This study was to investigate the association of built environment (BE) with physical activity (PA) and physical fitness of residents inside the city wall of Xi’an, one of the most historic cities in China. The cross-sectional study was conducted among 728 adults in this area. BE and PA were measured by Neighborhood Environment Walkability Scale and International Physical Activity Questionnaire, respectively. Body mass index (BMI), body fat percentage, blood pressure (BP), lung capacity, curl up, sit and reach, reaction time, balance, and grip strength were also measured. The results showed, for men, aesthetics was positively associated with total and leisure-time PA, and curl-up tests, respectively. Walking/cycling facilities were positively associated with leisure-time PA. Street connectivity was negatively associated with leisure-time PA and BMI. Residential density was positively correlated with BMI. Access to service was positively associated with lung capacity. Crime safety was negatively correlated with reaction time. For women, residential density was negatively associated with transportation PA and BP. Street connectivity was positively associated with curl-up test. The results suggest some BE attributes are positively related to PA and physical fitness in this population. Creating more PA-supportive BEs is recommended in this historic area along with urban conservation. With the progress of economic development, the health consciousness of residents in China has been constantly improving. However, studies have shown that most Chinese adults do not have enough time and place to exercise, which could be harmful to their health ,2. ReseaBuilt environments (BEs) are one of the most important factors affecting PA, sedentary behaviors and health ,8,9. ForThe relationship between BE and PA has been confirmed in different countries and regions. For example, some studies found that higher scores for the BE were associated with higher levels of PA in residents of Brazil ,16,17. TPhysical fitness can predict changes in functional, psychological and social health in young and older populations . PhysicaXi’an, located in central-northwest China, has more than 3000 years of history, including over 1100 years as the capital city of ancient dynasties. It is also the oldest prefecture capital, and one of the four great ancient capitals. The city walls of Xi’an, built as a military defense system in the 14th century, represent one of the oldest, largest and best preserved Chinese city walls. It is on the tentative list of United Nations Educational, Scientific and Cultural Organization as the World Heritage Sites under the title “City Walls of the Ming and Qing Dynasties”. Since 2009, the city walls and the areas around have been protected by the cultural relics, which are different from other modern cities. New building construction or major social events inside the city wall must be approved by the government. Additionally, the Xi’an Muslim Quarter, which is a relatively large Hui community (non-Uyghur Chinese Muslims), is located inside the city wall. The Muslim Quarter has existed for centuries since the Ming Dynasty and covers several blocks inhabited by over 50,000 Muslims. Therefore, the area inside the city wall is a very well-known tourism site which is famous for its long history, diverse culture and feature food. To date, no study has investigated the BE and its relationship with PA, and physical fitness in such a historic area with traditional urban landscape.Thus, our study aimed to investigate the BE, PA and physical fitness of adults living inside the city wall of Xi’an. In our research, we hypothesized that there was a positive correlation of BE with residents’ PA and physical fitness. More activity-supportive BE (higher scores in BE attributes) were significantly related with increasing levels of PA, lower risk of obesity, lower blood pressure (BP) and increasing levels of physical fitness, respectively. Our analyses have provided new information for the association of BE with residents’ PA and physical fitness in a city like Xi’an, an ancient capital in China, and established a relevant theoretical model for improving the urban conservation while fulfilled the basic living, cultural and active living needs of local communities.The study area was the communities inside the city walls of Xi’an in the northwest of China. Xi’an is one of the few cities in China where the imposing old city walls still stand. Built in 1370 during the Ming Dynasty, the magnificent 12 m-high walls form a rectangle with a perimeter of 14 km. The opening of gates through the city wall helps to maximize its preservation while meeting the needs for urban transportation. Currently, the city wall has been transformed into an urban public space facilitated by the surrounding building into a city-dominated landscape. Xi’an was also the first city in China where Muslims started arrived since 651, during the Tang Dynasty. Xi’an’s Muslim community is located inside the city wall, and the population is estimated to be around 50,000.In this study, 728 residents from 15 different communities inside the city wall of Xi’an were recruited through community hospitals for our study. Participants were those aged 18 years and older, with normal reading and speech abilities, and no cognitive impairment diagnosed by doctors. The average age of participants was 46.9 ± 13.5 years old. All participants in this study have signed written consents to participate. The study was approved by the ethics committee of Shaanxi Normal University. A structured questionnaire was designed and issued in September 2018. Additionally, height, weight, body fat percentage (BFP), BP, lung capacity, curl up, sit and reach, reaction time, balance, and grip strength were tested in our laboratory.Participants were asked to fill the questionnaire about their individual characteristics, including sex, age, address, employment, history of chronic disease, family income, et cetera. The Chinese version of Neighborhood Environment Walkability Scale—Abbreviated (NEWS-A) and International Physical Activity Questionnaire—long version (IPAQ-L) were completed in the questionnaire survey. The questionnaires were filled by our research team members through one-to-one interviews to ensure the quality.There were eight dimensions in the NEWS-A, including residential density (score range: 173–594), land use mix diversity (range: 1–5), access to services (range: 1–4), street connectivity (range: 1–4), walking and cycling facilities (range: 1–4), aesthetics (range: 1–4), traffic safety (range: 1–4), and crime safety (range: 1–4) . IPAQ-L Body height and weight were measured with the participants taking off their shoes and standing on the scale platform. The participants were asked to stand in front of the vertical scale and face forward maintaining a horizontal focus. A bar from the top of the scale was pushed down to the top of the participant’s head. The height and weight were recorded by the scale.Body composition tests were performed by Inbody 230 . The participants removed all metal objects and took off their shoes and socks during the test. The metal area of the machine was in direct contact with the skin.BP was measured by trained staff using an automated device  with appropriate mid-upper-arm circumference cuff size. BP measurements were taken on the left arm of each participant in a sitting position after being at rest for at least two minutes. Two readings were made three to four minutes apart and the averaged readings were recorded.Lung capacity was measured by electron pneumonometer . The largest exhalation volume was recorded of three attempts. Participants were reminded not to blow too hard, not to stop halfway, and not to block the air outlet.Flexibility was tested by sit and reach test . Participants were told to straighten their legs after taking off their shoes, and their upper limbs are straightened to push the card mark at a uniform speed. Participants were reminded to keep the continuity of the movements. Both hands should remain at the same level, not one reaching further forward than the other. After some practice reaches, the participants reached out and held that position for one to two seconds while the distance was recorded.Curl up test was used to test the strength and endurance of the abdominal muscles. It required the participants to perform as many curl-ups as possible in one minute. The participant began by lying on their back, knees bent at approximately 140 degrees, feet flat on the floor, legs slightly apart, and arms straight and parallel to the trunk with palms of the hands resting on the mat. The fingers were stretched out and the head was in contact with the mat. The measuring strip was placed on the mat under their legs so that their fingertips were just resting on the nearest edge of the measuring strip. The feet cannot be held or rest against an object. Keeping their heels in contact with the mat, the participant curled up slowly, sliding their fingers across the measuring strip until the fingertips reached the other side, then curled back down until their head touched the mat. Movement should be smooth and at the cadence of 20 curl-ups per minute (1 curl-up every 3 s).Reaction time was conducted to assess the neurofunction and muscle response. The participants pressed the red button to initiate a signal so that the system  returned a signal by lighting one of five green buttons. The participant then pressed the lit green button as quickly as possible, and the time between the red and green button pressing was measured. A total of five measurements were taken and the average time was recorded.Grip strength was tested by hand dynamometer . Participants kept their feet apart in an upright position and their arms were drooped naturally. They were required to squeeze the dynamometer twice with the dominant hand and take the maximum value. Their hands were not allowed to touch their legs.One-foot standing test with closed eyes was used to evaluate their balancing ability. The participants were asked to stand on the sensor with their feet together and their arms at their sides. When instructed, they closed their eyes and lifted one foot (either one) off the ground until they swayed while balancing, used arms to balance, hopped to maintain balance, or put the lifted foot down. The participants repeated the assessment three times, and the longest time was recorded.The equipment, protocol, and testing items were calibrated, and the same models of the equipment were used for every measurement. For comparison, all equipment and protocols matched those used by the General Administration of Sport of China.p < 0.05. All the analyses were conducted by SPSS 24.0 software .Independent variables were the eight dimensions of environmental variables , as well as the total scores of BE. The dependent variables included PA, body mass index (BMI), BFP, BP, lung capacity, curl up, sit and reach, reaction time, balance, and grip strength. Descriptive statistics were used to describe sample characteristics. Significant differences were found in most dependent variables between different sex groups. Thus, all the analyses were done within each sex group. A mixed regression model was used to analyze the association of BE with PA ) and physical fitness of the participants, with age, work status, ethnic group, number of family numbers, and marital status as the control variables. In the regression model for the relationship between BE and physical fitness , diastolic blood pressure (DBP), lung capacity, curl up, sit and reach, reaction time, balance, and grip strength), age, work status, ethnic group, number of family numbers, marital status, and total MVPA were controlled. Statistical significance was set at p < 0.05). The MET values of different types of PA for men and women are shown in p < 0.05). Women had significantly more household PA, household PA%, and less leisure-time PA%. BMI was significantly higher in men while BFP was significantly higher in women (p < 0.05). Men performed significantly better in grip strength, lung capacity, but worse in sit and reach than women (p < 0.06). Similar analyses have been done for different ethnic groups (Han or Hui groups). No significance has been found between Han and Hui groups (p > 0.05).The BE scores in each dimension were relatively medium to high according to the ranges of the scores  in this studied area. Significant differences existed in the scores of residential density and access to services between women and men (p < 0.05). Street connectivity was negatively associated with leisure-time PA in men (p < 0.05). Walking/cycling facilities were positively associated with leisure-time PA in men (p < 0.05). Residential density was negatively associated with transportation PA in women (p < 0.05). No significant correlation was found between other BE features and transportation/leisure-time PA (p > 0.05). Work-related PA and domestic and gardening PA were also analyzed in our study. However, no significant relationship has been found. Therefore, they were no longer presented in the table.The correlations between BE and PA are shown in p < 0.05). Street connectivity was negatively associated with BMI (p < 0.05). For the women, residential density was negatively associated with SBP and DBP (p < 0.05). No significant association was found in other measurements (p > 0.05).The correlations between BE and BMI, BFP, SBP, and DBP are presented in p < 0.05). Access to services, traffic safety, and land use mix diversity were negatively associated with sit and reach test, respectively (p < 0.05). Crime safety was negatively correlated with reaction time (p < 0.05). For women, street connectivity was positively associated with curl-up test (p < 0.05). No significant association was found in other measurements (p > 0.05). Due to the space limits, the testing results of grip strength and standing test with closed eyes were not listed in The correlations between BE and physical fitness are shown in In the present study, questionnaire surveys and objective physical fitness tests were conducted to identify characteristics and relationships of BE with PA and physical fitness among adults living inside the city wall of Xi’an. In recent years, Xi’an has become an important economic, cultural, industrial, and educational center in the central-northwest region of China. In this study, we found that the BE in this area is favorable for PA and physical fitness because the modern city can provide convenient facilities and resources. Men mainly engaged in leisure-time PA, while women mainly engaged in household PA. No significant difference has been found in PA and physical fitness between Han and Hui ethnic groups, indicating their lifestyles may be similar after long-term cultural communication with each other. For most measures, more activity-supportive BE attributes were associated with higher levels of PA and better physical fitness among residents living inside the city walls in Xi’an, especially for men. Our study is one of the first to investigate the association of BE inside the city wall of Xi’an with PA and physical fitness of residents living in such a historic area with diverse cultural context. It provides urban planners with potential priorities for healthier neighborhoods in local communities while improving the urban conservation in historic Chinese cities.In our analysis of the relationship between BE and PA, BE attributes were related to total PA, transportation PA, and leisure time PA. This was consistent with the socio-ecological model  and seveIn our analysis of the association of BE with BMI and BP, residential density was positively correlated with BMI, and street connectivity was negatively associated with BMI in men. BE was not associated with the adiposity of women. Previous research has shown that a more activity-supportive BE and a higher level of PA were related to a lower probability of obesity ,43,44,45The association between BE and physical fitness was mixed between men and women. For men, access to services was positively associated with lung capacity. It has been shown that higher levels of access to services are significantly associated with PA ,50,51, tThe strengths of our study included: firstly, the selected research area was representative, and it was also the first time the correlation of the BE of a historic city with residents’ PA and physical fitness was analyzed in China. Secondly, the physical fitness, including lung capacity, curl up, sit and reach, reaction time, balance, and grip strength, as well as BMI, BFP, and BP were objectively evaluated in our study, providing detailed information about the aerobic capacity, muscle strength, flexibility, balance, and attention in this population. Finally, the NEWS-A and IPAQ-L are internationally recognized and have high reliability and validity, which can effectively provide the data needed for this study. The quality of questionnaire filling was high, which avoided the deviation of data caused by a different understanding of personal subjective factors. The present study had several limitations. Firstly, although we avoided deviations as much as possible in the process, the measurements of BE and PA were both evaluated by self-reported tools. Same source bias may result in associations between independent and dependent variables. However, it still provided some new information about the levels of BE and PA and their possible relationships for men and women living inside the city wall of Xi’an. Fortunately, the relationship between the BE and physical fitness was more convincing because objective measurements were conducted for the physical fitness tests. Secondly, it was a cross-sectional study, and causal relationships cannot be inferred. Third, the pattern of the results was mixed because the association for different sexes, aspects of BE, and physical fitness varied and needs to be discussed respectively. Finally, social and psychological factors were not studied in this study. Some research has shown that social support and self-efficacy may also be correlated with residents’ PA and health status. In the future, objectively measured BE and PA, such as by GIS and accelerometer, should be used to investigate this area. Longitudinal or experimental studies considering more personal deviation will help to figure out the impact of BE on PA and physical fitness.In general, higher rated BE attributes were associated with higher levels of PA and better physical fitness among residents living in this historic area, especially for men. Characteristics like residential density and street connectivity were better-related to BMI and BP, while access to services, aesthetics, and crime safety were better-correlated with some physical fitness variables. The study suggests designing activity-supportive BEs should be a higher health priority to increase PA and enhance physical health of local residents. Further research is necessary to dig out the exact impact of BE on PA and physical fitness to promote wellbeing of city residents while improving the urban landscape of those historic cities.


The logistic regression model incorporating age, depression, disability, and physical performance was found to have high discriminative accuracy  for predicting the risk of malnutrition. The results of the study confirm the need to assess nutritional status and to investigate the presence of risk factors associated with malnutrition in order to achieve effective prevention and plan a better intervention strategy.Malnutrition is common in older adults and is associated with functional impairment, reduced quality of life, and increased morbidity and mortality. The aim of this study was to explore the association between health (including depression), physical functioning, disability and cognitive decline, and risk of malnutrition. Participants were recruited from nursing homes in Italy and completed a detailed multidimensional geriatric evaluation. All the data analyses were completed using Stata Version 15.1. The study included 246 participants with an age range of 50 to 102 (80.4 ± 10.5). The sample was characterised by a high degree of cognitive and functional impairment, disability, and poor health and nutritional status , 38.2% were at risk for malnutrition and 19.5% were malnourished). Using a stepwise linear regression model, age (B = −0.043, SE = 0.016,  Malnutrition describes a deficiency of a wide range of nutrients and results in significant adverse effects on body composition, function, and clinical outcome. It is common in older adults, particularly in nursing home residents where prevalence is estimated to be between 20 and 90% due to different diagnostic criteria ,2. AnoreMalnutrition is associated with functional impairment, reduced quality of life, and increased morbidity and mortality ,7,8. TheIdentifying risk factors for malnutrition is of utmost importance to better guide intervention and prevention strategies. In all care settings, it is important to characterize the determinants of malnutrition, as intervention strategies may need to be more general and focused on the improvement of structural characteristics of the hospital/nursing home facility as well as on the specific rehabilitation process of the individual patient. Although several studies have been conducted in Italy on the prevalence of malnutrition in nursing homes ,17, few Although the main risk factors for malnutrition in nursing homes are known, the prevalence of malnutrition remains high. It is therefore important to continue to emphasize this contradiction between research and clinical activity in order to contribute to the improvement of care for nursing home residents.The aim of this study was to explore the association between health (including depression), physical functioning, disability and cognitive decline, and risk of malnutrition in an older Italian population of institutionalized adults.Participants were recruited from seven nursing homes in the Latium region, Italy. Full details of the methodology have been previously published . In brieThe study protocol was approved by the Local Ethics Committee-Sapienza University, Policlinico Umberto I of Rome, Italy (protocol number 847/17). Oral and written informed consent was obtained from all participants or their legal representatives where individual consent was not possible .All participants completed a detailed multidimensional geriatric evaluation administered by a trained investigator. The assessment lasted approximately two hours.Disease-related multi-morbidity was assessed using the Cumulative Illness Rating Scale (CIRS)  that ratGlobal cognitive function was assessed using the Mini Mental State Examination (MMSE) test . This inImpairments in Activities of Daily Living (ADL) were assessed using the Katz  scale. TThe Short Physical Performance Battery (SPPB)  was usedDepression was assessed using the Geriatric Depression Scale Short Version (GDS) , a 15-itHeight, weight, and calf and mid-arm circumference were measured. All methods followed the procedures as described in the “Anthropometric standardization reference manual” . The samn = 8 items: mobility, psychiatric, and neurological problems including stress, prescription medication use, living arrangements, functioning, mode of feeding); (2) anthropometric assessment (n = 4 items: body mass index (BMI), weight loss during the last three months, and mid-arm and calf circumference); (3) dietary assessment ; (4) subjective assessment . A weighted score is assigned to each item. The total score ranges from 0 to 30 .Nutritional status was assessed using the Mini Nutritional Assessment (MNA) . The MNAn = 2 items), psychiatric status , mobility (n = 1 item assessing ability to move about or being bed/chair bound), and comorbidity . This minimizes recall bias (in older participants with cognitive impairment/dementia) and redundancy with cognitive measures [For the main analyses, the score was modified (M-MNA) to remove subjective items related to nutritional and health status (measures . The totmeasures  using peContinuous variables are presented as means and standard deviation (SD), or as median and interquartile range (IQR) for non-normally distributed variables. A percentage (number) was used for categorical variables. Gender differences in nutritional status and demographic, health, functional, cognitive, and depression variables were tested using the chi-squared test for categorical variables or the t-test . All analyses were completed using Stata Version 15.1.p = 0.05) to determine independent predictors of nutritional status. The magnitude of associations was reported as beta coefficients and standard errors. Logistic regression analysis was used to determine how well the stepwise selected model predicted nutritional status. Predictive accuracy was tested using the area under the curve (AUC) with 95% confidence intervals (95%CI). The Hosmer–Lemeshow test was used to assess model goodness of fit.Multivariable linear regression analyses, controlling for age and sex, were used to test the association(s) between nutritional status  and each independent variable , separately. Significant variables were then entered into a stepwise linear regression analysis  were recruited; 4 subjects were excluded due to inclusion/exclusion criteria, while 4 subjects denied consent to participate (response rate 98.4%). The MNA score was therefore calculated in 246 participants. Age ranged from 50 to 102 . The percent of missing data was low and ranged from 0%  to <1% . Therefore, a complete case analysis was used.The clinical and functional characteristics of the present cohort are shown in p = 0.010), depression , disability , and physical performance  remained significantly associated with the M-MNA score and were therefore retained in the final model (adjusted R-squared = 0.298).As shown in n = 245) for predicting the binary outcome of normal nutritional status vs. impaired . The model was well calibrated, as indicated by the H-L test .The logistic regression model including age, depression, disability, and physical performance was found to have high discriminative accuracy  . This isMalnutrition was associated with increased age and high levels of disability and depression similarly to results from other studies. With regard to age, previous studies have found that the prevalence of protein-energy malnutrition increases with age, particularly in individuals 70 years old ,8,9. In In contrast, while cognitive status, physical performance, and disease-related comorbidity were significantly associated with malnutrition in the univariable analysis, they were dropped from the multivariate analysis. This is in agreement with some, but not other studies. Indeed, a study by Kaipainen et al.  found thIn our study, lack of significant findings could be due to multicollinearity. For example, physical performance is correlated with disability, while age and depression may stand for the impact of cognitive impairment and comorbidity on the nutritional status. Further, in a cross-sectional study, reverse causality is likely . The study is cross-sectional; therefore, it is not possible to test for causation or investigate changes in nutritional status over time.The age range listed in our sample is quite large. The nursing homes in which the study was conducted, on the basis of Italian law, admit mainly elderly subjects, but above all, subjects with a high degree of frailty. Only 17 subjects less than 65 years and 14 less than 60 years were enrolled in our study. The elimination of subjects under the age of 65 did not modify the results of the study.The study has a number of strengths. First, a nutritional evaluation was performed on all the nursing homes’ residents, thus avoiding selection biases. In particular, cognitive impairment, disability, and comorbidity did not impact recruitment, allowing a greater representative sample. Second, a multidimensional evaluation was performed and allowed for a more precise definition of the individual role played by different risk factors on nutritional status.https://www.nutritionday.org/cms/upload/pdf/11.resolution/Resolution_of_the_Council_of_Europe.pdf; accessed on 25 August 2020). These parameters are not surveyed in studies concerning malnutrition, even if their consideration and correction could contribute to significantly improve the nutrition status of residents in nursing homes.Age and physical and mental health were found to be significantly associated with poor nutritional status. This result suggests to assess nutritional status and investigate the presence of risk factors associated with malnutrition in order to achieve effective prevention and plan a better intervention strategy. In particular, in future studies, the quality of assistance in nursing homes should be considered. For many years, different aspects of nutritional care have been highlighted as important determinants of nutritional status in hospitals and nursing homes (


Moreover, there were significant differences of interaction factor when comparing MM vs. PE in total score at pre-post , favoring PE with medium and high effect sizes. Regarding General Health Questionnaire (GHQ) variable, practicing MM showed significant effects in time factor compared to pre-Fup2. No significant differences were found for IgA. Thus, practicing both MM and PE as recovery strategies during lunch breaks could reduce perceived stress after five weeks of practice, with better results for PE. Moreover, practicing MM could improve mental health with effects for 6 months.This research analyses the effects of mindfulness meditation (MM) and physical exercise (PE), practised as daily recovery activities during lunch breaks, on perceived stress, general mental health, and immunoglobin A (IgA). A three-armed randomized controlled trial with 94 employees was conducted for five weeks including two follow-up sessions after one and six months. Daily practice lasted 30 min maximum. Perceived stress and general mental health questionnaires and saliva samples were used. There were significant differences in time factor comparing pre- and post-test of Perceived Stress Questionnaire (PSQ) both for PE [Mdiff = 0.10, SE = 0.03,  The lifestyle of advanced industrial societies is characterised by time pressure, competitiveness, job insecurity, 24/7 availability, sensory overload and multitasking in order to successfully fulfill a variety of roles . Stress More specifically, stress may entail the continuous adaptation of the neuroendocrine and immune systems . In thisWork and workplace-related issues are common sources of stress . Work-reAll this implies significant financial costs to society. In the European Union, the cost of work-related depression is estimated at € 617 billion a year, including costs to employers resulting from absenteeism and presenteeism (€ 272 billion), loss of productivity (€ 242 billion), health care costs (€ 63 billion) and social welfare costs due to disability benefit payments (€ 39 billion) .In this context, it seems crucial to find effective solutions. Sometimes, employees seek help to develop stress management strategies through psychotherapy, training courses, effective communication techniques, social support and relaxation exercises. At other times, companies implement changes to the work process, introducing flexible schedules, effective division of tasks, or a combination of both . RichardBoth practices can be considered recovery activities, within the framework of active rest strategies widely researched by Sonnentag and Fritz since 2005 . AccordiRecovery processes can occur in various temporal and situational settings . In thisThere is a critical need for effective methods to reduce work-related stress that may be employed by a large number of people, are easily accessible and have few side effects, and can be self-directed and practised with no time or location restrictions . These fPrevious investigations show that mindfulness-based interventions (MBIs) and aerobic exercise could improve mental health and promote wellbeing ,51,52, pMindfulness meditation (MM) is a practice based on Buddhist traditions, which develops full attention and awareness through sitting meditation. It has rapidly gained popularity in the Western world due to its accessibility and easy practice. Jon Kabat-Zinn included this sitting meditation together with other practices—yoga and body scan—in his mindfulness-based stress reduction (MBSR) programme, an eight-week course, which trains full attention in everyday practice. Kabat-Zinn (1990)  defined On the other hand, physical exercise (PE) has been recognised for decades to maintain health, prevent illness and promote rehabilitation . Its effResearch has been conducted to compare the implementation of MM and PE in the workplace, whether combined or individually, with interesting results ,27,69. NWe hypothesised that both interventions would reduce perceived stress and improve general mental health after five weeks of practice, but we did not have specific hypotheses about how long the effects would last or which intervention would be most preferable for each measure because of the lack of previous research comparing these interventions during lunch break. We also hypothesised that there would be no significant effects or differences on the IgA from the interventions in the medium term (5 weeks). sIgA was analysed as an objective variable to indicate whether and when the practice of MM and PE improves its response capacity. This parameter has been chosen in order to gain insight into a subject which seems to divide researchers. Some trials have found a clear relation between MM or PE and improved sIgA response when the latter is measured before and after the practice, with an interval of between 30 and 120 min ,17. OtheThe analysis of the required sample size required 111 people, taking as reference the interaction factor with a power of 0.80, an alpha value of 0.05, and correcting the criterion of non-sphericity to 0.75 in order to reach a size of the effect between moderate and high (f = 0.39). Previous studies similar to ours (19) and WebPower package were used for R program (27).n = 23, 76.7% women) had an average age of 47.4 ± 3.84. The participants of the PE group  had an average age of 47.77 ± 5.16. Finally, the participants of the control group  had an average age of 45.44 ± 8.66. All participants were employed by a multinational telecommunications company specialising in the service sector, had a permanent contract and a 9 a.m. to 6 p.m. work schedule, with a maximum lunch break of one and a half hours. Regarding their marital status, most of them were living with a partner: 61.1% (n = 44) were married and 20.8% (n = 15) had a stable non-marital partner. 93.1% (n = 67) of participants had completed university studies, including bachelor’s, master’s and doctoral degrees.The random sample consisted of 123 people. All subjects were, coincidentally, white (100%), and 67% were women with an average age of 46.81 (SD = 6.37). The participants of the MM group  who already practiced MM (n = 2) or PE (n = 20) more than once a week or who suffered some type of mental illness (n = 4 needed medication for depression and insomnia problems) or physical illness (n = 3 had chronic back pain).In order to obtain a homogeneous sample within the framework of the service sector, the selection of participants followed two inclusion criteria: mid-level professionals of the same organization, in this case team leaders, with medium levels of perceived stress at 0.35 (SD = 0.14) according to the Perceived Stress Questionnaire , with a -Deverts . The samThe Human Resources department made the recruitment by sending emails with the invitation to participate in the trial to workers of the company with equal levels of responsibility. Once all participants were registered, and before agreeing to participate by signing the informed consent form, they were randomly allocated to the PE, the MM or control group conditions (ratio 1:1:1). Potential participants were given participant numbers upon enrolment with Stata software by independent research assistants who had no access to the randomization form. Participants received information on the condition to which they were allocated after the baseline measurements, composed of an online questionnaire for sociodemographic data, the Perceived Stress Questionnaire , the GenThe study was approved by the Research Ethics Committee at Rey Juan Carlos University  and registered at ClinicalTrial (NCT03728062). All participants completed the questionnaires and their saliva samples were collected at the end of the working day (at approximately 6 p.m.). Perceived stress and General mental health levels were measured at four different moments in time: pre-test, post-test and two follow-up measurements after one and six months. In the case of immunoglobulin A, saliva samples were collected three times . Additionally, each participant kept a record of his/her daily practice, which was supervised on a weekly basis.Each of the three groups attended a four-hour information session. The first part of the session included a brief talk, which explained the effects of stress on mental and physical health, and the importance of recovery strategies. The second part focused on the general protocol of the intervention—length of the practice, collection of saliva samples, when to complete questionnaires, how to keep record of daily practice, etc. These two parts of the session were the same for the three groups. The third part of the session only involved the active intervention groups and was specific to each case. A certified and experienced MBSR instructor gave the participants of the MM GROUP training on mindfulness meditation practice. The participants of the PE group also received training, in this case given by a certified and experienced physical education instructor who explained the main aspects involved in aerobic exercise—outdoor or gym workouts, number of beats per minute, warm-up routine, etc.The intervention took place during the five working days of five consecutive weeks, during which the two active groups practiced MM or PE during the lunch break (before having lunch), with equal time intervals of 15 min in the first week, 20 min in the second week, 25 min in the third week and 30 min in the fourth and fifth weeks. Each group had a weekly meeting with its instructor (MM and PE) who would introduce the weekly practice and clarify doubts. All participants kept a daily record of their practice in order to control that their adherence to the practice was at least 70%.The MM group met with its certified MBSR instructor on Mondays, who explained the week’s meditation, based on Jon Kabat-Zinn’s MBSR Programme . ParticiOn the other hand, the PE group practiced aerobic exercise, which mainly consisted of running, training on an elliptical machine, rowing or cycling, outdoors or in the gym. Participants could choose the type of exercise they wanted to do and where to do it. However, the records show that most of them used the company’s gym. Participants started their exercise routine with a 5 to 7 min workout. They also had to maintain between 120 and 140 heartbeats per minute during their practice. The intervention was supervised by a certified instructor—bachelor’s degree in physical activity and sports sciences—and experienced physical activity trainer.Stress levels were measured using the Perceived Stress Questionnaire designed by Levenstein et al. , where tGeneral mental health was measured using the short version of the General Health Questionnaire  validate® tubes . The saliva samples were frozen and kept at −20°C immediately after arrival at the university laboratory, until they were sent to an external laboratory for analysis. SIgA levels were measured by nephelometry (BN-II), using the reagent OSAR15 anti-IgA (Dade Behring), with a sensitivity of 0.2 mg/dL. SIgA levels are expressed in mg / dL.Salivary IgA response levels were determined through the collection of saliva samples in SalivetteOverall, three sets of statistical analysis were conducted. First, data were explored to verify normal distribution. Secondly, a descriptive analysis of the sample was conducted comparing, in addition, the experimental groups in the sociodemographic and dependent variables on the baseline, running the Chi-square test , together with a univariate ANOVA for the analysis of quantitative variables. Thirdly, the analysis of the effects of the interventions is carried out through an intention-to-treat analysis by adjusting a mixed linear model (MLM) using the maximum restricted likelihood method for the group, time and interaction factors (group x time). These models have several advantages over the general linear model, allowing the assumptions of independence to be relaxed, especially important in designs with repeated measures, as well as that of equality of variance, since it allows working with different covariance structures .On the other hand, it allows all available data to be used, which avoids having to use imputation methods for missing data. Likewise, effect sizes (ES) are reported by ω 2 in the analyses of the main effects, and d for the analysis of multiple comparisons . For eacmain effects of the intragroup (Time), intergroup (Group) and Time X Group interaction factors , p = 0.02, ω 2 = 0.09], and in harassment-social acceptance dimensions , overload , and irritability-tension-fatigue . However, no significant differences were found for the interaction factor in GHQ or IgA.Regarding the time factor, since the intragroup efficacy of the different interventions is evaluated, apart from the energy-joy dimension (PSQ) and the sIgA variable, the set of analysed variables showed significant differences , with effect sizes ranging from moderate to high in PSQ , and in GHQ .As for the group factor analysis compares the different interventions at each time point, regardless of the baseline. It has not shown statistically significant differences in any variable.The main effects seen above allow us to determine on which factor the significant effects  rest, but it does not allow us to discriminate between on which elements of the possible comparisons the differences occur within each factor. This issue is addressed by analysing the simple effects (multiple comparisons) with the corresponding correction of the type I error. These comparisons are made on those factors that have significant results in the variables previously analysed in the main effects  at each time point with respect to the baseline. The results show significant differences in most pre-post comparisons with medium and high effect sizes. Specifically, the total PSQ score for MM vs. PE was  and for PE vs. CG was . In the case of the subscales, it gave the following significant results: harassment-social acceptance for MM vs. PE  and for PE vs. CG ; overload for MM vs. CG  and for PE vs. CG ; and irritability-tension-fatigue for MM vs. PE  and for PE vs. CG .time factor. As seen in Finally, we have evaluated the intragroup efficacy of MM and PE interventions derived from the significant major effects of the In addition, correlations between the amount of final practice and the degree of recovery in PSQ, GHQ and IgA (pre-test—post-test change scores) were performed without significant differences .The present study proposes that both MM and PE practised during lunch breaks could be considered recovery activities from stress during lunch time since they significantly improve perceived stress of employees, where medium and high effect sizes are observed after 5 weeks of practice . HoweverRegarding mental health , we haveFinally, regarding IgA, neither one of these practices involve an improvement in sIgA response capacity, neither intragroup nor intergroup. As in the Song & Baicker study , we haveHowever, our results contradict those of other studies which did find significant results, such as the study conducted by Bellosta-Batalla et al.,  on MM anWe are not aware of any studies on mindfulness or physical exercise practised as recovery activities during lunch breaks, although there is evidence of comparisons of other practices, such as progressive muscle relaxation and small-talk break groups , exposurWe agree with Edwards’ systematic review  on the cThe strengths of this study include a three-armed randomised controlled design—with up to 8 repeated measurements—the use of scales validated for the Spanish population, statistical methods and biological measurements, with medium to large effect sizes in the results of subjective variables. However, the study involves certain limitations. For example, the sample cannot be considered representative of the population as a whole, since it consists of university-educated Caucasian workers employed in a very specific sector. Some of the study’s data were obtained from self-reported measures, subject to social desirability bias. Taking into account the limitations and results of this study, it would be relevant for future investigations to evaluate full attention and exercise programmes with a sample that includes higher racial/ethnic diversity, and different socioeconomic backgrounds and professional sectors. It would also be appropriate to increase the timespan of the practice to, at least, three months since most studies only entail eight weeks, and perhaps this is not enough time for significant effects of mindfulness intervention; since this is an eminently cognitive practice, it may require more time than physical exercise to learn, assimilate and have significant effects in the short and medium term.Finally, we have been informed that two small groups with 74% of participants of the MM group and 45% of the PE group, spontaneously developed from the original intervention groups, continued practising MM and PE after the end of the study. We consider that it would be interesting to conduct future studies on the effects of these “spontaneous” groups the interpersonal relationships in the workplace, in order to analyse whether these practices are beneficial in promoting better working environments. Previous research has shown the associated effects of social commitment on mental health ,96.The practical implications of this study derive from the results discussed. Additionally, the possibility of conducting short effective internal recovery practices during the lunch break may make these activities suitable for busy employees who have a higher workload, an important limitation in this type of intervention . AnotherThe present study provides preliminary evidence on Mindfulness Meditation and Physical Exercise as recovery strategies during lunch breaks in the workplace to reduce perceived stress after five weeks of practice, with better results for Physical Exercise compared to Mindfulness Meditation. However, practicing Mindfulness Meditation at lunch break could improve global mental health in the workplace with effects lasting for six months. No significant results were found for IgA in saliva neither in intragroup nor between-groups comparisons.


Data were collected through a questionnaire survey of community-dwelling people with severe disability attending 65 healthcare centers. The survey included the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) and sociodemographic factors. We categorized a registered grade of disability of 1 or 2 as severe disability. WHODAS 2.0 domain and summary scores were compared between the ABI and SCI groups, and risk factors associated with disability were identified through regression analysis. ABI participants had significantly higher disability in cognition and relationships, whereas patients with SCI had higher disability in mobility (p < 0.05). Onset duration was negatively correlated with cognition, relationships, participation, and summary scores in ABI participants (p < 0.05). Neither group’s socioeconomic factors were associated with WHODA 2.0 scores. Understanding the different patterns of disability between SCI and ABI in community-dwelling people with severe disability helps establish future plans for the management of health resources.Central-nervous-system (CNS) injuries constitute a significant cause of morbidity (often resulting in long-term disability) and mortality. This cross-sectional study compared the activity and participation of community-dwelling people with severe disability from acquired brain injuries (ABI) ( Neurological conditions are among the leading causes of disability and are associated with a substantial burden on patients, their families, and the public health system ,2. Of thThe incidence of stroke per one million persons with income in South Korea was 2650, while that of SCI was 50 ,4. InjurThere are numerous instruments for evaluating the severity and outcomes of patients with CNS injuries, including brain injury and SCI ,9,10,11.Many previous studies focused on the medical problems and treatment of CNS injuries ,15, whilIn Korea, disabilities are classified into 15 groups, and diagnosis is made by the respective medical specialist. Of the 15 disability groups, CNS injuries are divided into two groups: SCI is classified as a physical disability, while disabilities arising from the brain such as stroke, TBI, hypoxic–ischemic brain injury, and PD are classified as brain impairments. The severity of disability is graded from 1 to 6, indicating very severe to very mild disability, on the basis of functional losses and clinical impairment. The disability-grading system for SCI is based on the manual muscle test, whereas that for ABI is based on gait function and activities of daily living. Numerous public healthcare plans for people with disabilities have been equally applied to CNS injury patients with different disease groups. For example, a rehabilitation program incorporating neurodevelopment therapy was equally provided on the basis of medical insurance for both ABI and SCI groups. People with severe disability generate a higher burden for society and require substantial health-related resources throughout their lives. Thus, understanding the differences in patterns of disability between the two groups, and applying this understanding to healthcare plans may yield important benefits for health-resource management.This study sought to evaluate differences in the patterns of disability in people with severe CNS injuries from different causes. The objective of this study was to compare the activity and participation of community-dwelling people with severe disability of different origins, acquired brain injury (ABI) or SCI, and identify risk factors related to disability.This community-based cross-sectional study was conducted in public-healthcare centers (PHCs) in Korea from March to May 2013. Officers who worked in community-based rehabilitation programs in each PHC were trained to administer the 36-item version of WHODAS 2.0 in Korean via face-to-face interviews with home-dwelling people with severe disability. A written questionnaire survey was also administered. The study collected the following sociodemographic information: age, gender, duration of disability, area of residence, type of household, cohabitation with a partner, occupational status, and economic status. The ethics review board of the Korean National Rehabilitation Center approved this study (IRB No. NRC-2012-06-041).We enrolled participants with ABI and SCI aged 20 or older who had lived in the district for more than 2 years. Participants with stroke, TBI, hypoxic–ischemic brain injury, and parkinsonism were enrolled for the ABI group, while participants with myelopathy and traumatic SCI for the SCI group. The detailed International Classification Disease code for each disease is available online . This stTo compare the activity and participation of individuals with severe ABI and SCI, this study focused on people with severe disability, designated as Grade 1 or 2 in the Korean National Classification System of People with Disabilities. The study sample included two groups: ABI with severe disability and SCI with severe disability. Participants answered sociodemographic questions and completed the WHODAS 2.0. A total of 1340 community-dwelling people with disabilities received the questionnaire, and 1288 (96.1%) responded. Excluding responses with missing and invalid data, 967 (72.1%) responses were eligible for analysis. Among the eligible respondents, 505 matched the category of persons with severe disability: 322 in the ABI group and 183 in the SCI group. Age was divided into two groups according to the aging concept of the United Nations: under 65 and 65 or older .WHODAS 2.0 was used to measure participant activity and participation. It has high internal consistency , high test–retest reliability (intraclass correlation coefficient 0.98), and good responsiveness . We follp < 0.05. All statistical analyses were performed using SAS for Windows, version 9.4 .Baseline categorical variables, expressed as numbers and percentages, were compared between the groups using the chi-squared test, while Student’s t-test was used to compare means for continuous baseline variables, summary, and subscores of WHODAS 2.0. We explored the effects of age and onset duration on WHODAS 2.0 scores by performing linear regression analysis. After comparing the domain and summary scores of WHODAS 2.0 between the two groups, regression analysis was performed to determine the risk factors associated with disability. We estimated the adjusted odds ratio (OR) and 95% confidence interval (CI) for the relationships between socioeconomic factors and severe disability, measured using the ICF classification, by applying a multivariate-logistic-regression model. Statistical significance was considered for p = 0.017). The onset duration for participants in the SCI group was almost double that for the ABI group (p = 0.001). There were also significant differences between the two groups according to area of residence, and marital, occupational, and economic status (p < 0.05). The majority of participants in both groups were unemployed. p < 0.05). There were no significant differences in the self-care, life activities, or participation scores, or summary score of WHODAS 2.0 between the two groups (p > 0.05).p < 0.05); moreover, although statistically nonsignificant, the relationship domain showed a higher disability level in the ABI group than that in the SCI group, with a p-value of 0.05, very close to statistical significance. In the group under 65 years old, the ABI group had a higher level of disability in the cognition and relationship domains, while the SCI group had a higher level of disability in the mobility domain . This study investigated differences in disability patterns between ABI and SCI in community-dwelling people with severe disability, and sought to identify risk factors related to disability. The SCI group experienced more difficulties with mobility, whereas the ABI group had more problems with cognition and relationships. Mobility was consistently more impaired in the SCI group than in the ABI group, irrespective of onset duration or age. Onset duration was negatively correlated with the cognition, relationships, participation, and summary scores of WHODAS 2.0 only in the ABI group. There were no significant relationships between socioeconomic factors and severity of disability in either group, which might mean that the type of disease is a crucial factor for the pattern of participation and activity in patients with severe disability. This study enhances our knowledge of the differences in function and disability between individuals with brain and physical impairments with severe disability. This study aimed to identify the pattern of functioning and disability in community-dwelling people with severe disability, and only enrolled participants with disability Grades 1 and 2 from the physical-disability and brain-impairment groups. Mean onset duration was more than 10 years for both groups, and the WHODAS 2.0 scores, excluding the domain of cognition, were below 50. Our results showed that the SCI group had higher disability in the mobility domain of WHODAS 2.0 than that of the ABI group, irrespective of age or onset duration. This is consistent with results of previous studies that compared TBI and SCI using the 12-item WHODAS 2.0 , and stup < 0.05), which might demonstrate cognitive impairment after SCI. According to onset duration, mobility was only consistently impaired in SCI participants. There was a significantly different pattern of WHODAS 2.0 scores based on the participants’ age group. For participants under 65 years old, SCI patients revealed more difficulties with mobility and ABI patients had more problems with cognition and relationships. However, for participants 65 years old or older, the SCI group showed more disability in mobility compared to the ABI group, but there was no difference in cognition between the two groups. A previous animal study demonstrated that SCI induces chronic neuroinflammation and neurodegeneration in the brain, and is associated with cognitive decline . In addiIn regression analysis for predicting WHODAS 2.0 scores, onset duration was significantly negatively related to cognition, relationships, participation, and summary scores in the ABI group; there were no other significant associations. More attention is warranted to preserve the functioning of ABI participants with regular follow-up and close observation. Although multivariate logistic regression sought to identify socioeconomic factors that might severely limit participation and activity, there were no significant risk factors associated with severe disability. Age, income level, and area of residence may be related to poor functioning in SCI patients ,31, and This study has some limitations. First, our questionnaire did not collect information on comorbidities; however, comorbid diseases existing before the onset of a CNS injury and their later complications could influence functioning. Second, it was not possible to obtain information about the injury level and completeness of SCI; this survey was conducted in 65 PHCs involved in community-based rehabilitation programs and considered the type of disability, namely, brain or physical impairment, but detailed information on SCI was missing. Third, this was a cross-sectional study that cannot identify causal effects. Fourth, considering that our study participants visited the public health center, there is a possibility of selection bias, as our study sample may have had a higher level of activity and participation than the general ABI and SCI population. We did not specify the relevant parameters, such as cluster type or homogeneity, which could affect the dependent variable. Fifth, missing and invalid data could also cause selection bias; participants who had more difficulties in completing the whole questionnaire may also have more severe problems in communication and cognitive concentration. Sixth, the effectiveness of this population-based survey study might be limited to Korea. Differences in disability grading systems, and cultures between countries may cause differences in injury-related functional disability status. Lastly, differences of participation and activation according to gender were not investigated in this study. Future longitudinal follow-up studies with more detailed medical conditions are warranted.However, despite these limitations, one strength of our research is that it presents the results of a survey reporting the activity and participation of people with severe CNS injuries at the national level in Korea for the first time using WHODAS 2.0.This study identified the different patterns of disability according to CNS injury type in patients with severe disability. SCI patients consistently exhibited a higher level of disability in mobility than ABI patients. Onset duration negatively affected overall participation and activity level in the ABI group. The type of disease seemed to be a crucial factor for the pattern of participation and activity in patients with severe disability. Understanding the differences in the pattern of disability between these two groups of community-dwelling people with severe disability may help to establish appropriate management of health resources. Healthcare plans regarding transportation and accessibility problems for SCI patients need to be re-evaluated. Implementation of cognitive-rehabilitation programs with close follow-up and regular evaluations for elderly individuals with CNS injuries are warranted.


Objectives: To evaluate possible associations between chronotype, weight, sleep problems, anxiety, and depression among children from 6 to 12 years of age.Method: One-hundred children aged between 6 and 12 years were randomly recruited in five pediatrician clinics in the capital city of Beirut, Lebanon. The protocol was approved by the ethics committee of Saint-Joseph University and Hotel-Dieu Hospital and an informed written formal consent was obtained from one of the parents. The Sleep Disturbance Scale for Children (CCTQ), the Revised Child Anxiety and Depression Scale (RCADS)-Parent version, and the Children's Chronotype Questionnaire (CCTQ) were used.Results: The majority of the sample (47%) presented an intermediate chronotype. There was a shift toward evening chronotype with increased age and a significant association between electronic devices use and an evening chronotype. Higher sleep disturbances were also observed among children with an evening chronotype. In particular, disorders of initiating and maintaining sleep, non-restorative sleep, excessive somnolence, and total SDSC were significantly higher among evening type children in our study. Finally, major depression domain scores were significantly higher among children with an evening chronotype.Conclusions: Several findings of this study are important and explain factors associated to chronotype in children. Two important future perspectives can be highlighted: limiting electronic devices use among children in an effort to reduce circadian rhythm disturbances and identifying and treating sleep problems associated with eveningness, taking into account the possible presence of major depression among this population. Humans show cyclic rhythmicity in a wide range of psychological, cognitive, and physiological behaviors as well as in hormonal variations. This natural rhythmicity is called the circadian rhythm and it affects several processes such as sleep-wake cycles, mood, hormone levels, cognition, and temperature. The trait determining individual circadian preference in rhythm is known as chronotype, which is relative to cycles of external light and dark –5. ChronYoung children (2–6 years of age) seem to show a relatively strong preference for morningness  but tranExisting evidence suggests that sleep dysfunction during childhood could be an early manifestation of future adjustment problems , 29. ThuEven though several studies examined sleep among children, few of them focused on chronotype, and those were mainly conducted among adolescents. Eveningness has been previously linked to anxiety, depression, and general affective problems among adolescents –35 but nThe period just before adolescence can be critical in determining future sleep pattern and psychological problems and very little is known on the associations between sleep, circadian preference, anxiety, and depression in children during this period. Thus, the primary objective of this study was to investigate the links between the chronotype, weight, sleep problems, anxiety, and depression among children aged between 6 and 12 years.n = 3) was small, the two categories of physical activity (no activity and 1 h/week) were combined. The categories were 0–1 h/week, 2 h/week, and ≥3 h/week. For electronic devices use, four categories were used: 0, 1, 2, and ≥3 h/week.The study was conducted between March and December 2018. First, five pediatrician clinics were randomly selected from a list of clinics based in Beirut. and randomly recruited in five pediatrician clinics in the capital city of Beirut, Lebanon. Inclusion was done during vaccination visit (before the administration of the vaccine) to make sure that the child is not sick at the time of the inclusion. Briefly, a list of appointments was provided on Monday morning (and for the coming week) by the staff, highlighting vaccination visits. From this list, selection was randomly performed. The exclusion criteria were: children taking any medication, children with any chronic diseases. A trained research assistant interviewed the parents in the waiting room. One-hundred and fifty parent's children were approached, of whom 28 refused to participate in the study, and 22 children presented at least one exclusion criteria. The final study sample consisted of 100 children aged between 6 and 12 years. In addition to filling the questionnaires listed below, socio-demographic information was recorded. Physical activity and electronic devices use were also collected. For physical activity, since the number of participants with no activity  consists of 26 questions evaluating sleep problems during the 6 previous months. SDSC uses a five-point scale and a total sleep time of 1 (9–11 h) to 5 (<5 h) and for sleep latency of 1 (<15 min) to 5 (>60 min). The frequency of the symptoms of sleep disorder is measured on a likers scale of five-point: never ; often, The Children's Chronotype Questionnaire (CCTQ)  was deveThe CCTQ is a 27-item, mixed format. Parents can respond to several open-ended questions concerning sleep/wake parameters for scheduled days (non-holidays) and holidays (free days). It has 27 items and a five-point chronotype (CT) score . It contThe total score from the MES [morningness/eveningness (M/E) scale] is a sum of scores of items 17–26 only, and ranges from 10 to 48 . This scThe Revised Child Anxiety and Depression Scale (RCADS)-Parent version is a self-assessment scale developed to identify and screen for the clinical symptoms of anxiety and depression in children or adolescents and is filled by the parents. This questionnaire includes 47 questions grouped into six subscales: Separation Anxiety Disorder, Anxiety Disorder , Social Phobia, Panic Disorder, Major Depressive Disorder, and Obsessive Compulsive Disorder. RCADS provides a score for each subscale as well as a total score for anxiety, which is the sum of all anxiety subscales except MDD, a total score for all the scales . The higher the score, the more the child presents the clinical symptomatology of anxiety and depression , 46. TheThe study protocol obtained the approval of Saint-Joseph University ethics committee of and Hotel-Dieu Hospital ethic committee . Prior to participating, an informed written formal consent was given by one of the parents. The study was conducted between March and December 2018. The self-administered anonymous questionnaires were filled by the children's parent(s).t-test or non-parametric Mann-Whitney test and ANOVA  or its equivalent non-parametric Kruskal-Wallis test were performed. ANOVA  followed by Tukey post-hoc tests or its equivalent non-parametric Kruskal-Wallis test were performed to evaluate the association between continuous variables.The statistical analyses were performed with SPSS software for Windows . The level of significance was set at 0.05. The mean and standard deviation were calculated for continuous variables and percentage was calculated for categorical variables. The normality of the distribution of continuous variables was assessed by Kolmogorov-Smirnov tests. In the first step, univariate analyses using the Student's p- <0.200 were entered into the equation simultaneously. Collinearity among independent variables was also examined. Finally, two regression models were executed; the first model included age, electronic device, social phobia, major depression, separation anxiety, and SDSC. Since, the variables disorders of initiating and maintaining sleep, non-restorative sleep, and sleep breathing disorders are domains that belong to SDSC, they were not included in the same multivariate model. Hence, the second model includes: age, electronic device, social phobia, major depression, separation anxiety, and disorders of maintaining sleep, non-restorative sleep and sleep breathing disorders.To evaluate the association between continuous variables, Pearson and Spearman correlation coefficients were calculated, and to assess the relationship between categorical variables, Fisher Exact tests, and Chi-square independence tests were performed. In the second step, multiple regression analyses were performed according to the Enter Method; all independent variables with a -N = 50 + 8m (m being the number of independent variables for the primary outcome); Given that m = 6, we had to include at least 98 subjects in the study.The sample size was calculated according to the formula of Tabachnick and Fidell  taking iThe total number of children included in this study was 100 children. The mean age of the population is 9.10 (±2.25) years old. Twenty percent of the children were overweight and 19% were obese .Physical activity and electronic devices use are also reported.Approximately, half of the sample (47%) were classified as having an intermediate chronotype. The total SDSC and CCTQ scores were respectively 41.27 ± 8.875 and 29.57 ± 5.487. Detailed results are presented in Evening type children were significantly older, but no associations were observed between chronotype and BMI . FurtherLater chronotype (higher CCTQ score) was associated with higher SDSC score, indicating greater sleep disturbance; It was also associated with older age, electronic devices use and with higher score on the major depression domain of the RCADS-P .Our results showed that the majority of the sample (47%) presented an intermediate chronotype which is consistent with several previously conducted studies , 48; HowThere was a shift toward evening chronotype with increased age: evening type children were significantly older than morning type (9.97 ± 2.279 vs. 8.00 ± 1.713 years of age). It was previously reported that a shift toward later sleep rhythm occurs from early to late adolescence , 52 and Excessive use of electronic media  among adolescents was known to be associated with a disruption in the circadian clock, irregular, shortened, and later sleep onset . Little Higher sleep disturbances were also observed among children with an evening chronotype, similarily to previous report about eveningness among youth resulting in sleep deprivation , 50. SevFinally, anxiety domains of the RCADS-P were not associated to chronotype after performing the multivariate analysis but major depression scores were significantly higher among children with an evening chronotype –44. ExhiThe reciprocal effects between chronotype and depression are poorly understood during the critical developmental period extending from childhood to adolescence and the nature of our study  does not allow to draw hypothesis on the cause-effect relationship between chronotype and depression. In addition, the nature of the questionnaire used (RCADS-P), which is a screening and not a diagnostic tool, does not allow to assume a diagnosis of major depression, only a high suspicion of it.Our findings should take into account several limitations. The results were obtained through questionnaires filled out by the parent of the child. Although, parents are aware of when they put their children to bed and when they wake up, the ability of parents to report on their child's preference for evening vs. morning is more limited. No information about Tanner Stage was available even though it could affect chronotype. The cross-sectional design of this study limits the authors' ability to determine whether later chronotype preceded or followed the existence of high depression scores on the RCADS-P; thus, the methodology is not adapted to establish a causal relationship between chronotype and depression suspicion. Finally, we excluded any chronic disease and of chronic medication intake, which prevented us from studying the impact of comorbidities on chronotype.Despite these limitations, several findings observed in this study explain factors associated to circadian rhythm disturbances in children; the aspects explored are important and warrant further investigations.Significant associations were observed in this study between chronotype and sleep as well as between chronotype and major depression domain of the RCADS-P among children. Based on our results, two important future perspectives can be highlighted: (i) limiting electronic devices use among children in an effort to reduce circadian rhythm disturbances and (ii) identifying and treating sleep problems associated with eveningness, taking into account the possible presence of major depression among this population.The datasets generated for this study are available on request to the corresponding author.The studies involving human participants were reviewed and approved by ethics committee of Saint-Joseph University and Hotel-Dieu Hospital. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.BE and MB: data collection and analysis. P-HT and IM: data collection and protocol design. NE: statistical analysis and protocol design. JN and MS: data collection and writing manuscript draft. LR: protocol design, interpretation of data, writing the draft, and final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Dementia is a progressive neurocognitive disease with a substantial social burden. No apparent breakthroughs in treatment options have emerged so far; thus, disease prevention is essential for at-risk populations. Depression and cerebrovascular disease (CVD) are independent risk factors for dementia, but no studies have examined their interaction effect on dementia risk. This study aimed to identify the association of depression and CVD with the risk of dementia and evaluate whether dementia risk among patients with comorbid depression and CVD is higher than the sum of the individual risk due to each condition.A population-based cohort study was conducted to analyze the Korean National Health Insurance Service-National Sample Cohort data of all individuals over 50 years of age. Individuals who had not been diagnosed with dementia at baseline were included and followed up from January 1, 2005, to December 31, 2013. A time-varying Cox proportional hazard regression model adjusted for potential confounding factors was used for the analysis. The interaction between depression and CVD was estimated based on the attributable proportion (AP), relative excess risk due to interaction (RERI), synergy index (SI), and multiplicative-scale interaction.A total of 242,237 participants were included in the analytical sample, of which 12,735 (5.3%) developed dementia. Compared to that for participants without depression or CVD, the adjusted hazard ratio for the incidence of dementia for those with depression alone was 2.35 , CVD alone was 3.25 (95% CI 3.11–3.39), and comorbid depression and CVD was 5.02 (95% CI 4.66–5.42). The additive interaction between depression and CVD was statistically significant . The multiplicative interaction was significant too, but the effect was negative .In this population-based nationwide cohort with long-term follow-up, depression and CVD were associated with an increased risk of dementia, and their coexistence additively increased dementia risk more than the sum of the individual risks. Dementia is a neurodegenerative disease characterized by progressive cognitive decline. It precludes patients from carrying out daily life activities independently and often has devastating effects on the lives of patients and their caregivers. Although the prevalence and disease burden of dementia are increasing , there hDepression has been suggested as a risk factor for dementia. According to recent meta-analyses of several epidemiological studies , 4, lateHowever, the interaction effect of depression and CVD, that is, whether one disease strengthens the association of another with dementia risk, remains unclear. In contrast to dementia, the prevention and treatment of these two illnesses have been well established and are known to be effective , 10. TheIn the current study, we sought to evaluate the association of depression and CVD with subsequent dementia using a nationwide population-based cohort. We also aimed to investigate whether the interaction between the two conditions is additively associated with increased dementia risk. As the epidemiology of depression, CVD, and dementia is dependent upon age and sex, we examined whether the interaction between depression and CVD differed by age or sex.We used the nationwide population-based South Korean National Health Insurance Service-National Sample Cohort (NHIS-NSC) database , which cOf the 1,044,097 individuals who were enrolled in the cohort during the baseline period , we included 244,920 individuals over the age of 50 years and then excluded 2683 who had or received a dementia diagnosis during this period  and the documented administration of antidepressant medication  and the documented administration of anti-dementia medication  during the follow-up period , 21, 22.All analyses were adjusted for potential confounding variables—age, sex, residential area, income level, and comorbidities—during the baseline period from 2002 to 2004. With regard to the residential area, the capital city of South Korea and the surrounding metropolitan cities  were designated as the “capital region”; all other regions were designated as “non-capital regions.” Income levels were classified as low (up to the 30th percentile), middle (30th to 70th percentile), and high (70th to 100th percentile). The ICD-10 codes from the Charlson comorbidity index, which is used widely to adjust for the effects of comorbidities , were usWe assessed additive- and multiplicative-scale interaction measures to examine the interaction effect of depression and CVD on dementia onset. In terms of the additive interaction, we derived the attributable proportion due to interaction , relatiThe multiplicative-scale interaction [Eq. ] has beeDepression & CVD represents the hazard ratio (HR) for those who have both depression and CVD. HRDepression and HRCVD represent the HR for those who have depression or CVD alone, respectively, compared with individuals who have neither of the conditions.In Eqs. (1–4), HRWe used Cox proportional hazards regression models to determine the adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) of depression, CVD, or comorbid depression and CVD for dementia incidence. As the cohort design can cause an immortal time bias, we used a time-varying Cox regression model to prevent time-related biases , 27. An First, we used a log-rank test and evaluated independent associations of depression and CVD with subsequent dementia using aHRs and 95% CIs in two separate regression models. In this analysis, exposure of interest (depression or CVD) was treated as a time-varying variable, and the other comorbid illnesses were regarded as time-fixed confounders to be adjusted. Next, we examined the interaction effect of the two exposure diseases by calculating the additive  and multiplicative interaction. We verified the significance of the interaction term and then stratified each subgroup based on age or sex. The two-way interaction effect was tested on independent associations of depression or CVD with each subgroup, and the three-way interaction effect was tested on interactive associations of depression and CVD with each subgroup. We then conducted a subgroup analysis using a fully adjusted Cox regression model  in which dementia subtypes  were accounted into the outcome variables.We also carried out sensitivity analyses to ensure the robustness of the results. First, a lagged-time analysis was conducted because depression that occurs shortly before dementia onset can be a prodrome of dementia . We clasp value < 0.05).Participant characteristics are presented in Table N = 190,255; 78.5%), 1336 (6.8%) in the depression alone group , 3099 (11.6%) in the CVD alone group , and 775 (14.1%) in the comorbid depression and CVD group .When the patients were classified into the four categories as shown in Fig. p values for the two-way interactions between diseases and age or sex were <0.0001). The association between depression and subsequent dementia was especially high in those under the age of 65 and men, and the same was observed for CVD  only in women , CVD alone group , and comorbid depression and CVD group  were significantly associated with an increased risk of dementia . Figure S1. Unadjusted survival curves for dementia onset according to exposure diseases.


Toxoplasma gondii (T. gondii). Rodents, as intermediate and reservoir hosts, play a key role in the maintenance and transmission of T. gondii. They can be contaminated and maintain the parasite in the form of cysts in their bodies, demonstrating an infection source for their offsprings, predators (particularly felids), and other animals. Therefore, the present systematic review and meta-analysis study was carried out to evaluate the global seroprevalence of T. gondii in these mammals. For achieving the purpose of the current study, six English databases  were systematically searched for related studies from 1970 to 2018. Finally, a total of 52,372 records were screened, 105 records including 26,221 rodents were incorporated in the present study. By random effect models, the overall seroprevalence was calculated at 6% (95% CI = 6–7%), with the highest amount was observed in Africa (24%) and South America (18%), and the lowest amount in Europe (1%). The subgroup data analysis by gender manifested that the prevalence of Immunoglobulin G antibodies did not differ between genders (P > 0.05). Due to the significant heterogeneity, meta-regression models were applied based on serological techniques and continental regions; however, the obtained values were not statistically significant . The present study revealed a relatively low level of T. gondii seroprevalence in rodents; however, if they were the main food source for their predators, they would cause high transmission of T. gondii.Toxoplasmosis is one of the most prevalent infections in humans and animals caused by the intracellular protozoan parasite  Toxoplasma gondii (T. gondii), an obligate intracellular apicomplexan protozoan, that infects nearly 30% of the world human population  which infect intermediate hosts, a large range of homoeothermic animals , resulting in the formation of tissue cysts  , 5. TranT. gondii in immunocompetent people is mostly asymptomatic, or with non-specific flu-like symptoms. However, this single-celled microorganism is medically important and causes serious consequences in immunocompromised people and pregnant women , one of the largest rodents in the world, are used by some nations and may be a source of T. gondii if their meat containing parasitic cysts is consumed undercooked . The details of the study protocol are available on the website of the International Prospective Register of Systematic Reviews with the identifier Central Registration Depository of 42018107622 , (www.sciencedirect.com), (www.webofknowledge.com), (www.scopus.com), (www.search.proquest.com), and (www.scholar.google.com).To elucidate the seroepidemiological status of Toxoplasma,” “Toxoplasmosis,” “T. gondii,” “Seroprevalence,” “Seroepidemiology,” “Prevalence,” and “Rodentia.” In addition, perusing the reference lists to retrieve additional related publications was conducted manually.The keywords were used based on medical subject heading terms: “For the purpose of eligible screening, all the retrieved titles, abstracts, and full-texts if needed, were carefully perused and eligible studies were selected by two independent authors (TMG and MM). Disagreements, if any, were discussed and sorted out by consensus.T. gondii in rodents with the total sample size larger than 20 were selected. The reviews, experimental, human-based, non-serological, repetitive manuscripts and those with inadequate data were excluded from the present study.Finally, studies with full texts or abstracts available in English which examined the seroprevalence of antibodies against The data extraction process was performed by two independent authors (MM and TMG) and disagreements were resolved by discussion and consensus. Using an information extraction sheet, the following data were recorded from the selected studies: first author, publication year, geographical region, sampling period, total sample size, gender and age distribution, number and percentage of seropositive rodents, and serological methods. The quality of included records was appraised using the Joanna Briggs Institute (JBI) Prevalence Critical Appraisal Tool .Toxoplasma Immunoglobulin G (IgG) seroprevalence were calculated for all the selected records. Chi-squared and I-squared tests were applied to evaluate the extent of variations among the independent studies. The I-squared values of lower than 25%, 25–50%, and higher than 50% were considered as low, moderate, and high heterogeneity, respectively.The present meta-analysis was carried out using Stata software . Point estimations and 95% confidence intervals (CI) of anti-To explore the causes of heterogeneity among the selected studies, meta-regression and subgroup analysis were performed based on serological techniques and continental regions. The subgroup analysis was also conducted according to the genders. The publication bias was examined by Egger's regression test and funnel plot asymmetry. According to the results of the heterogeneity test, a random effect model was used to pool the estimates and a forest plot was drawn to visualize the outcomes.Furthermore, to evaluate the effect of each study on the overall effect size, a sensitivity analysis was performed by eliminating a single study at a time.T. gondii.In this universal scientific research, initially 52,372 records were retrieved through principled search, 105 records from 44 countries were finally appraised appropriately to be entered into this global research. Totally, 26,221 rodents and 2,263 positive cases were analyzed for IgG antibodies against Details of the search and study selection procedure are described in a PRISMA flow diagram . Table 1Toxoplasma IgG antibodies in rodents based on the random effect model was calculated at 6% . I-squared statistics indicated a high heterogeneity among the studies . The overall seroprevalence of anti-The seroprevalence in North America, Australia, and Asia was measured at 5% (95% CI = 4–7%), 4% (95% CI = 3–6%), and 4% (95% CI = 3–5%), respectively. The Europe had the lowest seroprevalence with 1% (95% CI = 1–1%).P > 0.05).The subgroup data analysis of 16 documents describing values of the seroprevalence parasite by gender manifested that the pooled seropositivity value in male and female rodents was 4% (95% CI = 3–6%) and 2% (95% CI = 1–3%), respectively . There wIn a subgroup analysis based on serological methods, the highest seroprevalence was found by IFAT 18% (95% CI = 13–23%), followed by LAT, SFDT, ELISA, MAT, IHAT, and DAT with the rate of 15% (95% CI = 9–22%), 14% (95% CI = 12–17%), 11% (95% CI = 7–15%), 8% (95% CI = 7–9%), 3% (95% CI = 1–6%), and 0% (95% CI = 0–1%), respectively. Other serological methods  showed the infection rate of 8% . Due to the lack of adequate data on the rodents' age, subgroup analysis was not performed. The results of Egger's regression test indicated that publication bias was statistically significant . The sensitivity analysis tool demonstrated that the effect of three studies on the overall effect size was significant . It has been recorded that infection leads to abortions in many mammals , could inhibit species recovery, and cause economic losses , 10, 119Rodents, as intermediate and reservoir hosts of this protozoan, can be contaminated and maintain the parasite in the form of cysts in their bodies, demonstrating an infection source for their offsprings, predators (particularly felids), and other animals  , 11, 14.By establishing the infection transmission cycle and consequently environment contamination by released oocysts from cats, rodents, especially species that live close to humans such as house mice, lead to increasing the risk of human exposure to the parasite . The rodAlso, the consumption of rats as food by some populations may increase the risk of direct transmission from these rodents to humans, when eating, handling or preparing infected rats before cooking . Hence, T. gondii, with maintaining parasite and its transmission cycle in these ecosystems may lead to increasing the probability of infection of wild felids and other animals, especially if they are the main prey , with the highest amount in Africa (24%), South America (18%), and the lowest amount in Europe (1%).The present extensive study was the first systematic review to concentrate on the worldwide seroprevalence of toxoplasmosis in rodents, by screening scientific studies published from 1970 to 2018. In this attempt, the overall seroprevalence of anti-T. gondii through eating the infective oocysts residing in water, soil, and food. Also, ingestion of meat infected with parasite tissue cysts , digesting earthworms as paratenic hosts of the pathogen, or congenital transmission lead to contamination of the rodents with T. gondii. The high level of congenital transmission recorded among some rodent species could affect the prevalence levels  affecting the sporulation and survival of oocysts , 70, 98.e levels , 121. Foe levels .The contamination level of the soil is different according to the region, depending on the densities of felids as definitive hosts, which excrete oocysts into the environment. In fact, rodents living in an environment with fewer cats, are less exposed to oocysts , 121. AsThe humid and warm climate is a suitable condition for the survival and dissemination of oocysts; therefore, areas with these climates show a high level of infection. In addition, water and damp soil can support the stability of oocysts for longer periods , 108. ThThe estimation of seroprevalence infection may not reflect the actual amount of infected individuals, because, contrary to the resistance of some species to infection, others may be more susceptible and show more casualties. Therefore, the casualties are not included in the study and the reported amount will not be actual .T. gondii infection, or Polymerase chain reaction (PCR)  , 69, 70.r living . In factr living , 122.T. gondii infection risk of felids in specific habitats , which increases the risk of predation of the infected rodents and lead to infection transmission to the felids (Moreover, e felids , 95, 98.Publication bias was statistically significant in the selected studies, probably for reasons, such as sample size, sampling procedure, and methodology.In our study, it was concluded that the high seroprevalence of infection among rodents in Africa and South America was due to climate conditions and other aforementioned factors indicating an increased risk of infection transmission to felids, humans, and other animals. Therefore, effective control measures and strategies should be implemented in order to reduce the infection rates among rodents in these regions.T. gondii antibodies did not differ between the genders with 4% in males and 2% in females, suggesting that both genders are almost equally exposed to this parasite. In some species of rodents such as rats, males have larger home ranges than females and thus a greater chance for acquiring infection (Data analysis of the few studies reporting infection rates by gender in rodents suggested that the prevalence of nfection .T. gondii has been expected to be higher in aged animals than in younger ones, as shown in numerous animal species and humans (Due to the lack of adequate data on rodents' age in the selected studies, subgroup analysis of age groups was not performed. In general, because of spending more time in the environment and the increased risk of exposure to parasites, the seropositive rate of d humans , 123–126Cannibalism, one of the routes of infection transmission in rodents that is observed in some species, is more common in males and older animals than in females and younger ones, that can affect the burden of infection . Hence, T. gondii seroprevalence in rodents; however, if they were the main food source for their predators, they would cause high transmission and subsequently increase environmental contamination and the risk of infection transmission to humans and other animals.In conclusion, the present study revealed a relatively low level of Consequently, effective control measures and strategies are needed to reduce the infection rate in these mammals. Further studies are required to use the serology technique along with bioassay and PCR to provide a more accurate estimation of the infection rate in these animals.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.AD and ShS contributed to the design of the study. TG and MMon conducted the systematic review of the literature and extracted data. MMoo performed all statistical analyses, data interpretation, and drafted the manuscript. TG contributed to the interpretation of data and writing of the first draft. AD supervised the study. All authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.