BackgroundThe application of the Box-Jenkins autoregressive integrated moving average (ARIMA) model has been widely employed in predicting cases of infectious diseases. It has shown a positive impact on public health early warning surveillance due to its capability in producing reliable forecasting values. This study aimed to develop a prediction model for new tuberculosis (TB) cases using time-series data from January 2013 to December 2018 in Malaysia and to forecast monthly new TB cases for 2019.Materials and methodsThe ARIMA model was executed using data gathered between January 2013 and December 2018 in Malaysia. Subsequently, the well-fitted model was employed to make projections for new TB cases in the year 2019. To assess the efficacy of the model, two key metrics were utilized: the mean absolute percentage error (MAPE) and stationary R-squared. Furthermore, the sufficiency of the model was validated via the Ljung-Box test.Results12 model proved to be the most suitable choice, exhibiting the lowest MAPE value of 6.762. The new TB cases showed a clear seasonality with two peaks occurring in March and December. The proportion of variance explained by the model was 55.8% with a p-value (Ljung-Box test) of 0.356.The results of this study revealed that the ARIMA ConclusionsThe application of the ARIMA model has developed a simple, precise, and low-cost forecasting model that provides a warning six months in advance for monitoring the TB epidemic in Malaysia, which exhibits a seasonal pattern. As per the WHO Global Tuberculosis (TB) Report of 2022, approximately 10.6 million new TB cases were diagnosed worldwide in the year 2021 . ThroughThe Box-Jenkins autoregressive integrated moving average (ARIMA) method is a time-series forecasting technique that relies on the behavior of observed variable data. Its strength lies in its ability to handle diverse data patterns, requiring the data to be stationary initially. Furthermore, it is highly proficient in accurate short-term forecasting. Lately, the ARIMA model has gained substantial traction in the domain of forecasting infectious disease cases, emerging as the predominant methodology for TB prediction worldwide -9. It haIn Malaysia, there remains a knowledge gap regarding the creation of forecasting models, specifically for the TB disease. Predicting TB cases in Malaysia holds great importance as it offers a vital foundation for public health planning and intervention initiatives, crucial in addressing the TB epidemic. Studies focused on TB and employing forecasting models have predominantly been confined to local areas, with the comprehensive nationwide trend yet to be documented -17. To b Study areaThe study was carried out in Malaysia, an Asian nation situated in Southeast Asia. Malaysia is partitioned by the South China Sea into two main regions: Peninsular Malaysia, encompassing 11 states and two federal territories, and East Malaysia, consisting of two states and one federal territory. Kuala Lumpur serves as the capital city, and Putrajaya acts as the hosting location for the federal government. Sharing borders with Thailand and Singapore, Malaysia spans an area of roughly 330,803 square kilometers and maintains a population density of approximately 92 individuals per square kilometer. According to the 2019 report from the Department of Statistics, Malaysia's total population had risen to 32.4 million. Healthcare in Malaysia is primarily subsidized by the government's MOH, operating within a two-tiered system that encompasses both government and private healthcare systems. An integral national health priority involves the reduction of infectious disease burdens, including TB. The changing patterns of TB contribute to some of the central health challenges faced by the nation.Study data sourceThe dependent variable is the new TB cases, which are newly registered cases in the TB Information System (TBIS). These cases are determined through chest physician evaluations, laboratory tests, and radiography findings. All data span from January 2013 to December 2018. Data from January 2013 to June 2018 were covered for model fitting, and the remaining six months of data (July 2018 to December 2018) were used for model prediction. Throughout the study period, Malaysia consistently executed stable TB control programs on an annual basis.Ethical approval was obtained from the National Medical Research Registry (NMRR) NMRR-19-451-45857 (IIR). The analysis was primarily conducted using IBM SPSS Statistics for Windows, version 23.0  to develop the ARIMA model.Time-series analysisDuring the study, an ARIMA model was developed using the time-series data of new TB cases. The initial stage in employing the Box-Jenkins methodology involves the identification of the appropriate ARIMA class for the given data series. Autocorrelation function (ACF) and partial autocorrelation function (PACF) coefficients are common statistics used for this purpose. ARIMA models are categorized as ARIMA s. In the case of non-seasonal ARIMA, the parameters include autoregressive terms (p), differencing orders (d), and moving average terms (q). For seasonal ARIMA  or SARIMA, the model incorporates seasonal autoregressive terms (P), seasonal differencing (D), and seasonal moving average terms (Q), all of which are determined in relation to a specific period denoted as "s." The methodology follows the foundational steps of the Box-Jenkins approach for time-series modeling, which consists of three phases: identification, estimation/testing, and application. During the identification phase, the assessment of the dependent variable's stationarity involves the examination of ACF and PACF with a lag equivalent to one year (12 months). ARIMA requires the dependent variable to be stationary, which means a constant mean and variance over time. Stationarity can be attained by either applying differencing to the series or utilizing a logarithmic conversion on the dependent variables .In this research, the stationarity of the series was achieved through both seasonal and nonseasonal differencing. The examination of correlograms indicated that the series became stationary, with residuals showing no time-based correlation, and fluctuating around a constant mean with zero variance. Once the data have been made stationary, the subsequent step involves generating ACF and PACF plots. These plots serve as the foundation for constructing the preliminary ARIMA prediction model , where the value of order "p" is ascertained from the PACF plot and the value of order "q" is derived from the ACF plot. The determination of order "d" is contingent on the number of differencing operations applied to the data. The most suitable model was identified by comparing the mean absolute percentage error (MAPE) and the stationary R-squared value. Lower MAPE values were favored, while a higher stationary R-squared value indicated a larger proportion of the dependent variable's variance explained by the model. Once the optimal model was identified, forecasts were generated for monthly values spanning January to December 2019.Explanatory statisticsThe total number of new TB cases in Malaysia from January 2013 to December 2018 was 150,606 cases. It was found that the new tuberculosis cases showed an uptrend from 24,007 new cases in 2013 to 25,900 new cases in 2018. The maximum and minimum new TB cases were 3,166 cases/month and 1,545 cases/month, respectively. The monthly average of new TB cases from January 2013 to December 2018 was 2,092 cases  2022-2162). Based on data from the TBIS from January 2013 to December 2018, the highest number of new TB cases was recorded in Sabah with a total number of 28,802 cases. The other states with high new TB cases were Selangor  and Sarawak . The lowest number of new TB cases was recorded in Labuan and Perlis with a total number of 712 and 794 cases, respectively. Throughout these years, three states, namely, Selangor, Sabah, and Sarawak, had shown the highest increment of new TB cases compared to other states in Malaysia. The distribution of new TB cases by states in Malaysia from 2013 to 2018 is shown in Figure Time-series analysisy = 1925.45 × time + 4.506. Hence, in our further modeling strategy, we assumed that the number of new TB cases fluctuates around a consistent mean. Furthermore, the annual cycle of a seasonal index of the new TB cases exhibited a seasonal pattern from January 2013 to December 2018, as shown in Figure Figure 12 model was chosen as the fundamental framework for the potential model.The results of the ACF and PACF examinations for new TB cases unveiled that the series lacked stationarity, primarily due to the presence of seasonal components Figure , 2b. Theq being 1, as the autocovariance approach zero for lags beyond 1. Meanwhile, the post-differencing PACF plot in Figure p should be 2, as the partial autocorrelations are in proximity to zero for all lags surpassing 2.Figures p, d, and q. The optimal model was determined by evaluating the model fit statistics and the Ljung-Box test. None of the models were statistically significant (p > 0.05), indicating no significant autocorrelation between residuals at different lag times, thereby suggesting that the residuals represented white noise. The best model was the model with the lowest value of MAPE and higher stationary R-squared value. The ARIMA model 12 emerged as the best selection, boasting the lowest MAPE of 6,762 12 model was developed using data collected from January 2013 to June 2018, and its accuracy was assessed using data gathered between July and December 2018. The model's validity was tested and then utilized to produce forecasts for new TB cases spanning January to December 2019. The outcomes demonstrated a satisfactory alignment between the actual values and predicted values, as depicted in Figure Table  model 2,,1An early epidemic prediction tool plays a crucial role in assessing outbreak risks. Detecting outbreaks early allows for timely interventions and prevention measures rather than just managing a full-blown epidemic. The necessity for an early warning system arises to pinpoint and assess the risk of TB within a population. The ARIMA model proves valuable for interpreting and applying surveillance data. Its potential is significant as a decision support tool, aiding in enhancing preparedness planning and public health interventions in the field. The findings of this study demonstrate that the developed ARIMA model closely mirrors the trend of new TB cases, confirming the presence of TB in Malaysia. This predictive model was constructed using data on new TB cases recorded from January 2013 to December 2018. It assumes a sustained pattern in various conditions, such as climatic factors, control measures, prevention efforts, treatment-seeking behavior, and population migration. The model's validation process established its suitability for Malaysia's context, evidenced by the manageable level of errors in this forecasting study.12 was found as the best-fit predictive model in our study, with the least MAPE values and highest stationary R-squared. The result predicted that the number of new cases of TB in Malaysia from January to December 2019 was 1,899, 1,950, 2,217, 1,984, 2,113, 1,872, 2,236, 2,124, 2,964, 2,452, 2,047, and 3,049 cases, respectively. These 12-month forecasted new TB cases will be a useful tool for the MOH Malaysia to estimate the real number of new TB cases in Malaysia while targeting the control measures at the states using the spatial distribution of new TB cases of the previous years. The results in this study also matched several studies in other Asian countries, which predicted seasonal and increasing patterns in new TB cases. In Iran, a study identified the ARIMA 12 model as the best fit for TB data, with the peak cases occurring in May [12 model was deemed best fit with seasonal differencing [Among all models, ARIMA In this study, we also recognized a seasonal distribution based on the monthly new TB cases from January 2013 to December 2018 in Malaysia. From an overall perspective, the monthly new TB cases was peaked in March with a trough in December. This is also consistent with the predicted data for 2019 with regard to the timing of the peak. Similar patterns in the seasonal distribution of new TB cases have also been observed in other studies, including those conducted in Malaysia. For instance, Portugal also exhibited a peak in new TB cases during March, followed by a trough in December . A priorIt is important to recognize limitations in interpreting forecasts. Factors, such as socioeconomic conditions and natural environments, could affect TB cases, but they were not considered due to data constraints and the study's focus on time-series forecasting. The ARIMA model is best for short-term predictions, requiring frequent new data for accuracy. Regular updates and adjustments to the model are crucial for dependable disease transmission predictions. In conclusion, the ARIMA model is best suited for short-term forecasting purposes. It is important to note that this model necessitates dynamic updating with new data to ensure the accuracy and stability of its forecasts over time.12 model is the best forecasting model for new TB cases in Malaysia. This model offers the MOH with advanced predictions of new TB cases, providing valuable guidance for timely planning of prevention and control measures. Having advanced knowledge into the spatial distribution of new TB cases in Malaysia for the upcoming 12 months would significantly assist in precisely directing control measures across the nation.The ARIMA


The inverse relationships between chronic disease multimorbidity and health-related quality of life (HRQoL) have been well-documented in the literature. However, the mechanism underlying this relationship remains largely unknown. This is the first study to look into the potential role of functional limitation as a mediator in the relationship between multimorbidity and HRQoL.n = 6,814). A panel mediation analysis was performed to assess the role of functional limitation as a mediator in the relationship between multimorbidity and HRQoL. The natural direct effect (NDE), indirect effect (NIE), marginal total effect (MTE), and percentage mediated were used to calculate the levels of the mediation effect.This study utilized three recent waves of nationally representative longitudinal Household, Income, and Labor Dynamics in Australia (HILDA) surveys from 2009 to 2017 (p < 0.05) of the link between multimorbidity and the composite SF-36 score for HRQoL. Functional limitation also mediated the relationship between the number of chronic conditions and HRQoL for each of the eight SF-36 dimensions, with a proportion mediated ranging from 18.4 to 28.8% (p < 0.05).This study found that functional limitation is a significant mediator in the relationship between multimorbidity and HRQoL. In the logistic regression analysis, the negative impact of multimorbidity on HRQoL was reduced after functional limitation was included in the regression model. In the panel mediation analysis, our results suggested that functional limitation mediated ~27.2% (Functional status has a significant impact on HRQoL in multimorbid patients. Treatment should concentrate on interventions that improve patients' functioning and mitigate the negative effects of multimorbidity. Australians are living longer lives than ever before, but many are dealing with multiple chronic diseases, resulting in a low health-related quality of life –3. With Health-related quality of life (HRQoL) is an important health outcome metric that assesses an individual's subjective physical and mental health. HRQoL, according to the WHO definition, is frequently multifaceted, encompassing both physical and mental health, and represents individuals' wellbeing in the context of their culture and values , 16. HRQSeveral studies, including high-level systematic reviews, have suggested that multimorbidity reduces HRQoL –25. A nuUntil now, the complex relationship between multimorbidity, functional function, and HRQoL has received insufficient attention. A mediation analysis is a statistical model that looks at the relationships between two variables and how much they are mediated by a third variable . In the current epidemiological and public health literature, this methodology is widely used to assess the mechanism by which disease affects health outcomes. To address this important evidence gap in the literature, this is the first longitudinal study to investigate the role of functional limitation in the influence of multimorbidity on HRQoL using three waves of nationally representative data in Australia. This study looks specifically at the role of functional limitation as a mediator in the relationship between multimorbidity and HRQoL in a population-based sample of Australian adults.This study utilized three waves of longitudinal data from Waves 9 (2009), 13 (2013), and 17 (2017) of the Household, Income, and Labor Dynamics in Australia (HILDA) survey. The HILDA survey is a nationally representative, household-based panel study that collects information on the health, wellbeing, socioeconomics, and labor market dynamics of Australian residents over the course of their lives. Commenced in 2001, data were collected annually through interviews with individuals aged 15 years and above from the selected households. Wave 1 (2001) data were collected from 13,969 individuals, and a sample top-up of 4,009 individuals was added in wave 11 (2011). A detailed description of the survey objectives and methods is provided elsewhere . In thisHILDA survey contains 36-item short questionnaires deriving from SF-36 Health Survey, which is a widely used instrument for assessing HRQoL. SF-36 includes eight dimensions of scale scores ranging from 0 to 100  that measure physical and mental health: physical functioning (PF), role physical (RF), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role emotional (RE), and mental health (MH). The overall health status of the individual was based on the overall SF-6D score, which is derived from the SF-36. Finally, these scores were converted to binary variables with a threshold of 25th percentile as 1 indicating poor health and 0 indicating better health.The physical conditions included in HILDA were as follows: arthritis/osteoporosis, asthma, cancer, chronic bronchitis/emphysema, type 1 diabetes, type 2 diabetes, heart disease, high blood pressure/hypertension, and any other serious circulatory condition, depression/anxiety, and “other mental illnesses.” Respondents who answered affirmatively to the question “Have you been told by a doctor or nurse that you have any of these conditions?” were defined as reporting a health condition. We counted the number of self-reported health conditions to quantify the number of physical conditions .The HILDA survey questionnaire inquired about respondents' functional limitations. Respondents were classified as having functional limitations if they answered yes to the following question: “Do you have any long-term condition, impairment or disability that restricts you in your everyday activities, and has lasted or is likely to last, for 6 months or more?.”The covariates of this study are as follows: sex (men and women), age group , marital status (married/cohabitating and single/separated/divorced/widowed), geographical region of Australia by state , and locality . Socioeconomic status was obtained using the quintile of Socio-Economic Indexes for Areas (SEIFA) relative to socioeconomic advantage/disadvantage .We adopted a panel mediation study design to explore the role of functional limitations (2013) on the relationships between multimorbidity and HRQoL using three waves of panel datasets. We performed the analysis following the steps suggested by Baron and Kenny, which consists of a series of panel data regression analyses . We examAll statistical analyses were performed using Stata 15 Corp. The panel data mediation analysis was conducted using the Stata paramed program, and a significance was set at 0.05. All statistical models were adjusted for the covariates mentioned above.de facto, and 85.6% were residing in urban areas. In total, 55.2% reported not having any NCD, while 7.2% reported having three or more NCDs and 20.7% of the sample reported disability.The participant's characteristics against key indicators are presented in p < 0.05) and physical functioning  scales. Additionally, the second equation revealed a significant correlation between the number of NCDs and functional limitation . The third equation, which included both HRQoL measures and functional limitation in the model, revealed that the number of NCDs and functional limitation were both significantly associated with poor HRQoL outcomes. It is important to note that when functional limitation is included in the model, the magnitude of the effect between multimorbidity and HRQoL decreases in all measures, indicating that the impact of the number of NCDs on HRQoL outcomes was partially mediated by functional limitation.TE:1.78, 95%CI: 1.65–1.92), with 27.2% mediated by functional limitation. The decomposition of total effects indicated statistically significant NDE  and IE .TE: 2.22, 95%CI: 2.03–2.41) and general health , the associations of which were 23.9 and 18.4%, respectively, mediated by functional limitation. Functional limitation showed the largest mediation effect of the association between the number of NCDs and role physical (28.7%). Consistent results were found in other SF-36 domains .We also investigated the role of functional limitation in each dimension of the SF-36 separately. The most significant result was observed for physical functioning (ORThis is the first study that uses a panel data study design to investigate the role of functional limitation as a mediator in the relationship between multimorbidity and health-related quality of life in Australia. We found clear evidence that functional limitation acts as a partial mediator on the relationships between multimorbidity and the overall HRQoL score as well as each SF-6D dimension, with the percentage of mediation ranging from 18 to 28%.The possible explanation is that disabled older adults or those with greater functional limitations have a negative impact on their self-care ability, physiological activities, and social interaction, all of which have a negative impact on their physical and mental health, reducing HRQoL. Multimorbidity, functional limitation, and disability all have a negative impact on HRQoL outcomes , 33, 34.Multimorbidity has been found to have a negative impact on the health-related quality of life of patients, partly due to its association with functional decline. Therefore, managing functional limitations effectively could help maintain the HRQoL of patients with multimorbidity. This implies a need for a more comprehensive approach to managing both conditions and recognizing their equal importance, which could ultimately improve the overall wellbeing of patients. In clinical practice, a thorough assessment of the various types of functional limitations in patients with multimorbidity could help guide appropriate preventive and supportive care, not only to maintain HRQoL but also to prevent further decline in function dependence.This study has several limitations, including the use of self-reported measures which may be subject to recall and social desirability bias. Although a well-validated questionnaire was used to measure HRQoL, subjective measures may not fully capture the objective reality of patients' health status. Additionally, the study is not causal and only identified associations between variables. Although panel data was used, unobserved confounding variables cannot be completely ruled out. Notably, important clinical factors such as disease severity and duration of the illness were not included in the study, which could have affected the relationship between multimorbidity and HRQoL.Furthermore, the mechanisms underlying the relationship between multimorbidity and HRQoL are complex and may involve multiple mediators. While the current study focused on function limitation as a mediator, other mediators such as psychological distress or social isolation may also play vital roles. Further research utilizing more comprehensive measures and sophisticated statistical techniques, such as structural equation modeling, may offer more insights into the mechanisms underlying the relationship between multimorbidity and HRQoL.This study contributes to the existing literature to understand the mediating effect of functional limitation and disability on the relationships between multimorbidity and HRQoL. Our study highlights the importance of improving patients' functional ability and preventing disability for patients with multimorbidity to improve their HRQoL. Therefore, healthcare that improves the management of patients with multimorbidity should include interventions that aim to encourage patients to participate in physical activity and increase social participation. Given the important mediating role, our study highlights that functional limitation or disability might be considered an intermediate outcome for evaluating interventions aimed at managing multimorbidity.https://melbourneinstitute.unimelb.edu.au/hilda.The study utilized HILDA survey in Australia, which can be apply for access to the dataset through the following link: The aim of the research was developed by JL and MI. The methodology development and analysis were conducted by JL, MI, and TH. JL and MI drafted the manuscript draft. SP, YZ, RP, KA, RA, and BO contributed to all sections. All authors reviewed, edited, and commented on multiple versions of the manuscript. All authors contributed to the article and approved the submitted version.


Background: Digitalization in the health system is a topic that is rapidly gaining popularity, and not only because of the current pandemic. As in many areas of daily life, digitalization is becoming increasingly important in the medical field amid the exponential rise in the use of computers and smartphones. This opens up new possibilities for optimizing patient education in the context of anesthesia. The main aim of this study was to assess the implementation of remote consent in Europe. Methods: An online survey entitled “Digital online Patient Informed Consent for Anesthesia before Elective Surgery. Recent practice in Europe,” with a total of 27 questions, was sent by the European Society of Anesthesiology and Intensive Care (ESAIC) to their members in 47 European countries. To assess the effect of the economy on digitalization and legal status with regard to anesthesia consent, data were stratified based on gross domestic product per capita (GDPPC). Results: In total, 23.1% and 37.2% of the 930 participants indicated that it was possible to obtain consent online or via telephone, respectively. This observation was more often reported in countries with high GDPPC levels than in countries with low GDPPC levels. Furthermore, 27.3% of the responses for simple anesthesia, 18.7% of the responses for complex anesthesia, and 32.2% of the responses for repeated anesthesia indicated that remote consent was in accordance with the law, and this was especially prevalent in countries with high GDPPC. Concerning the timing of consent, patients were informed at least one day before in 67.1% of cases for simple procedures and in 85.2% of cases for complex procedures. Conclusion: Even European countries with high GDPPC use remote informed consent only in a minority of cases, and most of the time for repeated anesthetic procedures. This might reflect the inconsistent legal situation and inhomogeneous medical technical structures across Europe. In recent years, efforts have been made to shorten patients’ hospital stays and to streamline processes . On the The World Health Organization (WHO) highlights healthcare-associated infections (HCAIs) as a major issue for healthcare providers, patients, and public authorities worldwide . The EurEnabling remote contact and communication with patients using digital media tools instead of physical visits may facilitate a reduction in HCAIs. Especially for surgical interventions, this may help to keep the pre-operative hospital length of stay as short as possible. Currently, however, pre-operative anesthesiological evaluations are performed in most hospitals during the pre-operative stay or on an outpatient basis in advance. This practice is supported by the recommendations and guidelines of many medical societies that emphasize physical contact in the form of consultation, during which a patient is to be legitimately informed about his/her future anesthetic procedure .Especially in light of the COVID-19 pandemic, a reduction in the length of hospital stay is of utmost desirability. Furthermore, social distancing is even more important for vulnerable patient groups, such as those with multiple comorbidities and immunosuppressed or elderly patients , even beDespite all the advantages, it also remains to be mentioned that older people or those from lower income strata in particular do not always have access to computers or the Internet. In addition, in the future, there will still be a certain clientele of patients who, due to the severity and complexity of their illness, prefer a personal conversation with the attending physician.The goal of this study was to identify differences in the implementation of telemedicine for pre-operative anesthesiological consultation across Europe. Furthermore, anesthesiologists’ knowledge of the legal framework was assessed, and the technical applicability of remote consent was highlighted.To provide a Europe-wide overview of the current state of technical support and legal frameworks for telemedical consultation, a cross-sectional study in the form of a survey comprising 27 questions was sent through the European Society of Anesthesiology and Intensive Care (ESAIC) to its members in 47 European countries.The survey was designed as a multiple choice questionnaire, with the possibility of adding comments or omitting questions. Written answers were not analyzed in this study and did not contribute to the results presented here. Test runs revealed that the questionnaire could be completed within 7–10 min. It was possible to resume the survey if the session had to be interrupted, and respondents were allowed to omit questions.The main focus of the survey was particularly on the general and technical possibility of digital education in the field of anesthesia and the assessment of whether a remote online or telephone-based anesthesia consent procedure could comply with the current prevailing legal frameworks across different European countries. The participating anesthetists were asked to judge this according to their own assessment and to the best of their knowledge. Information was also collected on the timing of the preoperative visit, and a distinction was made between low- and high-risk procedures.https://data.worldbank.org/indicator/ny.GDPPC.pcap.cd), and the countries represented in our study were assigned to one of three groups: high, middle, and low GDPPC. The assignment process was performed such that each group had a similar number of countries. A detailed overview is provided in the Supplementary Material . This was considered when discussing whether significant disparities existed or not. Quantitative data for GDPPC were accessed online on 16 February 2022 , and it was hosted on a secured Linux Debian (Version 10.11) server. The link to the questionnaire was distributed by the ESAIC communication committee (https://kai-survey.de/limesurvey/733779/) to 42,433 active members, and the survey was conducted over a three-week period (July to August 2021).The survey was implemented using an open-source online questionnaire tool, “LimeSurvey CE” . An interactive web application was programmed to provide additional insights into the survey population (https://kai-survey.shinyapps.io/ESAIC-KAI-survey-2021). All codes for statistical analysis and visualization can be accessed online (https://github.com/GrigorijSchleifer/EJA-ESAIC-survey).Absolute numbers and proportions of responses were calculated for the questions used in the survey. Differences in the study population and sub-analysis groups were compared using the chi-squared test for independence. The nature of the association between the row (GDPPC) and the column (the likelihood of giving a certain answer) in contingency tables was interpreted by identifying cells with the highest Pearson residuals as an estimate of the raw residuals’ standard deviation (r). The cells with the highest Pearson residuals show the direction and strength of the associative effect between the dependent and independent variables. Residuals that exceed 2 in absolute value indicate a strong association between gross domestic product per capita and the likelihood of giving a certain answer. The significance level was set at n = 920), nurses , physician assistants , and other undisclosed professionals . Of the survey participants, 56% (n = 521) were male, 43.6% (n = 406) were female, and 0.3% (n = 3) were diverse. Consent was obtained predominantly by consultants  or residents  (n = 132), Spain , and Switzerland   . Most of n = 65) . Two parn = 486) of the responses, informed online consent was not possible or it was not uniformly implemented . However, 23.1% (n = 160) of the respondents stated that consent via the Internet was already used in clinical routines. Anesthesia consent via the telephone could not be obtained in 56.7% (n = 391) of cases. In contrast, 37.2% (n = 257) of the respondents answered that patient education via telephone was available, and 6.1% (n = 42) mentioned varying technical solutions , countries with higher GDPPC were positively associated with online remote consent  per capita A. Interen = 298) of respondents stated that remote informed consent was not in accordance with legal regulations in their country, while it was legally sound in 27.3% (n = 219) of cases. For complex procedures, remote consent was not possible owing to legal requirements in 42.5% (n = 341) of cases, and only in 18.7% (n = 150) of cases was it compliant with the law according to the participants’ understanding of their judiciary setup. Overall, respondents were unsure about legal regulations with respect to Internet or telephone informed consent 35.5% (n = 285) of the time for simple procedures and 38.8% (n = 311) of the time for complex procedures , 4.33 (complex), and 5.35 (repeated)). On the contrary, in countries with low GDPPC, online remote consent was more often stated as not being in accordance with legal requirements for simple, complex, and repeated anesthesia , −2.98 (complex), and −4.21 (repeated)) . These on = 103) of the time 2 days or more before surgery, and in 54.2% (n = 433) of cases, it was obtained 24 h or less before surgery (n = 263) of cases, consent was obtained on the same day of surgery. In comparison, for complex procedures, consent was obtained in 33.6% (n = 269) of cases 2 days or more before surgery, and 51.6% (n = 413) of the time it was obtained 24 h or less before the surgical intervention. On the day of surgery, consent was acquired in only 14.8% (n = 118) of cases. Here, we observed that patients who needed an extended procedure were more likely to stay overnight than those who underwent simple procedures.It was further investigated whether procedural severity affected the timing of obtaining informed consent. For simple procedures, informed consent was obtained 12.9% ( surgery . In 32.9n = 269), middle GDPPC: 83.6% (n = 102), low GDPPC: 79.1% (n = 216), n = 89), middle GDPPC: 16.5% (n = 20), low GDPPC: 20.8% (n = 57), for detailed information see The effect of economic status (GDPPC) on anesthesiologist preference to obtain informed consent in the future was also assessed. In all three GDPPC groups, most of the respondents answered that they would still prefer to obtain informed consent in person . The restrictive attitude may be due to the fact that there is no clear legislation in this regard and the anesthetist is legally on thin ice when it comes to the use of telemedicine media. Healthcare is the responsibility of individual member states, and there is no uniform, Europe-wide regulatory body. Specific legal regulations for the use and handling of telemedicine are lacking in many countries, and harmonization across the EU is often described as unfeasible because of data protection regulations .Currently, a new electronic cross-border health service is being established for the EU  , and theComparing countries with a higher GDPPC with those with a lower GDPPC, we find that in the first group, remote informed consent is more often considered legitimate . TherefoLooking at the time frame, in most cases, the patient was informed at least one day before the procedure; this applied to simple and complex procedures (67.1% vs. 85.2%).The current procedure for major surgery is an inpatient stay where the patient’s consent is usually obtained within 24 to 48 h, allowing for sufficient reflection time ,22.However, a time course of 24 to 48 h is often not sufficient to achieve comprehensive pre-operative risk mitigation . In ordeIn another study, it was shown that remote information for patients was not inferior to face-to-face conversation. Even though this was information about a clinical trial, it is evident that the content can be communicated equally well to the patients .However, despite the potential benefits of telemedicine, especially in terms of less stress and shorter waiting times, the primary wish for the future in countries with high, medium, or low GDPPC is still to carry out face-to-face patient information . The assThe questionnaire was sent to 42,433 active ESAIC members from 47 countries. The response rate was only 2.2%, with 930 responses, and responses were not equally distributed across all countries. Nevertheless, responses from anesthesiologists from 47 different nations were obtained.Furthermore, although the questionnaire was designed with maximum care by experienced clinical and research anesthesiologists, a response bias may have arisen. As the questionnaire was only sent out once by the ESAIC, there was no possibility of pre-testing to evaluate the possible bias effect of the primer questions. Thus, the validity of the results could be limited because of question order effects. However, the survey was performed anonymously without any human contact, and socially desirable responses and interviewer bias should not be a concern.The present survey was able to show that, especially in low income countries, telemedicine in the field of anesthesia is not frequently used in Europe, even though many professional societies have been recommending it for years ,27,28. T


Whether neutrophil-lymphocyte ratio (NLR) is an applicative predictor of poor prognosis in patients with hepatocellular carcinoma (HCC) remains controversial. In response to the current conflicting data, this meta-analysis was conducted to gain a comprehensive and systematic understanding of prognostic value of NLR in HCC.Several English databases, including PubMed, EMBASE, and the Cochrane Library, with an update date of February 25, 2023, were systematically searched. We set the inclusion criteria to include randomized controlled trial (RCT) studies that reported the prognostic value of serum NLR levels in patients with HCC receiving treatment. Both the combined ratio (OR) and the diagnosis ratio (DOR) were used to assess the prognostic performance of NLR. Additionally, we completed the risk of bias assessment by Cochrane Risk of Bias Assessment Tool.This meta-analysis ultimately included 16 studies with a total of 4654 patients with HCC. The results showed that high baseline NLR was significantly associated with poor prognosis or recurrence of HCC. The sensitivity of 0.67 ; specificity of 0.723 (95% CI: 0.64-0.78) and DOR of 5.0 (95% CI: 4.0-7.0) were pooled estimated from patient-based analyses. Subsequently, the combined positive likelihood ratio (PLR) and negative likelihood ratio (NLHR) were calculated with the results of 2.4 (95% CI: 1.9-3.0) and 0.46 (95% CI: 0.39-0.56), respectively. In addition, area under the curve (AUC) of the summary receiver operating characteristic (SROC) reflecting prognostic accuracy was calculated to be 0.75 (95% CI: 0.71-0.78). The results of subgroup analysis suggested that high NLR was an effective predictive factor of poor prognosis in HCC in mainland China as well as in the northern region.Our findings suggest that high baseline NLR is an excellent predictor of poor prognosis or relapse in patients with HCC, especially those from high-incidence East Asian populations.https://www.crd.york.ac.uk/prospero/#recordDetails, identifier CRD42023440640. Hepatocellular carcinoma (HCC) is a malignant tumor that seriously endangers human health, and its pathogenesis is still unclear , 2. AccoEast Asia is a region with a high prevalence of viral hepatitis B and primary liver cancer . Most liMore recently, there is growing evidence that increased systemic inflammation in a wide range of cancers is associated with poor cancer-specific survival . Both elIn this study, we aimed to evaluate the predictive value of high NLR in predicting prognosis and recurrence in patients with HCC. In addition, we considered several sub-analyses to determine the differences in predictive outcomes across countries or regions and dimensional divisions.Several English-language databases were systematically searched, including PubMed, EMBASE and the Cochrane Library, from creation to 25 February 2023. The following search terms were used , 23. Thiin vitro studies only; (3) presence of duplicate data or insufficient information; and (4) article type of review, poster, commentary, editorial or supplemental question.All citations are reviewed in order. Search for full text of potentially relevant articles by title or abstract, and two investigators (Chunhua Xu and Shan Lin) independently reviewed to identify eligible studies. Disagreements about eligibility were resolved through discussions with the arbitrator (Fenfang Wu). Studies that explicitly met the following inclusion criteria were considered for inclusion: (1) serum NLR levels were measured prior to formal treatment; (2) participants in human studies were ≥18 years old; (3) sample size was >20; (4) randomized controlled trials (RCTs) are observational; and (5) false positive (FP), sufficient true positive (TP), false negative (FN), as well as true negative (TN) data were provided to calculate the predictive power of NLR in patients with HCC. Studies meeting the following exclusion criteria were excluded. (1) lack of information on the prognostic accuracy of the control or experimental groups; (2) animal or The data of each experiment were collected by Xu Chunhua and Lin Shan respectively. All disagreements or differences among the reviewers were discussed and evaluated by a third-party reviewer (Lailing Du) until a consensus was reached. Pre-specified data for each study included a request to record and recalculate the following variables: first author, country or region, publication year, study design, entry time, sample size , median age (years), area under the curve , sensitivity, specificity, and baseline NLR cutoff value.In this study, we applied the Cochrane Risk of Bias Assessment Tool with 2 independent reviewers (Chunhua Xu and Shan Lin) to assess the quality of the articles . The tooAdditionally, eligible studies were assessed using the Newcastle-Ottawa scale (NOS) . EstimatP-values <0.05 for the Q statistic as well as I2 values >50% for the I2 statistic were all considered to be statistically significant heterogeneity (I2 > 50%), a random effects model was applied  software for all statistical analyses of TN, TP, FP and FN rates for each study, as well as diagnostic odd ratio (DOR) sensitivity, specificity, positive likelihood ratio (PLR), as well as negative likelihood ratios (NLHR) were fully assessed. ogeneity . When he applied . Hardy-Wue <0.05 .p-value < 0.05  curves and pooled sensitivity and specificity forest plots by assessing AUC as a summary metric . Then, se < 0.05 , 32.Initially, a search of an electronic database yielded 698 potentially relevant papers, but after culling the duplicates, 315 papers were eliminated. From the title and abstract, 112 studies were obviously irrelevant and were therefore excluded. After the remaining 271 papers were reviewed, 185 papers were rejected and 70 papers were rejected. In the end, 16 papers were selected. Through 16 literatures, including 4654 cases, the role of NLR in the prognosis of HCC was evaluated by using the Meta method. All 16 papers are written in English. To assess the quality of the included trials, basic data were extracted, as shown in In this study, all trials had detailed inclusion criteria and excluded patients. Second, the quality of each included study  was assessed using the Cochrane risk of bias tool (Cochrane). In addition, the overall quality of the included studies was average. Moreover, the probability of publication bias was evaluated by Begg’s and Egger’s funnel plot, and the results were shown in Sixteen data sets were extracted from 16 qualified literatures Table 2,In addition, forest plot of AUC of high NLR predicting HCC prognosis was carried out and shown in To further understand the differences in the predictive value of high NLR for recurrence and poor prognosis of HCC in populations from different countries (or regions) and in populations with different dimensional gradations, we performed a systematic subgroup analysis, and the results were shown in Generally, the optimal cut-off value of NLR was determined by using receiver operating characteristic (ROC) curves. For the subgroup analysis of method of NLR cutoff identification Table 3,Each study included in the meta-analysis was removed each time to investigate the impact of a single data set on the combined OR. The results of the sensitivity analysis demonstrate the robustness of the findings in this study (data not shown).I2 = 88.2%, P = 0.000) and mainland China  may be the main source of heterogeneity, while the factor of low-latitude  may not be a source of heterogeneity in the predictive value of NLR. For subgroup analysis with heterogeneity, the random effects model was used to combine the effect size. For subgroup analyses without heterogeneity, fixed-effect models were used to combine effect sizes.In addition, possible explanations for heterogeneity were evaluated by meta-regression and subgroup analyses. The factor of high-latitude (Factors affecting the prognosis of patients with primary HCC include tumor-related factors (such as the volume and load of the tumor) and patient-related factors . In addiSystemic inflammatory responses are associated with the recurrence of certain tumors . The intIn recent years, some simple indicators of inflammation have been used to predict tumor recurrence and metastasis with good practical value . NLR canRecently, several studies showed that the NLR may be correlated with the prognosis of patients with HCC, but most of them were initially treated by liver transplantation (LT) , 45, 68.Intriguingly, it is worth mentioning that there were other biomarkers not only inflammatory ones, such as APRI and CRP. It is reported that high APRI levels are associated with poor OS and DFS in the patients with HCC, and pretreatment APRI can be used as an independent prognostic factor, but it is necessary to incorporate other predictive prognostic systems to ensure accuracy . FurtherThere are some limitations in this study. First, the included studies were retrospective, and patients had different late treatment regimens, which may have had an impact on patient prognosis. Second, the levels of preoperative neutrophil and lymphocyte counts are susceptible to a variety of factors, such as hepatitis and the degree of cirrhosis. Furthermore, it was shown that there is low level of publication bias. Even though the overall risk of bias may be low, it can be avoided by including more published articles to inflate the sample size in the future. In addition, most of the original studies demonstrated an association between high baseline NLR and poor prognosis of HCC, which may be due to the ease of publication of positive results, ultimately making it difficult to find more controversial studies. Finally, the cutoff value for defining high NLR differed in studies, and it is essential that they be unified before high NLR can be utilized in clinical prognostication for HCC.A high level of NLR is an excellent prognostic indicator for HCC and can be used to predict early relapse, late relapse and long-term survival of HCC. It can be an effective reference indicator for clinicians to judge the prognosis of patients and adjust the treatment in a timely manner. Even so, larger and better-designed investigations are needed to further fully elucidate the predictive value of NLR for the prognosis of HCC patients.The original contributions presented in the study are included in the article/CX and SL contributed to the conception and design. CX and FW contributed to the administrative support. CX and LD contributed to the provision of study materials or patients. SL and YD contributed to the collection and assembly of data. CX contributed to the data analysis and interpretation. All authors agree to the submission for publication.


To determine the prevalence of cardiovascular disease (CVD) types in the Asir region of Saudi Arabia and the importance of hematological testing for CVD patients in the context of disease management.This retrospective study comprised 416 CVD patients, and samples were divided based the type of CVD. The Mann Whitney U test was used to compare patients’ hematological markers and coagulation profiles to those of healthy controls.The rate of ischemic heart disease (IHD) was 80.7% that of other CVDs, and the rate of ST-elevation myocardial infarction (STEMI) was 37.3% the rate of CVD. Significant differences were observed in the hematological and coagulation parameters of CVD patients compared to the control group. White blood cells (WBC) were significantly higher in STEMI, non-ST-elevation myocardial infarction (NSTEMI), unstable angina (UA), and heart failure (HF) groups. Red blood cells (RBC) were significantly lower in STEMI, NSTEMI, UA, chronic coronary syndrome (CCS), HF, dilated cardiomyopathy (DCM), and ischemic cardiomyopathy (ICM). Red distribution width (RDW) was significantly greater in the HF, DCM, and ICM groups. Prothrombin time (PT) was significantly higher in the STEMI, HF, and DCM groups.ST-elevation myocardial infarction has a higher prevalence rate among CVD patients in the Asir region. Both coagulation and hematological indicators have high potential utility as CVD diagnostic and prognostic markers. Cardiovascular disease (CVD) is one of the leading causes of mortality and morbidity. As a term, CVD refers to a wide range of conditions that affect the heart and blood vessels; it thereby encompasses heart failure (HF), atherosclerosis, myocardial infarction (MI), hypertension, coronary artery disease (CAD), coronary heart disease (CHD), and acute coronary syndrome (ACS). Despite recent advances in medication and technology, CVD mortality and morbidity remain high, with 17.3 million deaths attributed worldwide according to the 2013 Global Burden of Disease (GBD) study; moreover, CVD caused more deaths than all communicable, maternal, neonatal, and nutritional illnesses combined, accounting for 31.5% of all deaths and 45% of non-communicable disease (NCD) deaths. According to a prediction of the World Health Organization (WHO), the number of individuals suffering from CVD is expected to exceed 23.6 million by 2030. Ischemic heart disease (IHD) and stroke are among the top 10 causes of death in the Middle East, with IHD ranking second and stroke ranking fourth in Saudi Arabia. Several risk factors contribute to the development of CVD, a few of which are hypertension (HTN), diabetes mellitus (DM), hypercholesterolemia (HyCh), cigarette smoking, and obesity. Controlling these factors may contribute to the management and prevention of CVD occurrences.In Saudi Arabia, NCDs overall account for approximately 73% of all mortality and CVD in particular is the main cause of death, accounting for approximately 37% of all NCD deaths.When CVD occurs, early and accurate detection is essential for disease control and management. Diagnosis of CVDs generally requires clinical evaluation utilizing costly procedures; however, physicians frequently use the complete blood count (CBC) and other routine tests to monitor the health of both sick and healthy people. The low cost and accessibility of these tests make them ideal for investigating and diagnosing concerns such as anemia, infection risk, hematologic malignancies, and coagulation abnormalities.The hematological parameters of CVD patients show functional disturbances owing to the involvement of inflammation and systemic hypoxemia in the pathophysiological processes. Several studies have identified a link between risk of adverse outcomes in CVD patients and hematological parameters which could lead to circulatory failure; thus, hematological and coagulation markers have prognostic significance in CVD. Red distribution width has also been associated with inflammation in rheumatoid arthritis, cancer, autoimmune hepatitis, COVID-19 infection, and autoimmune diseases. Mean platelet volume (MPV) is a platelet activation measure that is commonly utilized for routine screening and has been demonstrated to be a prognostic predictor in CVD patients. The MPV hemogram measurement has been associated with a diverse range of inflammatory diseases, including type 2 DM, diabetic nephropathy, hypothyroidism, vertebral discopathies, infection, irritable bowel syndrome, rheumatoid arthritis, obesity, mortality in ICU population, and liver fibrosis. As inflammation and cardiovascular conditions are closely related, RDW, MPV, and other hematological markers investigations in cardiac conditions are of interest. There is additional evidence that RDW, white blood cells (WBC), and MPV, when combined with the coagulation profile, can contribute to the diagnosis of acute coronary syndrome (ACS) in individuals presenting with chest pain. Thus, CBC can be utilized to monitor CVDs and evaluate patient prognosis. However, the importance of these hematological markers in predicting in-hospital and short-term outcomes in patients with ACS and other CVDs remains to be determined.In patients with chronic heart failure (CHF), increased red distribution width (RDW) is a significant independent predictor of increased morbidity and mortality.This study aims to assess the prevalence of various types of CVD in the Asir region, Saudi Arabia, as well as the relevance of hematological and coagulation biomarkers for CVD patients in the context of subsequent management and care.This retrospective study was carried out by collecting patient data of hematological parameters and coagulation profiles from Prince Faisal bin Khalid Cardiac Center, Abha, Asir region, Saudi Arabia. Patients with CVD who were admitted to the hospital as inpatients between December 2020 and January 2022 were included in the study. A total of 54 healthy individuals without health issues were collected from the blood bank unit and screened for comparison with the patients’ samples.The diagnosis, age, gender, and medical history of CVD patients were provided by the medical record department, while hematological and coagulation parameters were provided by the laboratory department for each patient. Patients were classified into categories according to the type of cardiovascular disease they suffered. Patients with a history of CVD met the inclusion criteria. Patients who were anemic or who had an infection were excluded. Ethical approval  for this study was obtained from the research ethics committee at King Khalid University (HAPO-06-B-001).p-value of <0.05.The GraphPad Prism (version 9.3.1.471) and Excel (version 22052000) were used. The quantitative variables , partial thromboplastin time [PTT], and international normalized ratio [INR]) were presented as mean and standard error of the mean (SEM), whereas the qualitative variables  were presented as frequency and percentage. To compare study parameters between CVD and control groups, the nonparametric Mann-Whitney U test was performed. Kalmogorove Smrinov (K-S) test was used to check the data normality. Statistical significance was defined as a A total of 433 patients with CVD were investigated, 416 patients fulfilling the criteria and the remainder being ruled out. A total of 416 CVD patients with an average age of 60 years were included in the study (79.3% men and 20.7% women). Saudi citizens comprise most of the patients. ST-Elevation Myocardial Infarction (STEMI), as shown in p<0.001 and significantly lower RBC  with p=0.01, HGB  with p<0.001, HCT  with p=0.001, MCHC  with p=0.02, and MPV  with p=0.010 as compared to the control group  with p=0.002, HGB  with p<0.001, HCT  with p<0.001, and MCHC  with p=0.010 as compared to the control group  with p=0.001, HGB  with p<0.001, HCT  with p<0.001, MCHC  with p=0.02 and MPV  with p=0.01 as compared to control group  with p<0.001, HCT  with p<0.001 and MPV  with p=0.01 as compared to the control group  with p<0.001 and significantly reduced RBC  with p<0.001, HGB  with p<0.001, HCT  with p<0.001, MCV  with p=0.046, MCH  with p=0.003 and MCHC  with p<0.001 as compared to the control group  with p<0.001, HGB  with p<0.001, HCT  with p<0.001, and PLT  with p=0.01 as compared to the control group  with p=0.009, HGB  with p<0.001, HCT  with p<0.001, MCV  with p=0.04, MCH  with p=0.02 and MCHC  with p<0.001 as compared to control group  with ol group . Non-ST-ol group . Data deol group . Chronicol group . The HF ol group . Data deol group . Ischemiol group .p<0.001, PTT  with p<0.001, and INR  with p<0.001 are substantially higher in the STEMI group compared to the control group  with p=0.001 and INR  with p<0.001 are substantially greater in the HF group compared to control group  with p<0.001 are substantially greater in DCM group compared to control group  group compared to control group  with ol group . While dol group . Unstablol group . But no ol group . Data deol group . Researcol group . While Iol group . HoweverThe values of hematological parameters and coagulation profiles among less prevalent CVD patients were examined and determined to assess the relevance of such values for disease prognosis and prevention.  Cardiovascular disease causes a wide range of impairments to the body, involving variations in hematological parameters. The inflammatory and hypoxemic nature of CVD activates bone marrow, resulting in the release of immature cells or an increase in other cells in circulation, depending on the degree of stimulation. The current study investigated the prevalence of numerous forms of CVD in the Asir region, as well as how valuable hematological and coagulation biomarkers are for CVD patients on the basis of further control and management.In Saudi Arabia, CVD is one of the primary causes of death. Several prior studies revealed that hematological or coagulation parameters had a role in the diagnosis and prognosis of CVD. In line with previous studies, there had been a variance in the hematological and coagulation parameters of different types of CVD, as well as a variable in the prevalence of CVD by gender.The study found that the risk of IHD was 80.7% higher in CVD than in other types. Moreover, STEMI has a greater rate at 37.3% than other types of CVD. Ischemic heart disease is well addressed in the literature as being the major cause of death among CVD patients. According to our findings, overall IHD (80.7%) had the greatest incidence rate in the Asir region, which is consistent with prior research.Ischemic heart disease affects roughly 126 million individuals , accounting for 1.72% of the global population. It has caused the deaths of 9 million people worldwide. The global incidence of IHD is rising, and by 2030, it will have exceeded 1,845 million people. Women, on the other hand, have a higher death rate and a worse prognosis following an acute cardiovascular (CV) event than males. The cause of such gender differences would be estrogen’s protective effect on the development of CVD risk factors, particularly hypertension and dyslipidemia. Premenopausal women exhibited lower systolic blood pressure, higher high-density lipoprotein (HDL) cholesterol, and lower triglyceride levels than males, presumably due to estrogen. Even though the exact mechanism of this protection is unknown, estrogen is known to have a variety of effects on the atherosclerotic and blood-lipid management processes. The fact that this protection is lost following menopause contributes to the evidence that estrogen has a protective effect. Women, on the other hand, had greater rates of hypertension and cardiovascular illness by the age of 75 than males.Our data show that men had a higher prevalence of CVD than women, which is consistent with prior research. Consequently, our study indicated that WBC levels were considerably higher in the STEMI, NSTEMI, UA, and HF groups, as comparable to findings obtained in other investigations.An increase in total WBC is a typical laboratory result during inflammation. Cardiovascular diseases have been attributed to inflammation and inflammatory markers, and it has been demonstrated that atherosclerosis has a key inflammatory basis as a multifactorial disease that predisposes to the majority of CVDs, including myocardial infarction (MI) and heart failure (HF). Despite the fact that the association between inflammation and CVDs is not entirely understood, examining inflammatory markers is expected to be beneficial in determining the prognosis of CVD patients. RBCs are also implicated in the development of atherosclerosis, this occurs when CVD inhibits normal RBC activity due to reduced tissue perfusion in atherosclerosis and hence reduced oxygen supply to peripheral tissue. Our data showed that RBCs, HGB, and HCT levels were significantly lower in STEMI, NSTEMI, UA, HF, DCM, and ICM patients. This is consistent with previous study that demonstrated RBC, HGB, and HCT levels to be much lower in people suffering from acute coronary syndrome (ACS).Red blood cells are well-known oxygen and carbon dioxide carriers between the lungs and peripheral tissues. Substantial differences in RDW levels were seen between the HF, DCM, and ICM groups and the control group. Red distribution width is a prognostic indicator for CVD patients, although RDW’s relationship mechanism with cardiovascular diseases remained unclear. The most accepted explanation for the link between RDW and CVDs is that systemic factors include inflammation and oxidative stress play a role. Inflammation appears to produce changes in RBC maturation, anisocytosis, and increased RDW via increasing adrenergic and neuroendocrine activity and stimulating the renin-angiotensin system. Moreover, oxidative stress can raise RDW in acute inflammatory circumstances by damaging RBC membranes and prompting bone marrow (BM) to release immature RBCs into the circulation.Furthermore, a correlation between high RDW and mortality has been demonstrated. As a result, our findings lend credence to the suggested use of various hematological variables as prognostic markers for certain diseases.Hemoglobin and RDW parameters were recently introduced as predictors of recurrent hospitalizations; as a consequence, physicians should monitor these levels in diabetic and cancer patients in particular. The MPV measures the average size of platelets in the blood as well as the rate at which bone marrow creates them and previous research suggests that increased MPV levels are related to worse cardiac outcomes in ACS patients. Another research discovered no connection between higher MPV and death in individuals with coronary artery disease. In our investigation, we found that the MPV value was considerably lower in the STEMI and UA groups when compared with control, which contradicted prior findings. We propose that the difference between our study and prior studies is that all patients in our study do not have complications and are discharged from the hospital once they have recovered. In contrast, most prior research had focused on the role of high MPV in CVD patients’ increased morbidity and mortality.According to recent research, platelets play a key role in the pathophysiology of atherothrombosis by having a significant influence on the development of atherosclerotic plaques. Larger, more reactive platelets hasten the formation of an intracoronary thrombus, which leads a variety of heart conditions, including ACS. Unstable angina and myocardial infarction are associated to platelet aggregability. Platelet size and activity are connected, with MPV levels being greater prior to an acute myocardial infarction. We found that the PT, PTT, and INR levels in our investigation were comparable to the findings of prior investigations. The retrospective study performed by Kırış et al reported that prolonged initial PT without anticoagulant medication use has been linked to all-cause death in patients with ACS following percutaneous coronary intervention (PCI) and PT can be used to determine ACS patients with high risk. Prothrombin time and APTT were elevated in acute MI patients receiving anticoagulants therapy in a study carried out by Saxena et al and by Khan et al. According to the studies carried out by Babes et al and Adam et al, PT was useful in predicting mortality and consequences in ACS patients.Clinical laboratory testing for coagulation, such as the prothrombin time (PT), activated partial thromboplastin time (APTT), and the international normalized ratio (INR), are essential. The exposure of tissue factor-bearing inflammatory cells to blood in ruptures of atherosclerotic plaque leads to activation of coagulation. Furthermore, consumptive coagulopathy can occur because of the elevated inflammation and the activation of the coagulation pathway. As result, many studies have suggested that the prolonged PT in ACS is associated with the inflammation, which contributes to consumptive coagulopathy. However, prolonged PT and INR can occur for other reasons, such as the decreased production of the clotting factor in liver disease or hepatic injury from diminished arterial perfusion or passive congestion in heart failure.Inflammation and coagulation both contribute to the progression of atherosclerosis as well as in the pathogenesis of vascular diseases. Between these 2 systems, there are increasing clues of an interference relationship, which means that one system can trigger the other. Ischemic heart disease is divided into 2 categories: CCS and ACS, with ACS further subdivided into STEMI, NSTEMI, and UA. In our study, we identified 35 patients diagnosed with CCS in this group; we observed a noticeable reduction in some CBC parameters, including RBC, HGB, HCT, and MPV, while coagulation parameters remained unaffected. We discovered a variation in WBC and coagulation markers when we compared these data to an ACS group and previous studies. According to a 2018 study, IHD patients had a considerable rise in WBC count. Moreover, a higher neutrophil-to-lymphocyte ratio was shown to be significantly linked with overall mortality and cardiovascular disease mortality, but not cancer mortality.Ischemic heart disease is a group of clinical conditions characterized by myocardial ischemia and a mismatch between blood supply and demand in the myocardium.The key limitation of the research was the inability to have access to data from previous years. Although our retrospective investigation was carried out on available hematological parameters and coagulation profiles between December 2020 and January 2022, larger sample sizes and a longer time of observation may provide a more robust result. In conclusion, even though our data was based on a single source, the Prince Faisal bin Khalid Cardiac Centre, Asir region, they provide an important observation to our study because the center receives patients from all Asir-region cities and is the only cardiac center in Asir-region in Saudi Arabia.In conclusion, there is a high demand for useful, noninvasive, and widely available prognostic markers that can contribute to disease management. Patients with cardiovascular diseases, in particular, require frequent monitoring to avoid complications that may result in death. The current investigation found considerable aberrant alterations in hematological markers and coagulation profiles in patients with cardiovascular diseases. Thus, routine monitoring of significant markers that could be a sign of disease complications might be utilized for disease management. This study clearly demonstrates a significant frequency of STEMI disease among CVD patients in the Asir region.Furthermore, coagulation and hematological markers are assumed to have significant diagnostic or prognostic utility. Testing methods are widely accessible and can be utilized to monitor CVD patients, particularly those with ACS or HF. Further research with such a larger sample in different Saudi cities is required to assess the prevalence of CVD and variations in hematological and coagulation parameters between patients at admission and discharge.


Language disorders are characterized by impairments in verbal expression/understanding, including difficulties with one or more language components. The Virtual Reality Rehabilitation System (VRRS) is a bioelectromedical device equipped with exercise sections aimed at improving cognitive and language deficits. It also increases patient motivation and engagement. The aim of our study was to test the feasibility and efficacy of VRRS intervention to improve speech therapy treatment for children with speech disorders. Thirty-two patients were enrolled in this study and randomly assigned to the experimental (EG) or control group (CG). The CG underwent conventional speech therapy, while EG underwent VRRS-implemented speech therapy. Both groups were evaluated before (T0) and after (T1) the intervention using the Language Assessment Test. The results showed improvements in both groups. However, the EG group showed greater improvement in various areas, including comprehension of total words, repetition, naming of body parts, naming of everyday objects, total naming, morphosyntactic accuracy, sentence construction, average length of utterance, and spontaneous word production. This study demonstrated that VRRS can be a valuable tool for implementing effective speech rehabilitation. Further studies are needed, as the use of VRRS is still in its early stages, requiring larger samples sizes and long-term follow-up. Developmental language disorder (DLD) is a neurodevelopmental condition characterized by persistent difficulty in the acquisition and use of language in all its modalities . Children may present deficits in both comprehension and production, with a reduced number of words known and a persistent difficulty in their correct usage, limited ability to connect sentences to explain or describe a topic or series of events, or difficulty sustaining a conversation .According to the literature, DLD is one of the most common disorders, and affects about 3–7% of preschoolers ,3,4. LanOver the past decade, virtual reality (VR) has played an increasing role in the treatment of several neurological disorders ,21. VR iThe purpose of this study is to test the feasibility and clinical effectiveness of speech therapy with the VRRS device in children with speech disorders, comparing the results with conventional treatment.This pilot randomized control trial was developed in order to evaluate the feasibility and compare the efficacy of speech intervention implemented with a virtual reality system with treatment as usual (TAU) delivered to children affected by DLD. This study has been reviewed and approved by the Local Ethics Committee  and completed in accordance with the CONSORT guidelines  Figure . WrittenAll patients underwent a complete and exhaustive assessment performed by expert clinicians. Diagnoses were made by a medical team comprised of pediatric neuropsychiatrists, psychologists, and speech therapists based on direct observation, a play session, a medical examination, a neuropsychological evaluation, and an interview with the parents. Children were assessed at baseline (T0) and at the end of the protocol (T1) with the Test of Language Assessment (TVL)  by an inEach child participating in both groups received two 1-h sessions per week of treatment for a period of six months. The CG underwent conventional speech therapy, while the EG underwent speech therapy implemented by VRRS sessions. This virtual reality device is recognized as one of the most advanced, comprehensive, and clinically proven systems for rehabilitation ,42. It ip < 0.05 as statistically significant. A nonparametric analysis was performed. A Wilcoxon signed-rank test was used to compare scores between baseline and follow-up.Data were analyzed using R version 4.2.3, considering a n = 16) or the control group (CG: n = 16). A more detailed description of the two groups is given in A total of 45 children with DLD were screened for eligibility. Thirty-two children  met the inclusion criteria and were randomly assigned to either the experimental group  and developmental coordination disorder . p = 0.011), naming body parts (p = 0.033), naming everyday objects (p = 0.011), total naming (p = 0.029), morphosyntactic accuracy (p = 0.012), sentence construction (p = 0.030), average utterance length (p = 0.013), and spontaneous word production (p = 0.031). Significant improvements were not registered in comprehension—total sentences, construction—style, and construction—spontaneous production for the control group. For more details, see The feasibility appears to be well supported, as all patients accepted the procedures, attended regularly, and actively participated in the therapy, indicating that the DLD children were able to tolerate the virtual reality and the protocol. The retention rate of patients completing six months of treatment was 100%. Speech therapy led to improvement in both groups. In the EG group there were greater improvements in: comprehension—total words , morphosyntactic accuracy, period construction, average utterance length, and spontaneous word production. It was not possible to compare all the areas of language investigated through TVL, as in the literature studies were not found that implement virtual reality and evaluate the improvement of language in children in all the components of TVL. This shortage is likely attributable to the lack of high-tech rehabilitation tools in hospitals due to high costs, accessibility issues, and lack of highly trained therapists . CurrentVirtual reality is applicable in many areas of rehabilitation ,57. SuchChildren also improve language skills through social and experiential games to which, however, they are increasingly less exposed, such as outdoor activities with animals and exposure to different stimuli . VirtualOverall, these results are in line with several studies conducted on DLD using VR, although our study is the first to provide a detailed picture of all the components of language that can improve in children through a speech intervention associated with VR investigated with TVL.In conclusion, this study demonstrates that VRRS can be a valuable innovative tool for implementing feasible and effective speech rehabilitation, as it allowed greater recovery of abilities in different areas of language than usual treatment alone, thus promoting psychological well-being.The VRRS is equipped with a large screen and contains many virtual exercises divided into specific categories in order to perform speech disorder training tailored to the specific needs of children.It can therefore be considered a useful complementary treatment to reduce symptoms by providing fun and actively engaging children, increasing motivation and adherence to treatment. This is why VRRS should be widely implemented in clinical practice.This is a preliminary study, as we are conducting further research to highlight what we found in our sample. However, our study has limitations in that it examines a very small sample with heterogeneous issues. The children also had possible comorbidities with other disorders. These factors might make the reader uncertain with respect to the methodology, however, we have positive results regarding the rapid recovery of language skills. The innovative element of our project concerns the rehabilitation of language components through high-tech tools. The technological aspects are appealing because they are immediate, allow for the breaking down of logistical barriers, and promote learning motivation through sounds, colors, and setting. To improve clinical practice in the future, more studies are needed as the use of VRRS is still in its early stages, so larger samples and long-term follow-ups are essential.


Regular consumption of legumes is recommended worldwide for its environmental and health benefits. Cowpea, the most frequently consumed pulse in West African countries, is rich in nutrients and health-promoting bioactive compounds. A one-week retrospective food frequency questionnaire was used to estimate the contribution of the cowpea-based dishes to the recommended nutrient intake (RNI), based on their consumption frequency, intake, and nutritional composition. Participants were 1217 adults (19–65 years) from three urban or rural areas in southern Benin. Out of all respondents, 98% reported that they usually consumed cowpea-based dishes. The mean consumption frequency was 0.1 to 2.4 times/week, depending on the type of cowpea-based dish. The mean amount consumed was 71 g and 58 g of seeds/adult/day in urban and rural areas respectively. The mean daily contribution of cowpea-based dishes to RNI was 15% for energy, 42% for fibre, 37% for magnesium, 30% for folate, 26% for protein, and just above 15% for zinc and potassium. Thus, such regular cowpea consumption should be maintained. The increasing industrialization and urbanization worldwide are associated with ‘nutrition transition’, characterized by diets richer in fats and sugars, and with more sedentary lifestyles . As a coThe ongoing nutritional transition in many urban areas of sub-Saharan Africa, characterized by an increased demand for processed and quick-to-prepare foods, leads to a gradual shift from the traditional diet , to a diet rich in refined foods, low in fibre, and high in fat, salt and sugar . The lonTen years ago, in Benin, Madode et al.  investigThe aims of our study were: (i) to update data on cowpea consumption patterns in South Benin, and (ii) to estimate the nutritional intakes linked to the consumption of cowpea-based foods. Among the 18 cowpea-based dishes listed in the work by Madode et al. , the ninWe carried out this study in three different municipalities in the southern part of Benin, Cotonou , at the end of 2017, and Adjohoun and Allada  in early 2019. In Benin, municipalities encompass administrative units called ‘arrondissements’ that, in turn, contain city districts  or villages . Adjohoun is a rural municipality in the Ouémé Department, that produces 65% of the total amount of cowpea seeds grown in Benin . ConversIn each study area, we carried out representative two-step random sampling by considering city districts or villages as clusters . In the A food atlas was developed for the nine cowpea-based dishes described in Food atlas validationWe carried out a validation study in Cotonou to compare the portion sizes chosen by respondents listed in the food atlas to the corresponding weighed records. A convenient sample size of 50 customers per cowpea-based dish produced as street food was initially targeted. Finally, the number of people we actually surveyed varied between 19 and 52 respondents per dish, because for some dishes, there were very few street vendors. The study was performed on two days at various selling places for each cowpea-based dish. On day 1, the quantity of the cowpea-based dish consumed by the respondent was weighed using a kitchen scale . An appointment was made to perform the 24 h recall  using thFFQ validationWe validated the FFQ with a sample of 50 respondents in each of the three study areas. Briefly, three 24 h recalls were carried out in the same week , followed by the FFQ at the end of the week . The usuThe FFQ included two parts. In the first part, data on the household head’s socio-professional characteristics, household income and expenses (feeding and clothing), household belongings, and housing characteristics were collected to characterize the household socio-economic index. In the second part, data on the consumption of cowpea-based dishes and the estimation of the quantities consumed over one week were recorded. During the FFQ-based interviews, we first asked general questions about the consumption of various legume species (results published elsewhere ). This wData were collected on digital tablets, using surveyCTO™-generated Excel forms to allow their quick and correct transfer to the SurveyCTO™ platform.For the FFQ validation study, data were collected on paper forms and then entered in the Epidata software (version 3.1).The nine most frequently eaten cowpea-based dishes were sampled at 27 street food vendors  in Cotonou and transported in a cooler containing ice to the laboratory, where they were stored at −20 °C until analysis.Proximate composition.Lipids  and proteins  were determined for each cowpea dish using standard methods . AvailabMicronutrients.Lactobacillus rhamnosus ATCC 7469 as the growth indicator microorganism [TM Ultra Performance LC (UPLC) system , equipped with an AcquityTM fluorescence detector and an Acquity UPLCTM column, using a method adapted from Schmidt et al. [Minerals were extracted with a closed-vessel microwave digestion system  . Extractorganism . Total tt et al. .For both validation studies, we used Spearman’s correlation tests after checking the data normality. We assessed the concordance between methods using the Bland–Altman test. For this, we log-transformed data  to narroThe household socio-economic index (SEI) was determined separately for the rural and urban populations by considering 17 variables related to the housing quality, assets owned, household income and expenses, and household head’s socio-professional characteristics. A multiple-correspondence analysis with the selected variables was performed using the Rstudio software (version 3.5.1). We chose the axis that accounted for the highest percentage of the inertia, and performed an ascending hierarchical classification with the coordinates of the individuals on this axis. The dendrogram partitioning after the ascending hierarchical classification allowed the generating of socio-economic classes. Then, the surveyed households were clustered in three different SEI classes in each area: low, middle, and high .We determined the contribution of each cowpea-based dish to the RNI using the daily consumed quantity for each traditional dish during the 7-day recall  and the daily frequency of consumption (number of consumption times over a week divided by 7). For all respondents, we calculated the daily nutrient intake and compared them to the mean RNI for men and women. We used the reference values provided by FAO and WHO ,29 for mAs the number of city districts/villages or their population density may vary from one arrondissement to another, we calculated a design weight (Dw) that corresponded to the representativeness of each city district/village in its cluster, and applied it to each respondent. The Dw is defined as the inverse of the probability to include a respondent in the sample . In our First step: sampling of city district/rural villages in the arrondissementSecond step: sampling of subjects within city districts/rural villagesi) per respondent (i) was:The formula to determine the design weight , we calculated a weighed design weight (WeDwi) for each respondent as follows:The weighting was realized for urban and rural data separately to perform the statistical analyses per area.t-test, and chi-2 test. The level of statistical significance was set at p < 0.05.Data were analysed with the Rstudio software (version 3.5.1). We used the weighting variables as a correction factor for the statistical analyses with the package ‘Survey’, to ensure that the results were representative of all studied areas. To identify the factors  that influenced the quantity of cowpea-based dishes consumed, we used general linear models (GLM) adapted to the weighted data and also the one-factor analysis of variance, The validation of the portion sizes in the food atlas, using the 24 h recall data and the recorded weights, gave Spearman’s correlation coefficient values that ranged between 0.2 and 0.8 . MoreoveThe respondents’ mean age was 39 years in Cotonou and 36 years in the two rural areas . As dataNearly all respondents (98%) reported consuming cowpea-based dishes regularly and more than 70% at least once per week . BetweenThe mixed-dish Atassi and the stew Abobo were the most consumed cowpea-based foods in all study areas . We obseBy grouping the different cowpea-based dishes consumed by each respondent during the 7-day recall, the total number of combinations reached 102 in the rural areas and 113 in the urban area. The most consumed combinations were a two-dish combination that included Abobo and Atassi  in the rural areas and a three-dish combination  in the urban area.Among people who said they had consumed cowpea-based dishes during the 7-day recall, the frequency of consumption was significantly different between urban and rural consumers, except for Atassi, Abobo and Djongoli . The freThe mean portion size varied from one dish to another. Abobo, Atassi and Djongoli were consumed in quite large quantities  . Doughnup < 0.05). This conversion into ‘cowpea seed equivalent’ also allowed us to calculate that, with cowpea consumption alone, 51.5% and 49.7% of the surveyed population, in urban and rural areas, respectively, reached the recommendations of the EAT-Lancet Commission on Healthy Diets from sustainable food systems [When we converted the daily intake of cowpea-based dishes into ‘cowpea seed equivalent’ , the mea systems  in termsWe observed some associations between socio-economic and demographic factors and (i) the daily intake of the studied dishes and (ii) the total quantity of cowpea seed equivalent consumed  in both p < 0.05) among dishes for all the quantified nutrients: protein (3.0–9.9 g/100 g), dietary fibre (2.7–7.2 g/100 g), lipid (0.4–33.3 g/100 g), magnesium (13–68 mg/100 g), potassium (90–500 mg/100 g), zinc (0.3–1.6 mg/100 g), iron (0.4–8 mg/100 g), thiamine (28–175 µg/100 g) and folate (12–84 µg/100 g). Moreover, for each dish, we detected significant differences for most nutrients in function of the street food vendor  was higher than that for the energy. The consumption of the cowpea-based dishes during the 7-day recall allowed for the covering 42% of the RNI of dietary fibre, the highest percentage among the studied nutrients. Their contribution to the RNI of magnesium (37%), folate (30%), protein (26%), zinc (18%) and potassium (17%) was also interesting, being higher than 15% . ConversIndependently of the area , the Abobo stew, widely consumed and in large quantities by the adult population according to the 7-day recall data, was the dish that most contributed to the RNI of the studied nutrients . We observed that the number of different dishes consumed was strongly and positively associated with the amount of cowpea seed equivalent consumed . Consequently, the contribution to the RNI also increased with the number of different dishes consumed .In this study, we developed a FFQ to identify the consumption patterns of cowpea-based dishes and estimate their contribution to the RNI in adults in Cotonou and in two rural areas in the south of Benin. First, we performed two validation studies to assess the accuracy in the estimation of the quantity of the traditional cowpea-based dishes consumed, using a food atlas and a FFQ as tools. For this we used correlation tests and the Bland–Altman method that are commonly employed in validation studies at the individual and group level, respectively ,34,35. TIn our study, more than 70% of respondents said to consume cowpea-based dishes at least once per week in both urban and rural areas. This percentage was higher than that reported in 2009, in the survey  carried out among 200 urban adults in Benin , in whicAmong the cowpea-based dishes, the higher consumption of the stew Abobo and the mixed-dish Atassi could be explained by the fact that their processing involves few steps and that they can be easily prepared at home. Many other cowpea-based dishes are often bought as street food and consumed out of the house, particularly in urban areas where street food consumption is more developed than in rural areas . This laThe total daily intake, expressed in cowpea seed equivalent, estimated at 71 g in the urban and 58 g in the rural areas, was in agreement with the value (77 g) reported by Delisle et al.  for leguThe nutritional composition of traditional cowpea-based dishes varied widely depending on the street food vendors, reflecting variations due to cowpea cultivars, as concluded by Madode et al. , and proOur results finally show a positive relationship between the number of different cowpea-based dishes consumed and the total seed equivalent consumption. Moreover, we observed that for both urban and rural areas, the higher the number of different cowpea-based dishes consumed per week, the higher the overall contribution to the RNI. Thus, the availability of a wide variety of traditional cowpea-based dishes is also a factor that promotes total cowpea consumption: one cowpea-based dish not only replaces another cowpea-based dish, but also replaces other types of dishes.Our study presents some strengths and limits. The FFQ was validated for the estimation of the consumed quantities and consumption frequency of the nine traditional cowpea-based dishes.The nutritional composition of the nine cowpea-based dishes used for the study were determined by laboratory analyses on samples collected in the study areas, and therefore reflected the actual nutritional value of these composite dishes. The resulting data sets are made available and may be used to complete food composition tables.Food intake estimation using a FFQ might lead to the underestimation or overestimation due to social desirability, as observed by Steinemann et al. . SeveralThe surveys in Cotonou and in the two rural sites were separated by a few months, which could have led to seasonal variability. However, cowpea seeds are available all-year-round for purchase, and when directly questioned, respondents did not indicate any variation in consumption during the year.Cowpea was highly consumed in the form of various dish types in all the study areas, resulting in important daily intakes. Indeed, with cowpea consumption alone, 51.5 and 49.7% of the surveyed population in urban and rural areas, respectively, reached the recommendations of the EAT-Lancet Commission on Healthy Diets from sustainable food systems, in terms of pulse consumption. The current consumption level by the adult population in the study areas corresponded to an estimated contribution by traditional cowpea-based dishes, all dishes combined, to the RNI of ~15% for energy, above 20% for protein, magnesium and folate, and over 40% for dietary fibre. The amount of cowpea seed equivalents consumed, and hence the contribution to nutritional requirements, was higher in participants who consumed a greater number of different cowpea dishes. This shows the value of having a wide variety of dishes. Thus, this regular and high cowpea consumption, together with that of other pulses, should be encouraged and maintained, as it may contribute to the nutritional security of the population, and may help prevent malnutrition.