school; (b) IQ ≥ 80; (c) monolingual speakers or bilingual speakers with perfect (native-like) mastery of the Italian language. Moreover, inclusion criteria for children with DD were: (a) having been previously diagnosed with DD on the basis of standard inclusion/exclusion criteria ; (b) absence of comorbidity with ADHD and other neuropsychiatric or psychopathological conditions ; (c) not having received neuropsychological treatment for DD before. Inclusion criteria for TD children were: (a) normal school achievement as reported by teachers and parents; (b) no z-scores below −1.5 with respect to age mean in text, word, and nonword reading tests and in tests of writing to dictation . The study was approved by the Local Ethics Committee in accordance with the Declaration of Helsinki.The study is part of an ongoing project on the efficacy of PUFA supplementation to enhance the effects of neuropsychological treatment for children diagnosed with DD .All measures involved in the present study were collected as part of the pre-test assessment of the main project. Reading and neuropsychological tests were administered individually by trained psychologists in one session of about an hour and a half. The blood samples were collected by nurses of the Scientific Institute Eugenio Medea during the same assessment session.The methodology described in Marangoni et al.  was usedTotal PUFA, total omega-3, total omega-6 compositions were measured as a percentage of the total fatty acid. The ratios omega-6/omega-3, AA/EPA , AA/DHA , AA/ALA, LA/ALA were also computed.(a)Cognitive measures. The Wechsler Intelligence Scale for Children, Fourth Edition (WISC-IV) [WISC-IV)  and the WISC-IV) ,55 were (b)Reading and writing tests.All participants were tested before starting treatment. Assessment involved reading skills and a set of neuropsychological functions related to the process of reading. The results of all the tests are expressed as both raw scores and z-scores according to age norms, with the exception of the motion coherence test, the rhythmic pattern discrimination, and the cue effects in visual spatial attention, for which norms are not available, and therefore, only raw scores could be recorded. The following tests were administered:(b1) Single word/nonword reading. “DDE-2: Batteria per la Valutazione della Dislessia e Disortografia Evolutiva-2”   was used(b2) Word and sentence writing to dictation. Two dictation tasks were taken from the DDE-2 battery , giving (c)Neuropsychological tests: auditory.(c1) Rhythmic pattern discrimination. The pattern discrimination task proposed by Cantiani and colleagues  was adop(c2) Phonological awareness. A subtest of the Developmental Neuropsychological Assessment, Second Edition (NEPSY-II)  was used(c3) Rapid automatized naming. “Denominazione Rapida di Colori” (rapid automatized naming test—RAN for Colors)  was used(d)Neuropsychological tests: visual.The following two tests of VSA were administered.(d1) The flanker (FL) task was administered to assess cognitive inhibition. This test is taken from the Amsterdam Neuropsychological Tasks (ANT) , a set o(d2) Cue effects in VSA. A classical Posner’s cueing paradigm for measuring covert visual spatial attention (VSA) was constructed following exactly the same procedure described in Facoetti et al. . The fix2, dot diameter = 3 arcmin, dot density = 1.25 dots/deg2) that could either move coherently at a constant speed (1.5 deg/s) in one of eight directions in the space  or in a Brownian manner (noise dots) within a circular frame of 6.2 deg on a black background (0.2 cd/m2). The present test consisted of high-temporal-frequency stimuli that moved across the screen and required children to identify the direction in which the coherent dots were moving. The stimulus was presented on the screen for 1000 ms; Then it disappeared and all eight possible directions appeared on the screen, indicated by eight grey arrows. Children were required to indicate the direction of the coherent moving dots by clicking with the mouse on the indicated arrow. The test consisted of five levels, corresponding to five levels of coherence, and each level was composed of eight trials. The first level started from a condition of 100% coherence , and at each level the coherence rate decreased by 2 dB . The global score was calculated as the number of correct responses (range 0–44).(d3) Motion coherence. Motion perception was evaluated with the Motion Coherence test presented in Benassi et al. . The sti(d4) Visual search. “Ricerca visiva di Colori”   was usedt-tests were performed in order to ensure that the children of the two groups differed in all and only the measures related to diagnostic criteria. Correlational analyses were performed considering the entire sample of children (n = 30). This choice was met to maximize statistical power, but also following the observation that reading and writing scores in the sample were rather homogeneously distributed along a continuum  were analyzed in children with and without DD. A series of independent samples nuum see  and couldren n = 0. This cPower analysis (G*Power ) was conFirst of all, the associations of raw scores from reading and writing tests and the levels or ratios of PUFA in the blood were analyzed through partial correlation analyses with age as a control variable. Based on emerging correlations, the associations of selected reading and writing measures with visual/auditory neuropsychological tasks were analyzed. In the last step of the correlation analysis, the associations between the auditory and visual neuropsychological functions identified in the previous step with PUFA measures that had been found to be related to reading and writing were finally analyzed.p > 0.232), and based on previously observed partial correlation patterns, age was not entered in the models.Standard GLM Mediation models (Jamovi ) were adFor all the analyses, three general scores were computed for reading and writing measures based on raw scores: (1) DDE general reading time score, i.e., the average of time used for word and nonword reading (expressed in seconds), (2) DDE general reading errors score, i.e., the average number of errors in word and nonword reading, and (3) DDE general writing errors, i.e., the average number of errors in word and sentence dictation. The same averaging process was applied to z-scores, obtaining a general reading speed z-score, a general reading accuracy z-score and a general writing accuracy z-score.A Bonferroni correction for multiple comparisons was applied in the correlation analysis between reading/writing and PUFA ).No Bonferroni correction was applied to the correlations between reading/writing variables and neuropsychological tests, since clear a priori hypotheses based on the literature predicted the associations between variables, and since such associations often concerned groups of mutually correlated variables.For mediation models, which were constructed as post-hoc analyses based on the patterns of previously observed correlations, unidirectional hypotheses were considered, and one-tailed significance values were taken .t-tests were computed to compare age, IQ, and reading and writing abilities (expressed as z-scores) in the two groups. As clearly shown, the two groups significantly differed in only the variables of interest, but all of them (see them see .The distribution of reading and writing scores (expressed as z-scores) in the two groups is shown in t-tests showed no differences between TD and DD groups in all measures of the blood levels of PUFA .In order to perform such correlation analysis, the distributions of the other two groups of variables were also examined. Considering the blood levels of PUFA in the two groups of children, the distribution for TD children is characterized by lower variability as compared to DD children, with the exception of omega-6/omega-3 ratio, which is more similarly distributed . A serieTo the same end, the performances on the neuropsychological tests, which correlate significantly with PUFA and reading/writing, were plotted as separate histograms for the two groups so as to make comparison of the distributions easier. These graphs are reported in p < 0.003). The LA/ALA ratio was positively correlated with DDE general reading time and with DDE general writing errors. No other PUFA-related values were associated with reading and writing performances. At a post-hoc analysis, ALA significantly correlated with both general reading time and general writing errors  and the levels of AA and of ALA were not associated with any measure of interest .The relationships between reading and writing scores  and PUFA levels (n = 30) were analyzed by calculating partial correlations and controlling for age . The AA/p > 0.468).As a second step, partial correlations controlling for age were computed between the reading and writing measures that had been found to correlate with PUFA ratios and the scores of the various neuropsychological tests in the two modalities, visual and auditory . PhonoloThe last step of the correlation analyses was to assess the associations between auditory and visual neuropsychological functions that were found to correlate with reading and writing, and the PUFA ratios that were significantly correlated with reading and writing .p = 0.095) could be considered significant with respect to one-tailed significance . Post-hoc analyses showed an association of AA with phonological processing  and of ALA with the flanker effect . RAN and the remaining auditory and visual neuropsychological measures did not show any significant correlations with PUFA .Partial correlation analyses (with age as a control variable) highlighted a negative correlation of phonological processing with AA/ALA ratio, and with LA/ALA ratio, and positive correlations of the flanker effect with AA/ALA ratio, and LA/ALA ratio. The correlations of left–right accuracy difference in VSA cue effect with AA/ALA ratio and LA/ALA ratio were not statistically significant, although the last correlation . Only the direct effect was significant (p < 0.001), indicating an association between AA/ALA and reading ability independent of the neuropsychological mechanisms under consideration. In the component analysis, phonological processing was confirmed to be a significant predictor of reading speed (p < 0.001), and AA/ALA was found to predict flanker effect measures (p = 0.027). Considering the full regression model, the best predictor of reading speed was AA/ALA ratio (p < 0.001), followed by phonological processing (p = 0.001), and, not significantly, by the flanker effect (p = 0.093). Overall, the regression model was significant   in the association between AA/ALA ratio (independent variable) and DDE general reading speed (dependent variable) see . The ind< 0.001) .p < 0.001), whereas the indirect effects were non-significant (p > 0.084). The most significant component predicting reading speed was phonological processing (p < 0.001), followed by the flanker effect (p = 0.033). In addition, the effect of LA/ALA on the flanker effect was significant (p = 0.047). Considering the full regression model, the best predictor of reading speed was LA:ALA (p = 0.001), followed by phonological processing (p = 0.003), and then (not significantly) the flanker effect (p = 0.058). Overall, the regression model was significant  (The second mediation model tested the roles of the same mediators in the effect of the LA/ALA ratio on reading speed see . Additio< 0.001) .p > 0.075). Additionally, the direct effect of AA:ALA on writing accuracy was not significant (p = 0.194). In the component analysis, phonological processing was confirmed to be a significant predictor of writing accuracy (p = 0.003) and the flanker effect (p = 0.016). AA:ALA was found to marginally predict the flanker effect (p = 0.027). In the full regression model, the best predictor of writing accuracy was phonological processing (p = 0.011), followed by the flanker effect (p = 0.035), and not significantly, by the AA/ALA ratio (p = 0.076). The regression model was significant   .p = 0.040) (p > 0.087). No direct effect of LA/ALA on writing accuracy emerged (p = 0.402). Considering the component effects, the most significant component predicting writing accuracy was the left–right accuracy difference in the cue effect (p < 0.001), followed by phonological processing (p = 0.001) and the flanker effect (p = 0.010). Moreover, LA/ALA was found to predict the cue effect (p = 0.024) and marginally the flanker effect (p = 0.047). In the full regression model, the best predictor of writing accuracy was the left–right accuracy difference in VSA cue effect (p = 0.001), followed by phonological processing (p = 0.006), and the flanker effect (p = 0.029). LA:ALA was confirmed to have no predictive power (p = 0.409). The regression model was significant    and the = 0.048) .A series of analyses were conducted to explore the association of PUFA blood levels with reading and writing abilities, and to examine the influences of auditory and visual neuropsychological higher and lower-level functions on the associations between PUFA and learning abilities.The correlation analysis showed significant associations of two omega-6 to omega-3 ratios with reading and writing measures, which are in line with expectations. Specifically, it was found that higher AA/ALA and LA/ALA ratios, but not AA/EPA or AA/DHA ratios, are associated with worse performances in reading speed and in writing accuracy. Significant associations were also found between reading and writing measures and some of the examined auditory and visual neuropsychological functions. High scores on phonological processing tests were associated with better performance in reading speed and writing accuracy, as predicted and as shown in many other research studies—e.g., ,49.Considering inhibition functions in VSA, correlation analyses showed an association of better performance in reading and writing tasks with a reduced visual flanker effect. In the same direction, better performance in the writing task was associated with higher speed in rapid automatized naming. The processes involved in rapid automatized naming and in phonological processing appear different. RAN tasks, for instance, require speeded retrieval of phonological codes from long-term memory and involve visual search processes and automatization of name retrieval ,65,66. BMediation models analyzing the direct and indirect effects of PUFA on reading and writing scores showed that the effects of fatty acids on learning measures appear to be direct rather than mediated by the visual and auditory neuropsychological mechanisms under investigation. The only significant indirect effect was found for the difference in accuracy between the left and right visual fields in visual-spatial cueing tasks, acting as a mediator for the effect of LA/ALA on writing accuracy. Regression analyses, by contrast, confirmed the roles of phonological awareness and other visual attentional factors as predictors of reading and writing skills. The above-mentioned effect confirms the role of VSA mechanisms in reading and writing abilities and suggests that visual low-level mechanisms may be more sensitive to the effects of favorable conditions related to the presence of higher omega-3 blood levels. More specifically, the asymmetry described for cueing tasks between the left and the right visual field is generally interpreted as an effect of altered attentional focusing ,12, whicOn the whole, then, the relationships of two specific ratios of omega-6/omega-3 (AA/ALA and LA/ALA) with reading and writing skills emerged very clearly in the results of our study.p ≤ 0.395), confirming that the ratios emerging in the present study represent completely different aspects of the PUFA profile. Even if the first ratio involved AA, representing a large proportion of omega-6 acids, a post-hoc check revealed that partial correlations of reading/writing general scores with AA did not reach significance , confirming that the ratio is more relevant than absolute PUFA levels in the blood. LA/ALA, on the other hand, was not at all correlated with AA, nor with any other fatty acid considered in the present study, again suggesting possible specific effects (to be further investigated). It should be noted, moreover, that the correlations in the present study suggest that the effects of AA/ALA and LA/ALA on reading and writing abilities are mainly mediated by ALA , and to a lesser extent by AA  and LA .Since none of the neuropsychological mechanisms which are known to affect reading and writing seems to be mediating such a relationship, a series of possible explanations can be hypothesized. First of all, these findings could be explained by a non-specific effect of PUFA on reading and writing abilities, linked to the anti-inflammatory function that is usually described for omega-3 fatty acids. Surprisingly, the ratio AA/ALA but not the AA/EPA or AA/DHA ratios, showed correlations with reading and writing performances. The explanation for an impact by the parent omega-3 rather than the longer derivatives is not immediately clear, and similar results were not observed in the literature. One report in vitro  showed tAn ad hoc search of the literature highlighted that, even if no specific effects of AA/ALA and LA/ALA have been reported till now for reading skills and DD, inverse associations were observed between maternal intake of LA/ALA and mental and psychomotor development in 6-month-old infants . Anotherp = 0.007 with AA/ALA, r = −0.597, p = 0.031 with LA/ALA ratio). Post-hoc analyses revealed significant correlations with AA and ALA (p < 0.032). However, working memory measures were available for only a part of the participants (with DD), and further studies should allow better characterization of such associations with larger samples. Indeed, several studies investigated the association between working memory and dietary intake, specifically omega-3 and omega-6, but results were variable [A last check included the two ratios AA/ALA and LA/ALA and cognitive abilities. While no significant associations were found with full-scale IQ, interesting results were obtained considering the subtests of the WISC. In particular, significant associations emerged between the two PUFA ratios and the working memory index abilities might still differ in the two groups. If such a hypothesis were true, it would be necessary to run separate analyses in the two subgroups, but the size of the present sample did not allow for this operation. The small size of the sample can thus be considered as a limitation of the study. Further limitations include the cross-sectional nature of the present study (at least at this stage), not allowing us to draw any clear conclusions about the causal direction of observed relationships. Even if a hypothetical causal chain is not equally probable in the two directions , causation is just a hypothesis. The use of mediation models, evaluating the statistical tenability of a directional relationship from the independent variable to the dependent variable, through the action of mediators, may add strength to the hypothesis , but cannot prove any direct causal role.Furthermore, it should be noted that, as stated in the section about correlation analysis, we did not find the expected significant association of learning abilities and PUFA levels with some of the neuropsychological tests, such as visual search, motion perception, and auditory rhythm discrimination. Overall, we had expected much stronger and more significant associations, as reported in other published studies ,19,20,57Potential explanations for these differences could be, once more, related to the small sample size and the inclusion of both TD and DD children in the same analysis. Even if it is largely agreed that the two groups constitute a continuum  rather tFollowing this exploratory investigation, the larger project of which the present study constitutes the first step, and other future studies on larger samples may be able to provide clearer answers to some of these unsolved questions.Two important findings emerged from the present study. The first one was the confirmation of a general, direct relationship between PUFA and reading/writing skills, regardless of the presence of specific reading difficulties. The second one was the absence of the hypothesized mediating role of neuropsychological functions as a link between PUFA levels or PUFA ratios and reading and writing performance. Even if specific pathways, possibly differing between TD and DD children, may be identified in larger samples, the results in the overall sample do not show clear effects of PUFA on neuropsychological functions that are then expressed in literacy acquisition, and rather point to other effects of PUFA on cognitive functions, to be clarified in future studies and analyses.


Individual characteristics, physical function disability, emotional, as well as cognitive symptoms, along with the general health discernment might be associated or impact the quality of life of patients suffering from stroke directly or indirectly. Appropriate continuous nursing intervention is required to enhance the quality of life of patients with stroke. Therefore, the present study will be conducted to systematically investigate the application value of continuous nursing intervention for improving the quality of life of patients experiencing stroke.We will conduct a comprehensive search of electronic databases such as MEDLINE, Cochrane Library, CINAHL, EMBASE, Scopus, Chinese National Knowledge Infrastructure, and WanFang databases to identify relevant publications. We will only include studies published in English or Chinese languages. Accordingly, randomized controlled trials evaluating the application value of continuous nursing intervention for improving the quality of life of patients suffering from stroke will be included. We will use 2 independent authors to conduct study selection, extract data, and evaluate the quality of the included studies. In case of any discrepancies, they will be addressed by consensus. Also, we will use RevMan 5.3 software to carry out the statistical analysis.The current study will summarize high-quality evidence to systematically explore application value of continuous nursing intervention for improving the quality of life in patients with stroke.The present study will summarize the direct and indirect pieces of evidence to ascertain whether continuous nursing intervention can improve the quality of life in patients with stroke.Ethical approval will not be required.https://osf.io/xnrzt/).April 25, 2021.osf.io/xnrzt/ ( An estimate by some scholars suppose that the occurrence of stroke will be estimated to increase to approximately 3 times the current rate by 2030. Accordingly, stoke is estimated to cause many symptoms and can severely impair people's quality of life, causing “mental, physical, functional, and psychological disorders, and high cost of medical care.”,4Stroke is regarded as one of the common conditions with higher incidence rates, estimated to occur at 76 to 119 for every 100,000 population every year; and result in higher mortality and disability rates among affected populations.,6 Additionally, the recovery assessment of stroke should focus on these aspects. In regards to quality of life, in the context of a person's health condition, it is considered to be a health-related quality of life. Because the aspect of health entails multi-dimensional features, health-related quality of life also covers multi-dimensional domains that are linked to the social, physical, emotional, and psychological functions.Patients with stroke mainly induce cognitive and motor disturbances such as balance, muscle power, muscle tone, gait, proprioception, and coordination; these disturbances must be included into the rehabilitation process.,9 Therefore, the present study will be conducted to systematically investigate the application value of continuous nursing intervention for improving the quality of life among patients suffering from stroke.Improving patients’ physical and mental health, along with their quality of life, it is needful to ascertain variables that can relate to stroke and manage factors that are already eminent. In conventional nursing, there are systematic educations as well as discharge guidance of disease-related knowledge in the period or process of hospitalization. This terminates the health guidance of patients following discharge. Still, with constant nursing, as an extension of high-quality medial services to the family, it is possible to comprehend the compliance behavior and treatment effect, or psychological state of a patient following their discharge from a healthcare institution. Generally, provision of medical and psychological guidance to the patients is critical to improving their quality of life.2The present study aims to explore the application value of continuous nursing intervention for improving the quality of life of patients with stroke.33.1http://osf.io/. The study will follow the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols.We have registered the protocol on the Open Science Framework  to identify relevant studies: “RCT,” “randomized controlled trial,” “randomized controlled trial,” “stroke,∗” “continuous nursing,” “quality of life.”3.3.2In addition, we will search other sources to identify relevant publications related to continuous nursing intervention.3.43.4.1We will use 2 independent authors to evaluate titles/abstracts generated using the predetermined search strategy to identify eligibility of titles and abstracts obtained from the above-mentioned electronic databases. They will consider eligibility of these papers according to the inclusion criteria specified above. They will then examine the full-texts to identify relevant studies. We will include all eligible studies in this study and resolve any discrepancies between the authors through consensus. Figure 3.4.2We will use 2 independent authors to extract data from the retrieved publications that met the inclusion criteria. We will extract the following data:1)general information: title, author, country, source, year of publication;2)intervention characteristics: nursing intervention method , duration, intervention time, length of follow-up;3)participants characteristics: sources , mean age, gender, ethnicity, sampling, number of participants;4)outcomes: Beck Depression Inventory, Fear of Stroke Recurrence Scale, degree of physical function disability, and Stroke-specific quality of life scale.3.4.3 We will resolve any discrepancies between the authors through consensus.We will use 2 independent authors will examine the risk of bias in all included texts, as per the Cochrane Risk of Bias Tool.3.4.4We will use the relative risk and 95% confidence interval to analyze the dichotomous data, and use the mean differences or standardized mean differences and 95% confidence interval to analyze the continuous data.3.4.5Where needful, we will contract corresponding authors to verify any missing outcome data.3.4.62 test and the I2 statistic will be used to assess the statistical heterogeneity across studies. In particular, P value less than .1 or I2 more than 50% will be indicative of statistical heterogeneity. Also, we will utilize the random-effects model to combine data; otherwise, we will use the fixed-effects model to merge data.Furthermore, the Chi3.4.7Sensitivity will be undertaken to examine the robustness and stability of our conclusions.3.4.8Funnel plots will be established to explain the possible small study and publication bias if applicable.4The current study aims to summarize high-quality pieces of evidence to examine the application value of continuous nursing intervention for improving the quality of life among patients suffering from stroke. Accordingly, it will explore a reference for nurses and the improvement of clinical guidelines. We consider that this is the first study to focus on evaluating the application value of continuous nursing intervention for improving the quality of life in patients with stroke. Following an increase in the number of studies that have examined the application value of continuous nursing intervention for improving the quality of life of patients suffering from stroke, it is evident that the results are debatable. To this end, the current study will be carried out to systematically explore the application value of continuous nursing intervention for improving the quality of life among patients suffering from stroke.Conceptualization: Cai-Yan Han, Xia Yu.Data curation: Cai-Yan Han, Xia Yu.Formal analysis: Cai-Yan Han, Xia Yu.Funding acquisition: Cai-Yan Han, Xia Yu.Investigation: Xia Yu.Methodology: Cai-Yan Han.Project administration: Xia Yu.Resources: Xia Yu.Software: Cai-Yan Han.Validation: Cai-Yan Han.Visualization: Cai-Yan Han, Xia Yu.Writing – original draft: Cai-Yan Han.Writing – review & editing: Cai-Yan Han, Xia Yu.


Spontaneous bacterial peritonitis (SBP) is a common and life-threatening infection in patients with decompensated cirrhosis (DC), and it is accompanied with high mortality and morbidity. However, early diagnosis of spontaneous bacterial peritonitis (SBP) is not possible because of the lack of typical symptoms or the low patient compliance and positivity rate of the ascites puncture test. We aimed to establish and validate a non-invasive diagnostic nomogram to identify SBP in patients with DC.Data were collected from 4,607 patients with DC from July 2015 to December 2019 in two tertiary hospitals in Chongqing, China (A and B). Patients with DC were divided into the SBP group (995 cases) and the non-SBP group  depending on whether the patients had SBP during hospitalization. About 70%  of patients in hospital A were randomly selected as the traindata, and the remaining 30%  were used as the internal validation set. Patients in hospital B (770 cases) were used as the external validation set. The univariate analysis and least absolute shrinkage and selection operator (LASSO) regression were used to screen variables, and logistic regression was used to determine independent predictors to construct a nomogram to identify patients with SBP. Area under curve (AUC), calibration curve, and dynamic component analysis (DCA) were carried out to determine the effectiveness of the nomogram.OR] = 1.010, 95% CI: 1.004–1.016), prothrombin time , lymphocyte percentage , prealbumin , total bilirubin (OR = 1.003 95% CI: 1.002–1.004), abnormal C-reactive protein (CRP) level , and abnormal procalcitonin levels (OR = 1.975 95% CI: 1.522–2.556). Good discrimination of the model was observed in the internal and external validation sets . The calibration curve result indicated that the nomogram was well-calibrated. The DCA curve of the nomogram presented good clinical application ability.The nomogram was composed of seven variables, namely, mean red blood cell hemoglobin concentration (odds ratio [This study identified the independent risk factors of SBP in patients with DC and used them to construct a nomogram, which may provide clinical reference information for the diagnosis of SBP in patients with DC. Liver cirrhosis (LC) results from different mechanisms of liver injury that lead to necroinflammation and fibrogenesis. Histologically, it is characterized by diffuse nodular regeneration surrounded by dense fibrotic septa with subsequent parenchymal extinction and collapse of liver structures, together causing pronounced distortion of hepatic vascular architecture –3. LC isA particular threat for patients with DC is the development of bacterial infections . PatientSpontaneous bacterial peritonitis is acute bacterial peritonitis caused by non-abdominal organ infection. Given that ascites is a good culture medium for bacteria, patients with cirrhosis are prone to SBP after ascites. SBP is a serious complication of advanced liver disease and chronic severe hepatitis, with a prevalence of 10–30% among hospitalized patients . DiffereAlthough many studies have discussed the morbidity, diagnosis, and treatment of SBP, its early diagnosis still presents some difficulties. Currently, many risk factors and diagnostic studies of DC based on clinically recognized risk factors are small-sample studies. The model has not been further verified, and the availability and accuracy of the model in clinical use cannot be guaranteed. The clinical factors involved in the study are non-clinical common factors, in daily monitoring, doctors or nurses cannot be reminded of the risk of early detection of SBP. The study design has few clinical factors, strong intervenability and is easily affected by a single influencing factor. This study aimed to establish a simple and effective method for diagnosing whether SBP occurs in patients with DC based on large samples and common clinical indicators of DC. In this study, a nomogram was employed. In addition, we developed an online application based on the nomogram to diagnose SBP in patients with DC. This work can be used to clinically evaluate patients with DC to assess the risk of SBP.This study is a retrospective review. We collected data from 4,607 patients diagnosed with DC in A hospital  and B hospital (770 cases) in the Big Data Platform of Medical Data Research Institute of Chongqing Medical University between July 2015 and December 2019.The inclusion criterion was a diagnosis of DC between July 2015 and December 2019. Exclusion criteria were as follows: patients younger than 18 years old; patients suffering from acquired immunodeficiency syndrome; patients suffering from tumors; patients with secondary peritonitis; patients with tuberculous peritonitis; and indicators with a missing rate >30%.9/L and neutrophils >0.25 × 109/L; and positive bacterial culture of ascites.The diagnosis of DC is based on LC, with complications of portal hypertension and (or) liver dysfunction. There is a basis for the diagnosis of LC: the diagnosis of LC is confirmed by liver biopsy, clinical, biochemical, and imaging data or past medical records, and the diagnosis is in accordance with the “Chinese guidelines on the management of liver cirrhosis” . The porThis study included common clinical indicators of patients with LC by consulting clinical experts and inquiring about the related literature. Etiology of LC: hepatitis B, hepatitis C, alcoholic liver, biliary hepatitis, and autoimmune hepatitis. Common complications of patients with SBP: upper gastrointestinal bleeding and hepatic encephalopathy. Laboratory data: blood routine, liver function, renal function, electrolytes, blood coagulation function indexes, and model foe end stage liver disease (MELD). Basic information and medical history information: age, sex, smoking history, drinking history, high blood pressure, and diabetes. C-reactive protein (CRP) >8 mg/L is defined as abnormal CRP, whereas procalcitonin >0.5 μg/L is defined as abnormal procalcitonin.p < 0.05. The enumeration data were expressed by rate and percentage, and the chi-square test was used for comparison between groups. All the quantitative variables do not obey the normal distribution. Those were represented by median and interquartile range (IQR) [M(Q25–Q75)], and comparison between groups was represented by the Mann–Whitney U-test. We use Originlab to draw stacked histograms of antibiotic usage. In the second step, with the aid of R software , we randomly divided the patients into two groups, namely, traindata  and internal validation set , according to a theoretical ratio of 7:3. In the third step, we adopted the least absolute shrinkage and selection operator (LASSO) regression method to analyze variables. LASSO was applied for data dimensionality reduction. The LASSO regression model employs a double-standard error by constructing a penalty function. Concerning the characteristics of this method, we screened suitable and effective risk factors for patients with DC and SBP in LASSO regression analysis and selected nine characteristic factors. Variables selected through logistic regression analysis were considered for odds ratio (OR) and p with 95% CI, and the statistical significance levels were all two-sided. On the basis of the logistic regression results, we selected risk factors with p < 0.05 and constructed a nomogram prediction model. In this study, seven variables were selected. For the validation of the model, we calculated C index, receiver operating characteristic (ROC) curve, and dynamic component analysis (DCA)  .A total of 3,873 patients were included for analyses. The baseline data of enrolled patients are summarized in The percentages of abnormal CRP level and procalcitonin in patients with SBP were 56.78 and 30.38%, respectively, or 44.60 and 12.30%, respectively, compared with those without SBP. The median hospitalization time was 15 days , 22 in pp > 0.05). The remaining variables were statistically significant, such as CRP level, procalcitonin level, length of hospital stay, calcium concentration, prothrombin time, and MELD score (p < 0.05). The analysis results are shown in A total of 50 indicators were included in this study, and seven indicators were not statistically significant after univariate analysis. For example, no statistical significance was found between patients with SBP and patients without SBP in lymphocyte count, platelet count, hemoglobin concentration, magnesium ion concentration, potassium ion concentration, albumin concentration, and creatinine concentration  for the incidence of SBP in the training cohort is shown in https://cqmuxss.shinyapps.io/dynnomappdc_and_sbp/). Doctors can enter the indicators for each patient to automatically calculate the patient's probability of SBP. To provide a plain and clear illustration of the integrated model, an example of a patient with DC is shown in The diagnostic nomogram that integrated seven selected features  and 0.117 (95% CI: 0.109–0.126), respectively. We compared the nomogram and Child-plug based on DCA. DCA visually showed that the nomogram had a superior overall net benefit within the wide and practical ranges of threshold probabilities. It further indicated that our nomogram conferred significantly high clinical net benefit, which is of great value for the accurate individualized assessment of the incidence of SBP , prothrombin time , lymphocyte percentage , prealbumin , total bilirubin (OR = 1.003 95% CI: 1.002–1.004), abnormal CRP level , and abnormal procalcitonin levels  were associated with a higher incidence of SBP. Furthermore, we developed an effective prognostic nomogram composed of seven features. The nomogram had significantly high sensitivity and specificity to distinguish individuals with SBP from DC. DCA further indicated that our nomogram conferred significantly high clinical net benefit, which is of great value for the accurate individualized assessment of the occurrence of SBP.Spontaneous bacterial peritonitis is a serious threat to the quality of life and survival time of patients with DC. Early detection of the risk of SBP in patients with DC is helpful to improve the quality of life of patients. The survival time of patients can be prolonged, and antibiotics can be better managed and utilized. In this study, we found that mean red blood cell hemoglobin concentration .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.