Objective: Internet addiction (IA) has become a global public health issue. Although previous studies revealed several risk factors related to IA, most of them focused on the western societies. The present study assesses the relationships between gender and other factors with IA in university freshmen in the South China.Methods: A total of 3,380 first-year college students  participated in an evaluation of their experiences surfing on the Internet. We investigated the severity of IA in the participants by considering their psychological characteristics, such as acceptance, anxiety levels, and coping styles. Then, we compared the results between males and females and between those in addiction group  and non-addiction group (CIAS scores ≤27). We also conducted a logistic regression analysis to detect the relationships between severity of IA and psychological characteristics and gender differences.Results: We observed that males showed significantly higher scores in CIAS than females. The addiction group exhibited significantly higher state anxiety and trait anxiety, and experienced less acceptance of self and others and acceptance by others, and adopted less positive coping style and preferred negative coping style than non-addiction group. The logistic regression analysis revealed that three factors  had a significant association with more severe IA.Conclusion: Gender differences affect the severity of IA in the first-year students in South China. Males with state anxiety and negative coping styles deserve attention because they are likely to be addicted to the Internet. Thus, health practitioners should perform efficient strategies while considering gender differences to precaution first-year college students with the risk factors for IA. The number of Internet users increases rapidly worldwide given that the Internet altered people's lifestyles through its advantages in communication, socialization, and even online education . HoweverEducation institutions have efficiently used Internet instruments to train students, especially in academic lectures, interaction with teachers, classroom discussion, homework, and sharing of learning resources . HoweverRegarding the gender influence on IA, previous studies produced inconsistent results –19. AlamAnxiety is a dangerous element for IA , 25 and Young adult Internet users, particularly college students, are more likely to be addicted to the Internet than older Internet users . PsycholWe conducted a cross-sectional study in Changsha, one of the largest cities in the South China, from October 10 to December 20, 2019. Inclusion criteria were as follows: (1) active Internet users for more than 1 year; (2) college freshmen agreed to complete the questionnaire. The exclusion criteria were those who were unwilling to complete the questionnaires or had no access to the Internet. Two master level research assistants spearheaded the recruitment of the participants. They carefully explained the research purposes and procedures and highlighted confidentiality problems to obtain a written informed consent from the participants. A total of 1,995 males and 1,385 females participated in this study. The participants were 16–24 years old. The average age of the participants was 19.8 years old. Then, they were divided to two groups, including the addiction group and non-addiction groups according to the Chinese Internet Addiction Scale (CIAS). Concerning the procedural side, the researchers first explained to the students the purposes of the research. Then, before handing out the questionnaires to the willing participants, the research assistants asked for their informed consent . During the survey, the research assistants instructed the participants to sit separately, stay quiet, and not participate in discussions.Our study involving human participants obtained approval from the Ethics Committee of the Second Xiangya Hospital of Central South University and the university's institutional review board and executed in line with the Helsinki Declaration.CIAS was used to evaluate the severity of IA in the participants. CIAS is one of the most widely applied assessments on IA with a good internal consistency . CIAS isSTAI was used to evaluate the severity of anxiety. It is a 40-item questionnaire on a four-point Likert scale, which comprises two separate subscales that measure the participants' state and trait anxiety levels, respectively, with good reliability and validity  , 42. HigAO was compiled by American psychologist Fey  and tranSCSQ, including 20 items on a four-point Likert scale with scores on each item ranging from 0 to 3, assesses the participants' positive and negative coping styles , 46. Thet-tests. Previous studies showed the cut-off point of 63/64 or more in CIAS has good accuracy, sensitivity and specificity for diagnosing IA . For the family factor, only a small percentage of participants lost their father or mother, and no significant differences were found in the parents' alive condition between the male and female groups. Significant differences were evident in single-child families between the male and female groups (P <0.05), more participants in the male group were not single-child . By contrast, no substantial differences were evident in the adoptive parent condition between the two groups. Most participants had no adoptive parents . The details were offered in A total of 1,995 males and 1,385 females participated in this study. Among them, 33 lacked a record of their age who were not removed from the study, and 98 individuals lacked a record of whether they were a single child. Moreover, 16 participants lacked a record of whether they had stepparents; 109 participants lacked a record of whether their father is alive; 93 participants lacked a record of whether their mother is alive; 17 participants lacked a record of their satisfaction degree for the admission. The mean age of male and female participants was 19.91 ± 0.86 and 19.73 ±0.73, respectively (P < 0.05), which indicated that the former had a higher risk factor of IA than the latter. Females experienced more acceptance of self and others (P < 0.05) and acceptance by others (P = 0.003) and adopted more negative coping styles (P = 0.004) than males. No gender differences were evident in state and trait anxiety levels and positive coping styles (Ps > 0.05). The details were offered in Males showed significantly higher scores in CIAS than females , acceptance by others , positive coping styles , negative coping styles , and state and trait anxiety levels  after controlling the confounding effects of age  because of the high number of participants in our study. The details of correlation analysis result were offered in the The CIAS scores in the male and female groups had significant correlations with acceptance of self and others , and experienced less acceptance of self and others and acceptance by others (P < 0.05), and adopted less positive coping style (P < 0.05) and preferred negative coping style (P < 0.05) than non-addiction group, indicating that IA was associated with emotional and behavior disorders  and non-addiction group  based on the cut-off point of 64 for diagnosing IA , 40. Theisorders .P < 0.05), acceptance of self and others (P = 0.001), and state anxiety levels (P = 0.003)  to investigate the predictors in the addiction and non-addiction groups while controlling the effects of age . We found significant relationships between IA and negative coping styles (= 0.003)  in adjus= 0.003) .Our study focuses on exploring the relationship between IA and gender, coping styles, anxiety, and acceptance in the first-year college students in the South China. The results disclosed that males had higher scores in CIAS than females indicating that male might be a risk factor for IA, which is consistent with previous findings , 21. AmoSome possibilities might explain these differences. First, we found that males had a higher risk of developing IA than females. Previous studies revealed that males are more likely keen on the Internet for games, cybersex, and gambling to pursue feelings of achievement than females , 49. In Regarding psychological characteristics, the correlation analysis and logistic regression results in the present study showed that IA has a significant association with negative coping style, acceptance of self and others, and anxiety levels. This finding is consistent with previous studies that IA has a significant relation to emotional and behavior disorders, including anxiety, depression, obsessive-compulsive, aggressive, and avoidance behaviors , 27. Thep-values were significant for correlation analysis because of the high number of participants in our study. Usually correlation coefficients reflect that r < 0.20 is very weak, and 0.20–0.40 is weak correlation. Our results show significant relationships between IA and negative coping style, acceptance of self and others, and state anxiety by using a logistic regression. Thus, health practitioners and scholars should pay attention to these three factors when consulting with Internet addicts or doing some researches on IA.The addiction group experienced little acceptance of self and others and acceptance by others. These individuals adopt negative coping styles rather than positive coping styles when they encounter some obstacles. Wei-Po showed that using less effective stress coping styles might induce high risk of IA, significant depression, and suicide attempts in college students after 1 year follow up . IndividThe Internet provides many benefits to its users, which tempts an increasing number of college students to become immersed in it. Previous studies have revealed that parental guidance of Internet behavior is associated with IA, especially when parents rarely communicate with regards to Internet use, lack of rules regarding Internet time  and lackSeveral limitations in the present study should be considered. First, the cross-sectional design in the present study could not allow inferring cause–effect relationship between IA and its related factors. Second, we collected data from a single college, and the findings might not generalize to all China or all university students. Third, this study did not explore the details of the participants' Internet use. We were unclear which games, social networking services, or other scanning habits might significantly change Internet habits or dependence in the freshmen. Fourth, although the CIAS involves an assessment of time management to the Internet, we did not measure how much time the subjects spent in the Internet, and the usage of media device, such as game, smartphone, and laptop was not recorded in the present study. Fifth, the assessments are self-rating scales, which could easily generate potential information deviation. Sixth, previous studies have revealed that the acceptable alpha values range from 0.70 to 0.95 , 60. TheThe present study revealed that IA is more common in male first-year college students than in their female counterparts, and males have a greater risk of developing IA than females. Although some studies have shown opposite results or no difference, research evidence , 21 has All datasets presented in this study are included in the article/The study involving human participants was reviewed and approved by the Ethics Committee of the Second Xiangya Hospital of Central South University, and was also approved by the university's institutional review board and executed in line with the Helsinki Declaration. All the participants provided informed consent. An additional informed consent was obtained from the parents or guardians for those aged below 18 years old.XS is mainly responsible for essay writing and conducting the study. YO, YD, and HY managed and analyzed the data. WG, JC, and JZ designed the study. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


They were recommended to increase physical activity and energy and protein intake from regular diet plus two servings per day of a specialized ONS enriched with HMB or standard ONS for up to 6 months. Dietary records, adherence and tolerance to ONS, nutritional status, body composition, handgrip strength, and blood analysis at the beginning and the end of the intervention were recorded. This program improved nutritional status from 100% malnourished or at risk of malnutrition at baseline to 80% well-nourished at final visit. It also increased body weight by 3.6–3.8 kg, fat-free mass by 0.9 to 1.3 kg, and handgrip strength by 4.7 to 6.2 kg. In a subgroup of patients ( Malnutrition is an increasingly prevalent condition in healthcare, which has a profound impact on patients’ clinical and functional outcomes. Prevalence of malnutrition ranges between 30 and 50% in hospitalized adult patients and 30–60% in older adults from nursing homes . MalnutrIn a recent study, Pourhassan et al.  demonstrThese findings are remarkable and suggest that, ideally, identifying and treating malnutrition should have a focus on trying to maintain or prevent muscle mass and function loss .However, the screening and assessment of muscle loss may be a significant challenge for clinicians, as this strongly depends on the use of validated and sometimes expensive tools, which are not always available in clinical practice.The incorporation of muscle mass-loss assessment as an essential phenotypic criterion into the recent GLIM criteria for the diagnosis of disease-related malnutrition (DRM) , makes iThe traditional standard tool, BIA, estimates body composition indirectly based on predictive equations. Bioelectrical impedance vector analysis (BIVA) provides raw electrical values such as phase angle (PhA), which has been demonstrated to be a good predictor of muscle abnormalities and function with a good diagnostic accuracy for detecting low muscle mass in cancer patients . ImportaReduced muscle mass and function has important health implications, especially in patients with disease or conditions with inflammatory components such as chronic obstructive pulmonary disease, chronic kidney disease, and cancer . Muscle Chronic diseases and inflammatory conditions systematically lead to muscle atrophy mainly due to altered protein synthesis, altered metabolism, and increased energy requirements. In particular, muscle mass loss in cancer patients is associated with increased treatment toxicity and reduced tolerance to anti-cancer treatment ,17.Malnutrition and associated muscle loss are not inevitable, as addressing the modifiable lifestyle factors of diet and physical activity has been proven to be the most effective strategy for prevention and treatment in clinical practice. Recently, in a large study recruiting 2088 patients, the Effect of early nutritional support on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT) showed that nutritional support was able to effectively counteract negative outcomes in hospitalized patients by increasing caloric and protein intake, which led to improved survival rates compared to standard hospital food .Nutritional support can reverse malnutrition and muscle loss. Different ingredients have been proposed to play an important role in improving nutritional status as well as preserving muscle health. Protein is one of the most effective anabolic stimuli to support muscle health. Current European Society for Parenteral and Enteral Nutrition (ESPEN) guidelines recommend protein intake between 1.2 and 1.5 g/kg of body weight (BW)/day for certain older adults who have acute or chronic illnesses .Another important anabolic nutrient is β-hydroxy-β-methylbutyrate (HMB), which has been recognized in ESPEN guidelines as an important functional ingredient to maintain muscle mass in cancer patients .Therefore, this evidence may suggest that reversing low muscle mass and function is feasible by using nutritional intervention and has the potential to improve clinical outcomes in patients with or at risk of malnutrition under different disease settings.Herein, the aim of this study was to observe the effect of a high-calorie, high-protein oral nutritional supplement (ONS) with HMB on nutritional status, body weight, and muscle-related outcomes in adult patients with or at risk of malnutrition under standard of care.n = 179). They were attended according to the clinical practice of the department, and the retrospective study of their data was approved by the Ethics Committee of the hospital.This study is a retrospective analysis of a database that was built at the Virgen de la Victoria Hospital, Malaga, Spain from April to December 2017. The patients attended consecutively to a specific nutrition medical office because they were diagnosed with malnutrition and they needed nutritional treatment. An important proportion of them were oncological patients  and trunk and lower limb .The dietician insisted on a series of points in all patients for caloric and protein enrichment, such as distributing the intakes, increasing and prioritizing the consumption of meat, fish, and eggs (minimum three servings a day), increasing the consumption of carbohydrates such as bread or flours, potatoes, pasta, legumes, rice, and incorporating caloric foods in food preparation: cheeses, fats, creams, nuts, olive oil, whole yogurts, powdered milk. The patients were asked also to supplement their regular diet with two servings of an ONS, either a specialized ONS (S-ONS group), high in energy and protein, and enriched with HMB  or a standard ONS (ONS group) until next visit, which was between 3 and 6 months. The ONS servings were recommended one in the morning and one in the evening, one of them around the time of exercise.Dietary recommendations and type of ONS were established individually for each patient based on their clinical needs and based on healthcare standards for malnutrition patients. The recommended calorie intake was set at 30–35 kcal/kg BW/day and protein at 1.2–1.3 g/kg BW/day. Dietary therapy, adherence, and tolerance to ONS, as well as body weight and body composition were evaluated at the beginning and the end of treatment. Both groups received the same nutritional care and physical activity recommendations.® Plus Advance, Abbott Nutrition, Spain). The supplements that were used by the standard ONS group contained 206–320 kcal, 10.7–20 g protein, 7.8–13 g fat, and 25.5–37.7 g carbohydrates.The specialized ONS contained 1.5 kcal/mL, 330 kcal energy, 20 g protein, 11 g fat and 37 g carbohydrate, 1.7 g fiber, 1.5 g calcium HMB, and 500 UI vitamin D per 220 mL serving  to confirm and evaluate intake. Dietary intake was assessed based on calories using IENVA © 2010 . TherefoBody-composition analysis was performed using foot-to-foot bioelectrical impedance . BIA results were recorded by the dietitian at the beginning and at the end of the study. Fat-free mass (kg), total body water (kg), and fat mass (kg) were evaluated and analyzed. Height measurements were measured with a 2 mm sensitivity laser height rod.Additionally, in a subgroup of patients, we also analyzed whole body bioimpedance measurements with a 50 kHz, phase-sensitive impedance analyzer  as previously described  Briefly,Other bioimpedance-derived parameters were calculated by the equipment software, namely: fat-free mass (FFM), fat mass (FM), body cell mass (BCM), total body water (TBW), extracellular water (ECW), intracellular water (ICW), appendicular skeletal muscle mass (ASMM), skeletal muscle index (SMI), hydration status, and nutrition status (creatinine excretion rate in mg/kg/24 h).All bioimpedance measurements were obtained with the patient in supine position on a bed. Bioimpedance results were recorded by the dietitian at the beginning and at the end of the study.Patient-generated subjective global assessments (PG-SGA) were used as a prognostic tool to evaluate the nutritional status of patients. We evaluated nutritional symptoms and weight loss. The total score was analyzed in three groups: A, well-nourished; B, moderately or suspected of being malnourished; C, severely malnourished.Handgrip strength was determined by means of the JAMAR-Dynamometer . The dominant hand was tested. Three measurements were taken, and the average was reported. Published population reference data were used as cut-off points .Finally, biochemical tests were analyzed by standard laboratory methods of the hospital: prealbumin (mg/dL) (Atellica Siemens), albumin (g/dL), C reactive protein  (Dimension EXL 200 Siemens), and CRP/prealbumin ratio.t-test for independent samples comparing the S-ONS vs. ONS groups was used to compare quantitative measures and chi-square for qualitative measures. A t-test for paired samples with baseline and end-of-study results were used to test for differences within each treatment. A multivariate weighted regression analysis was performed to compare the S-ONS vs. ONS effect along time and adjusted by relevant clinical variables, such as age, sex, adherence, and the use of parenteral nutrition during hospital stay. For continuous variables, linear mixed models were applied with subject random effects. For categorical ordinal data, a cumulative multinomial regression mixed model was applied. Weights were obtained to balance the number of patients per group using an optimal full-matching procedure of treatment regress by the rest of covariates, as a robust alternative to propensity score weighting.Characteristics of participants were compared in order to test for possible differences between groups. A A further description and comparison of the characteristic from the groups was performed to the subset of patients that had evaluation of the bioimpedance by phase angle.Due to the interest on assessing the influence of nutritional status on oncological patients, a further description of this subgroup is also provided.2. More than 60% of patients were previously admitted to hospital because of oncological surgery; the rest of the patients were admitted because of other surgical procedures or medical reasons. The oncological patients received chemotherapy or radiotherapy. Over 70% of patients were malnourished at entry and the rest of the patients were at risk of malnutrition according to PG-SGA of nutritional status. There were no differences at baseline between those who received the S-ONS or the ONS except for biceps fold and arm circumference. The S-ONS group had higher biceps fold and arm circumference. A higher proportion of patients in the S-ONS group reported acute weight loss, while in the ONS group a higher percentage of patients reported chronic weight loss . Nevertheless, the mean percentage of weight loss in both groups was similar, 10.3 and 9.5% for the S-ONS and ONS groups, respectively, and were not significantly different (p = 0.561).Of the 312 patients that were included in the study, 25 had missing data for intake at the end of the study and 4 did not take the supplement, so they were excluded for analysis. In total, 283 patients were analyzed, 240 took the S-ONS, and 43 received the other ONS. The baseline demographic and clinical characteristics of study participants are included in Over 65% of patients took more than 75% of the recommended dose, which was two servings per day. The regular diet, dietary counseling, and use of ONS significantly increased energy and protein intake in all patients. On average, before entrance to the study, they reported an intake of 1436 kcal and 55 g of protein per day (0.9 g/kg BW). With dietary counseling and the supplementation, they increased the consumption of energy and protein from the diet to 1667 kcal and 68 g of protein, and to 557 kcal and 31 g of protein from the oral nutritional supplementation. In total, they received an average intake of 2154 kcal and 97 g of protein (1.5 g/kg BW). Both groups received a similar amount of energy and protein/kg BW.Anthropometric, body composition, functional, and laboratory outcomes at baseline and after receiving the ONS categorized by group are shown in p-value < 0.005) with no significant differences between groups.There was a significant improvement in all outcomes in both groups indicating that the oral nutritional supplementation in this type of patient had a relevant effect on those measurements. The nutritional status measured by PG-SGA was significantly improved by the intervention as showed in 2 were gained by both groups. The estimated increase in handgrip strength was higher in the patients receiving the S-ONS than in those receiving ONS (6.2 vs. 4.7 kg), although these differences did not reach statistical significance. FFM significantly increased from baseline in the S-ONS group but not in the ONS group (1.3 vs. 0.9 kg).Body weight and BMI significantly increased from baseline in both groups. On average, 3.6–3.8 kg and 1.4 kg/mIn addition, the nutritional intervention affected positively several analytical outcomes. Albumin, prealbumin, cholesterol levels, and lymphocyte counts increased from baseline to the end of the follow up period. CRP decreased three-fold from baseline. The decrease in the ratio CRP/prealbumin was significantly different from baseline only for the S-ONS group.A total of 43 patients were studied by PhA: 31 were in the S-ONS group, and 12 in the ONS group.The baseline characteristics of this subgroup were similar to those of all patients as included in Anthropometric, body composition, functional, and laboratory outcomes at baseline and after receiving the oral nutritional supplementation for the subgroups that were tested by PhA are described on One hundred and fifty-five patients received the S-ONS. At baseline, 117 patients were considered malnourished (75.5%) and 38 at risk of malnutrition (24.5%). After the program including the oral nutritional supplementation, dietary counseling, and strength exercise, 108 patients were moved to the well-nourished category (70.1%), only 27 were still at risk of malnutrition (17.5%), and 19 were still malnourished (12.3%). All the anthropometrics and functional outcomes improved from baseline to the final visit . In partTo our knowledge, this is the first retrospective observational study showing the effect of oral nutritional supplementation along with dietary counseling and strength exercise recommendations on clinical, nutritional, and functional outcomes in outpatients attending a nutrition medical office and real-life clinical setting, including an important percentage of cancer patients under anticancer therapy who were sent to the nutrition clinical unit because of their poor nutritional status. The recommendations included both diet and exercise, which have been pointed to recently as a critical part of the clinical oncology practice by a panel of experts .All patients received nutritional support according to their needs and nutritional status. The majority of patients (84.8%) were prescribed with a specialized ONS containing high protein, HMB, and vitamin D. Main outcomes included standard anthropometric, nutritional, and functional outcomes such as BIA, handgrip strength, and PG-SGA. In a subgroup of patients, it was also possible to include PhA measurement, which is considered a global prognostic factor of cellular functionality and body composition , and whiIt is worth noting that the supplements were well tolerated in both groups and that the adherence was good or very good. Moreover, the whole program resulted in an improvement in energy and protein intake from about 1400 kcal to 2155 kcal per day, and from 0.9 to 1.5 g protein/kg BW/day on average. This is aligned with current ESPEN recommendations for older adults with or at risk of malnutrition .This study also demonstrated that provision of nutritional supplementation combined with dietary counseling and strength exercise was able to provide important health benefits. Namely, it was able to improve nutritional status, shifting patients from severe malnutrition to adequate nutritional status at final visit according to PG-SGA. It was also able to increase body weight, BMI, handgrip strength, FFM, as well as nutritional biochemical markers. In fact, blood levels of albumin, prealbumin, cholesterol, and lymphocytes were brought to normal range levels, and CRP, the standard marker of inflammatory status, was reduced to normal levels. This is particularly important for improving inflammatory status in this at risk-population. The group receiving the S-ONS also had a significant reduction in CRP/prealbumin ratio, which pointed to a higher anti-inflammatory effect on this group.Although all the patients showed improvement in main outcomes regardless of the type of ONS they received, there were some potential benefits associated to the use of the S-ONS, in particular those related to FFM and handgrip strength. This is also supported when the measurement of PhA is taken into consideration.PhA has become an emerging parameter among bioimpedance measurements because of its value to predict impaired clinical outcomes and mortality for several diseases ,26,27. ICurrently, there are no published randomized studies showing the impact of nutritional intervention on PhA measurements. Therefore, the present study, including observational data, provides a positive effect of nutritional intervention with ONS on PhA-related parameters.There are some differences in PhA and associated parameters that are remarkable in the S-ONS group: significant increase in PhA, BCM, nutrition status and ICW, and concomitant decrease in the percentage of hydration and ECW compartment.The main result of our study is an increase in PhA by 0.95 (0.13) degrees (estimated mean difference (SE)) after S-ONS treatment. This difference in PhA can be important as an increase of one degree in PhA has been associated with higher survival rates in patients in different conditions such as advanced cancer and intensive care units . In addiThe progression of the disease induces changes in inflammation and hydration, with increase in extracellular fluids and reduction in intracellular fluids . PhA is The group of patients who received the S-ONS also improved the urinary creatinine excretion predicted from analysis of BIVA, which is a nutritional score obtained from reactance scale into creatine excretion rate.An important contribution of our study is the high number of cancer patients that were included. There are scarce publications dealing with the use of ONS in oncology as the treatments are more focused on the disease per se than on patients’ nutritional status, primary manifested by severe muscle mass. Nutrition intervention including antioxidant supplementation, L-carnitine, or nutritional supplements with EPA combined with medication have demonstrated a significant improvement in muscle mass of patients with cancer cachexia ,34.n = 506) recently showed that in cancer patients with increased nutritional risk, individualized nutrition support significantly improved functional and quality-of-life outcomes and reduced mortality [Importantly, a secondary analysis of the EFFORT trial (ortality . Cancer-ortality ,37, but ortality ,39, treaortality  and decrortality .On the other hand, the evidence behind the use of specialized ONS containing HMB in cancer populations is very limited. Only two published studies using ONS enriched in HMB have included cancer patients. The study by De Luis et al.  includedOne of the limitations in the present study is that it is an observational retrospective analysis of clinical data recorded under standard of care in real-life conditions. Therefore, a cause-and-effect relationship could not be well established. Nevertheless, the use of real-world data has been considered to add additional evidence to randomized clinical trials, and to support healthcare decision makers . AnotherNevertheless, this study shows that a program including dietary and strength exercise counseling together with the use ONS is beneficial to support nutritional, clinical, and functional outcomes, especially those related to improved muscle health in adult outpatients with or at risk of malnutrition. In addition to this, the increase of 0.95 grades in PhA and 2.98 kg in BCM, that was found in the S-ONS group, were very important findings and support the effectiveness of the use of this supplement in the recovery of muscle mass, which serves as a global disease prognosis in malnourished patients. This study also adds more evidence to the use of an ONS, high in protein and with HMB, to improve nutritional status and body composition in malnourished patients, especially in cancer patients. However, more studies are needed to confirm these results.


Patients presenting with non-specific complaints (NSC), such as generalised weakness, or feeling unwell, constitute about 20% of emergency care consultations. In contrast to patients presenting with specific symptoms, these patients experience more hospitalisations, longer stays in hospital and even higher mortality. However, little is known about the actual resources spent on patients with NSC in the emergency department (ED).We have conducted a retrospective analysis from January 1st, 2013 until December 31st, 2017 in a Swiss tertiary care ED to assess the impact of NSC on the utilisation of diagnostic resources in adult patients with highlyurgent or urgent medical complaints.n = 1310, 87.3%) presented with a specific complaint; n = 190 (12.7%) with a NSC. Univariate analysis showed no significant difference in the utilisation of total diagnostic resources in the ED . A backward selection logistic regression model was adjusted for the identified covariates . This identified a significant association of NSC with lower utilisation of ED diagnostic resources .We randomly selected 1500 medical consultations from our electronic health record database: The majority of patients (Non-specific complaints (NSC) are a frequent reason for emergency medicine consultations and are associated with lower utilisation of diagnostic resources during ED diagnostic testing than with specific complaints.The online version contains supplementary material available at 10.1186/s12873-021-00531-2. Non-specific complaints (NSC), such as generalised weakness and fatigue or feeling unwell, make up a large group of complaints in emergency care –3. TheseIn the US, ED visits increased by 44% from 1996 to 2010 , and simVery little is known about the utilisation of diagnostic resources by patients presenting with NSC. In their cohort of elderly patients presenting to the ED with weakness and fatigue, Bhalla et al. found a significant increase in the number of diagnostic tests, and procedures . HoweverAs the number of ED consultations and overall health costs are both increasing and in view of the growing awareness of the important but largely unknown entity of patients with NSC, we have investigated the impact of NSC on the utilisation of diagnostic resources in the ED; to our knowledge, this has never been comprehensively studied. Our working hypothesis was that resource utilisation was greater in adult patients presenting to the ED with a medical NSC who were triaged as highlyurgent or urgent .Tarmed Suisse catalogue (TARMED Suisse. TARMED 01.08.0000). For each procedural code, a number measured in tax points is assigned, that reflects the effort of the procedure, independently of medical insurance status. There is no flat rate per case or DRG system (diagnosis related groups) for emergency treatments. The tax point is a hospital-specific, medical currency (1 tax point is roughly 1 Swiss Franc) and may depend on the individual hospital.This study is a retrospective analysis at the ED of the Bern University Hospital in Bern, Switzerland. Our ED is a tertiary care centre, caring for a patient population of around 2 million and treating over 50,000 adult patients each year with an interdisciplinary team . All patThis study was classified as a quality evaluation study by the local institutional review board (KEK-2018-00198) and the need for informed consent was waived.We randomly chose 1500 patients encounters from all adult patients (> 16 years of age) presenting to the ED between January 1st, 2013 and December 31st, 2017 triaged as urgent to highly-urgent, with a medical presenting complaint  or external  referral, repatriation from a hospital in another country).Sociodemographic  patient characteristics, encounter characteristics , transport by emergency medical service (EMS), Swiss triage scale, and patient outcome data  admission, in-hospital mortality, ED return visits for 30 and 365 days, respectively), as well as study outcome data  were collected from the hospital’s electronic patient documentation systems .Important comorbidities i.e. COPD, diabetes, liver disease, dementia, malignancy, cerebrovascular disease, peripheral artery disease, past myocardial infarction, and chronic kidney disease in the diagnosis list and specific drug intake were determined through a previously validated full-text parser of the ED medical report see  Table. TNemec et al. defined NSC as an entity of complaints that is not part of the set of specific complaints or signs for which evidence-based management protocols for the ED physician exist  . As theyTarmed Suisse catalogue (TARMED Suisse. TARMED 01.08.0000). For each procedural code, a number measured in tax points is assigned, that reflects the effort of the procedure. The tax point is a hospital-specific, medical currency (1 tax point is roughly 1 Swiss Franc) and may depend on the individual hospital.The primary outcome was the total utilisation of ED diagnostic resources, defined as the sum of all physician resources , as well as nursing, material , laboratory, and radiological resources. In the ED, all procedures are coded by the person who performed the procedure - using a procedural code of the Secondary outcomes were hospitalisation, length of stay in the ED and hospital, ICU admission, in-hospital mortality, as well as ED return visits within 30 and 365 days.The geometric mean of a distribution can be obtained by taking the exponentiated mean of the ln-transformed values. On the assumption that the mean of the ln-transformed total ED utilisation of diagnostic resources was about 6.55 (geometric mean of 700 tax points) with a standard deviation (SD) of 0.65, as based on a random sample of 100 consultations and a ratio between NSC- and non-NSC patients of 0.1, a sample size of 1500 patients is sufficient to show a difference of more than 20% in the geometric mean ratio (0.8–1.2) of the ED utilisation of diagnostic resources.Data was analysed in Stata® 13.1 .Baseline characteristics are presented as numbers and percentages or medians and interquartile ranges (IQR), using descriptive statistics as appropriate.To assess the interrater agreement, we used Gwet’s AC - the test parameter of choice for the case of two raters and low prevalence data . Gwet’s Groups of patients with specific or NSC were compared with respect to presentation, ED and hospital outcome, as well as utilisation of ED resources, using Chi-square and Wilcoxon rank sum tests as applicable. Logistic regressions were performed to reveal associations with a binary outcome - i.e. NSC; the effect sizes are presented as odds ratios (OR) and 95% confidence intervals (CI).p < 0.2) – both with the primary outcome (utilisation of ED diagnostic resources) and exposure (NSC) – were considered as potential confounders . For the different resource categories, patients presenting with NSC utilised significantly more physician resources than patients presenting with a specific complaint . Furthermore, utilisation of material, laboratory and radiology resources was found to be significantly less in patients presenting with a NSC  vs. NSC: 778 (551–1183) tax points, The associations of the various confounders with the total consumption of diagnostic resources are detailed in Table p < 0.2) – both with the primary outcome (utilisation of ED diagnostic resources) and exposure (NSC), i.e. age, private insurance, triage category, night or weekend admission and on any antidiabetic) showed that NSC was significantly associated with lower utilisation of ED diagnostic resources , corresponding to 9% less utilisation of total ED diagnostic resources .None of the added interaction terms  NSC and sex, iii) NSC and high triage category, and iv) triage category and age) improved the final model significantly  was actually significantly higher for patients with NSC than those presenting with a specific complaint. In contrary, material, laboratory and radiology resources were less utilised in patients with NSC. The reasons for this unexpected result are unclear. The clinical reasoning process mainly takes place during the consultation and administrative work, however, from the time spent we cannot deduce anything about the quality of the clinical reasoning process. We assume that physicians seem to sense that these patients with NSC present a challenge, but they just do not seem to know what to do about it. One may further speculate that the non-specific character of these complaints might lead to longer physician-patient consultation and the need for prolonged administrative activities , but may subsequently confuse or even discourage physicians from initiating further diagnostic evaluations. Another possible explanation for the lower utilisation of diagnostic resources might be that attending physicians do not realise the importance of this specific patient group. However, patients hospitalised with NSC tend to suffer from more serious outcomes, as in-hospital mortality and length of stay, thus utilising more resources and generating greater costs , 11, 14.Emergency physicians should be educated about the importance of NSC, in order to prevent underestimation of NSC and a delay in important diagnostic tests. In addition, it remains to be elucidated whether and which subset of patients presenting with NSC might benefit from additional resources spent in the ED to prevent deleterious outcomes. On the other hand, it is not yet clear what kind of resources  are needed to have a positive impact. Moreover, cost-effectiveness regarding resource utilisation in the emergency setting versus the admission greatly depends on local settings and warrants further investigations.In any case, further research is needed to better understand the different patient groups with NSC, as they seem not to be a single homogenous population but a symptom complex including high and low-risk patients.Our results must be discussed in the light of some limitations. Firstly, this study was conducted at a single centre, albeit one of the largest of its kind in Switzerland, and thus generalisations should only be drawn carefully. However, 69% of the patients were walk-in patients, thus, the selection bias caused by the university character of our hospital might be small. The data used to describe our study population are definitely helpful in comparing another centre to our patient collective and to decide on the transferability of our results. Furthermore, we have developed a resource consumption score of our patient data elsewhere . The ideNon-specific complaints (NSC) are a frequent reason for emergency medicine consultations and are associated with lower utilisation of diagnostic resources during ED work-up compared to specific complaints.Additional file 1: Table S1. Validation of the diagnosis and drug parser based on agreement with 500 manually coded ED reports.Additional file 2: Table S2. Associations with NSC status.


This study aimed to estimate the genetic parameters and genetic correlations for related feed efficiency, growth, and carcass traits in Hanwoo cattle.Phenotypic data from 15,279 animals born between 1989 and 2015 were considered. The related feed efficiency traits considered were Kleiber ratio (KR) and relative growth rate (RGR). Carcass traits analyzed were backfat thickness (BT), carcass weight, eye muscle area, and marbling score. Growth traits were assessed by the average daily gain (ADG), metabolic body weight (MBW) at mid-test age from 6 to 24 months, and yearling weight (YW). Variance and covariance components were estimated using restricted maximum likelihood using nine multi-trait animal models.The heritability estimates for related feed efficiency (0.28±0.04 for KR and RGR) and growth traits (0.26±0.02 to 0.33±0.04) were moderate, but the carcass traits tended to be higher (0.38±0.04 to 0.61±0.06). The related feed efficiency traits were positively genetically correlated with all the carcass traits , except for BT, which showed null to weak correlation. Conversely, the genetic correlations of RGR with MBW (−0.36±0.08) and YW (−0.30±0.08) were negative, and those of KR with MBW and YW were close to zero, whereas the genetic correlations of ADG with RGR (0.40±0.08) and KR (0.70±0.05) were positive and relatively moderate to high. The genetic (0.92±0.02) correlations between KR and RGR were very high.Sufficient genetic variability and heritability were observed for traits of interest. Moreover, the inclusion of KR and/or RGR in Hanwoo cattle breeding programs could improve the feed efficiency without producing any unfavorable effects on the carcass traits. The global interest in improving the profitability of beef cattle production systems has recently increased. It is therefore important to identify animals that can efficiently utilize feed resources for reducing feeding costs and improving feed efficiency. Presently, several economically important traits, including body weight, weight gains at specific ages or during specific periods, carcass traits, feed intake, and feed efficiency, are commonly considered as selection criteria in most beef cattle breeding programs –3.Measures of feed efficiency, including residual feed intake , feed coe.g. KR and RGR) and to compute the magnitude of the correlations of these traits with carcass and growth traits, which will allow the construction of an optimal multiple-trait selection index for increasing the profitability of beef production.Feed efficiency has been especially emphasized in Korea since high proportions of feeding resources depend on imports owing to the shortage of roughage and grain production. Nevertheless, the Hanwoo beef industry primarily aims to increase the quantity (carcass weight [CW]) and quality  of the meat, without considering the inclusion of feed efficiency traits in the selection indices for selecting young bulls or/and proven bulls . It is tTo accomplish these goals, we evaluated the genetic parameters for measures of related feed efficiency, including RGR and KR, for the first time, as well as measuring the phenotypic and genetic correlations between i) feed efficiency and growth traits, and ii) feed efficiency and carcass traits in Hanwoo beef cattle.Records of 15,279 animals  born between 1989 and 2015 from the Hanwoo Improvement Center of the National Agricultural Cooperative Federation were used for this study . The pedt) at the termination (t) of the test (body weight at ~12 months) and the previous weight (Wt−1) recorded at a time point (t−1) before (body weight at ~6 months) the termination, according to the equation described by Park et al [Yearling weight (YW) for each animal was determined from the weight , according to the following equation:0 is intercept, β1 is the linear regression coefficient that represents ADG, x is the age in days, and ɛ is the random residual effect.Where y represents the weight of the animal, β0 + β1x*)0.75, respectively; where agemin and agemax are the minima and maximum recorded ages for each animal. RGR was calculated using the following equation:The mid-test age (x*) and the mid-test metabolic body weight (MBW) were obtained by the following equation: in which FBW and IBW represent the final and initial body weights in addition to different maximum and minimum ages is based on year. KR was obtained as a ratio of ADG to mid-test MBW.The national genetic evaluation of Hanwoo considers YW as one of the traits for selecting young bulls at the performance test stage. Therefore, the YW of all the candidate young bulls are recorded, but the body weight traits at 15, 18, and 24 months, and the carcass traits are measured only for the offspring of the young bulls that are selected for producing steers . Hence, y is the vector representing the observations for the traits of interest; b is the vector representing the fixed effects, including batch-test place-sex  and birth place ; batch-test place-slaughter date , birth place , and slaughter age (days from birth to slaughter) as covariates for carcass traits ; u is the vector of random genetic additive effects; e is the vector of random residual effects; and X and Z are incidence matrices related to the fixed and random genetic additive effects, respectively. Var (u) = G⊗A and Var(e) = R⊗I, were assumed, where A is the numerator relationship matrix, I is the identity matrix, and G and R are additive genetic and residual covariance, respectively, for the two or three traits.where Indeed, a multi-trait analysis can be problematic as the number of traits analyzed increase particularly in the presence of wrong starting values for variance-covariance parameters. Hence, the reasonable starting values for genetic and environmental variance-covariance among the nine traits were considered using a series of two-trait analyses according to above the equation. Finally, the pooled estimates of (co)variances were obtained with the option “--pool” in Wombat software  because REMLF90  softwareIn addition, a single-trait analysis was performed using for each trait to obtain initial values of variances and covariances for subsequent restricted maximum likelihood multi-trait analyses.Recently, the characterization of economically important traits and their associations has been of great interest in developing effective genetic improvement programs to increase the overall profitability of beef cattle production systems. In the present study we evaluated, for the first time, the genetic parameters of KR and RGR (indirect measures of feed efficiency) and their correlations with growth and carcass traits in Hanwoo beef cattle.g) for MS and BT.In the present study, the heritability estimates for carcass traits were in accordance with most of the previous studies in Hanwoo cattle ,14,18, eAnalysis of the growth traits revealed that the heritability for YW (0.26) was slightly lower than that (0.30) obtained by Park et al , but higThe heritability estimated for ADG 0.33) was in line with the literatures ,25–28; b3 was in Heritability estimates for the related feed efficiency traits, KR and RGR (0.28), were slightly lower than that those reported by Arthur et al  in CharoAdditionally, the results showed that the heritabilities using single-trait were lower than those obtained by multi-traits for BT, CW, ADG, and MBW; while, similar heritabilities were observed for EMA, MS, and YW . HoweverIn general, our heritability results were in the range of the heritabilities previous reported in Hanwoo cattle and in most of the beef cattle studied. Nevertheless, the differences founded could be attributed to the differences in the number of animals considered, breed, the completeness of the pedigree, precision of recording, environmental variation, and statistical models used for analyses.Analysis of the phenotypic and genetic correlations among the carcass traits agree with the previous study in Hanwoo cattle carry out by Choi et al . HoweverAs depicted in Analysis of the estimated genetic correlations among the growth and carcass traits revealed positive, and low to strong correlations for all the growth traits with both CW and EMA, and especially ADG, which had the greatest correlation with CW (0.94). The results of this study are similar to the earlier observations of Choi et al  concerniAnalysis of the relationship among the related feed efficiency and carcass traits revealed that the genetic correlations of KR and RGR with the three traits, CW, EMA, and MS, were positive but the correlations with BT were weakly negative or close to zero. Hence, selection of animals to improve KR and RGR could lead to increased CW, EMA and MS and reduced BT. Finally, it can be said that the inclusion of KR and/or RGR in the breeding program of Hanwoo cattle could improve feed efficiency without having unfavorable effects on the carcass traits. Hoque et al  reportedThe genetic relationships among the growth traits observed in this study were positive and high, with YW exhibiting a relatively stronger correlation (0.89) with MBW in particular, in comparison to the other traits. Grion et al  observedYB = 2EBVYW+EBVMS, where, EBVYW and EBVMS are the standardized estimated breeding values for YW and MS (parents average), respectively [YB. Increasing the MBW will lead to rising the maintenance requirements and feeding costs, which could be managed by including KR and/or RGR in the young bull selection index.The index for selecting Hanwoo young bulls during performance testing was obtained using SIectively . As mentInformation on the genetic and phenotypic correlations of feed efficiency with growth and carcass traits in Hanwoo cattle is scarce, and our findings, notably, are the first reports of some of these estimates for this breed, and will, therefore, be useful in designing breeding programs aimed to improve these traits.The moderate to high heritability estimates for carcass, growth, and related feed efficiency traits, in addition to the sufficient additive genetic variability observed for some of these traits, indicates that further improvement is possible for these traits. Additionally, favorable genetic correlations of Kleiber ratio and relative growth rate with metabolic body weight and carcass traits along with positive and the low to relatively high genetic correlation with average daily gain observed in this study, suggest that the inclusion of related feed efficiency traits in selection programs for Hanwoo cattle is feasible.


In the field of environmental health risk assessment and management research, heavy metals in soil are a constant focus, largely because of mining and metallurgical activities, and other manufacturing or producing. However, systematic vulnerability, and combined research of social and physical vulnerability of the crowd, have received less attention in the research literature of environmental health risk assessment. For this reason, tentative design modelling for comprehensive environmental health vulnerability, which includes the index of physical and social vulnerability, was conducted here. On the basis of experimental data of heavy-metal pollution in soil and vegetables, and population and societal survey data in Daye, China, the physical, social, and comprehensive environmental health vulnerabilities of the area were analyzed, with each village as an evaluation unit. First, the polluted and reference areas were selected. Random sampling sites were distributed in the farmland of the villages in these two areas, with two sampling sites per village. Then, 204 vegetable samples were directly collected from the farmland from which the soil samples had been collected, composed of seven kinds of vegetables: cowpea, water spinach, amaranth, sweet potato leaves, tomato, eggplant, and pepper. Moreover, 400 questionnaires were given to the local residents in these corresponding villages, and 389 valid responses were obtained. The results indicated that (1) the average physical vulnerability values of the population in the polluted and reference areas were 3.99 and 1.00, respectively; (2) the village of Weiwang (WW) had the highest physical vulnerability of 8.55; (3) vegetable intake is exposure that should be paid more attention, as it contributes more than 90% to physical vulnerability among the exposure pathways; (4) arsenic and cadmium should be the priority pollutants, with average physical vulnerability value contributions of 63.9% and 17.0%, respectively; (5) according to the social vulnerability assessment, the village of Luoqiao (LQ) had the highest social vulnerability (0.77); (6) for comprehensive environmental health vulnerability, five villages near mining activities and two villages far from mine-affected area had high physical and social vulnerability, and are the urgent areas for environmental risk management. In order to promote environmental risk management, it is necessary to prioritize identifying vulnerable populations in the village-scale dimension as an innovative discovery. Heavy metals, as a representative type of environmental pollution  via diffOverall, the main approaches used to evaluate the cumulative health impact of pollution exposure and social stressors have different evaluation systems and frameworks because of their different emphases. Some quantitative or semi-quantitative methods, such as health risk assessment , health Pollution affects human health, particularly reproductive health ,30. HeavThe purpose of this research was to identify priority protection objectives with high health vulnerability among 16 villages in Daye through environmental health vulnerability assessment, and provide important information for environmental risk management. First, we investigated the pollution situation in the study areas, and analyzed the pollution exposure characteristics and pollution hazard level of the local residents. Then, we collected exposure parameters and socioeconomic data, and analyzed the social vulnerability. Lastly, we evaluated environmental health vulnerability, which is social vulnerability assessment combined with the hazard index of heavy-metal pollution.In central China, the city of Daye is located in the southeast of Hubei province. Sixteen villages in Daye were selected as the study areas, nine of which are mine-affected (polluted) areas in the northeast of Daye, while seven are relatively far from the mining (reference) area in the west of Daye. There are 32 random sampling sites distributed in the farmland of the selected villages, with two sampling sites per village. In the polluted areas, there were 18 sampling sites in 9 villages: Weiwang , Jinqiao , Wangjiazhuang , Luoqiao , Huajing , Chunguang , Changle , Guantang , and Tuannao . In the reference area, there were 14 sampling sites in 7 villages: Shangwang , Zhushan , Mingshan , Fandao , Wuduan , Yangqiao , and Shangzhuang . Villages in these two study areas were selected considering the inhabitants’ settlement and distribution. All geographical locations of the sampling points in the polluted and reference areas are shown in Vigna unguiculata (Linn.) Walp), water spinach (Ipomoea aquatica Forsk), amaranth (Amaranthus tricolor L.), sweet potato leaves (Ipomoea batatas Lam), tomato (Lycopersicon esculentum Miller), eggplant (Solanum melongena Linn), and pepper (Capsicum annuum Linn. var. gros-sum (L.) Sendt). A large number of local residents buy rice and meat from markets, and consume vegetables that they grow in their own field. Moreover, rice mainly refers to paddy rice, with supplements of wheat flour, and meat mainly includes pork, chicken (as food), mutton, and beef. The sample pretreatment and analysis were based on the method designed in our previous research, which was analyzed in detail by Jun et al. [Content analysis of heavy metals in soil and common vegetables in the study area was conducted to assess physical vulnerability. According to the Chinese Technical Specification for Soil Environmental Monitoring (HJ/166-2004), 32 surface soil samples (1 kg each and from the top 0 to 20 cm layer at the sampling sites) were collected. In total, 204 vegetable samples were directly collected from the farmland from which the soil samples were collected comprising 7 kinds of vegetables: cowpea  was used for statistical analysis.Vulnerability refers to the threat to which an area is exposed from the properties of involved chemical agents, the ecological situation of the community, and its general state-of-emergency preparedness at a given point in time . For envIntegrated population environmental health vulnerability is divided into two aspects, physical and social vulnerability. We examined how to evaluate the above-mentioned vulnerability. Hence, an analytical framework considering population environmental health vulnerability assessment on heavy-metal exposure was designed, as shown in The sensitivity of the human body to different heavy-metal species is different. Exposure to various heavy metals cannot be simply added up, so it is not appropriate to measure physical vulnerability by simply using the heavy-metal concentration in environmental media or average daily doses.v, HQo, HQd, and HQi are the hazard quotients caused by the four pathways of vegetable intake, soil ingestion, dermal contact, and inhalation, respectively; RfDv, RfDo, RfDd and RfDi are the corresponding reference doses for each heavy metal through one of the four pathways, respectively, as shown in v, ADDo, ADDd, and ADDi are the average daily doses from vegetable intake, soil ingestion, dermal contact, and inhalation, respectively (mg/kg·day); Cv is measured by the average heavy-metal content of vegetables sampled in each village (mg/kg); Cs is measured by the average heavy-metal concentration of soils from two sample sites in each village (mg/kg); IRv, refers to the intake rate of vegetable (mg/day); IRo refers to ingestion (mg/day); IRb refers to inhalation rate of soil (m3/day); EF is exposure frequency (day/year); ED is exposure duration (year); BW is the average body weight of the exposed individual (kg); AT is the averaged contact time (day); PEF is the particle emission factor (m3/kg); SA is the exposed skin surface area (cm2); AF is adherence factor (mg/m2·day); and ABS is the dermal absorption factor (unitless). Detailed information of the above-mentioned and probabilistic parameters can be found in Jun et al. [The index system of pollution hazard in health risk modelling provided by USEPA is used as a measure of physical vulnerability. The hazard index (HI) for the health risk of a variety of heavy metals is calculated by Equation (1), and the corresponding dose received through each of the four pathways was evaluated by Equations (2)–(5).n et al. , and Fein et al. . ParametFor a human community, health outcomes are impacted by the relationships among measures of socioeconomic level (ability to respond or recover), receptor characteristics , and population self-sensitivity. On the basis of a series of social vulnerability studies and the local conditions of the study area, 10 indicators were selected and divided into 3 categories. The important relationship among the indices was established by expert scoring, and the weights of these 10 indices were determined with the support of analytic hierarchy process theory. The experts who participated in the research had a wide range of health risks and a basic understanding of receptor vulnerability. Ultimately, social vulnerability scores were calculated and used to assess environmental health vulnerability.The explanation and quantification of indicators are shown in Multiple models are widely used in some regional vulnerability models and cumulative impact frameworks. However, for a group of population living in particular area rather than individual research subjects, it is interesting to simultaneously consider environmental health risks with physical and social vulnerability. The interplay of group behavior, habits, and population characteristics should not be ignored even in research of environmental health risk, which typically reveals social vulnerability. The environmental health vulnerability index is obtained by multiplying the quantitative physical-vulnerability value with the social vulnerability index, which can synthetically reflect the vulnerability of villages.Vulnerability thus consists of physical and social vulnerability. On the basis of these two dimensions, a four-quadrant chart is presented in According to the physical vulnerability evaluation method, the physical vulnerability value was calculated using Equations (1)–(5), and the evaluation results of 16 villages in the study area are shown in p < 0.05) than that in the reference area through each exposure route. The calculated average values of population physical vulnerability in the polluted and reference areas were 3.99 and 1.00, respectively. Values of physical vulnerability of all villages in the polluted area and ZS, YQ, and SZ in the reference area were significantly higher than the upper threshold of 1.0, among which the highest was 8.55. From the perspective of physical vulnerability, ZS, YQ, and SZ in the reference area were also key villages of heavy-metal contamination.The physical vulnerability of different villages was in the order of WW > JQ > GT > WJZ > LQ > HJ > CL > CG > ZS > YQ > TN > SZ > SW > WD > FD > MS. The physical vulnerability of the villages in the polluted area was significantly higher  > Cd (17.0%) > Cu (8.7%) > Zn (6.8%) > Pb (3.2%). In fact, heavy metals with a major contribution to the physical vulnerability were not the same in different exposure routes. As and Cd similarly contribute to physical vulnerability by the pathway of vegetable intake, reaching 36.5% and 37.3%, respectively. Additionally, As contributed the most among other metals to the physical vulnerability value through the exposure routes of soil ingestion and inhalation, reaching 76.9% and 87.8%, respectively. There was little difference in the contribution of Pb, As, and Cd through dermal contact, reaching 45.9%, 29.5%, and 23.0%, respectively.The average physical vulnerability value contribution of different heavy metals showed the order of AThe higher the score of social vulnerability is, the weaker the ability of the population to resist and protect themselves against potential pollution hazards and other pressure disturbances. That is to say, the group with higher social vulnerability may lose more when facing the same pollution threat. Scores of each index in the social vulnerability evaluation system and the composite score are shown in The total social vulnerability scores of 16 villages from high to low are as follows: LQ (0.770), FD (0.690), SW (0.688), MS (0.639), ZS (0.592), GT (0.543), TN (0.499), CL (0.490), JQ (0.464), WJZ (0.459), YQ (0.453), WW (0.360), WD (0.348), SZ (0.342), HJ (0.334), and CG (0.188). From the total score of each village, LQ had the highest social vulnerability, and CG had the lowest social vulnerability. Indicators of self-sensitivity show the local residents’ own sensitivity to pollution hazards. The higher the SS composite score is, the higher the sensitivity, and the more likely it is to have negative health effects in the face of pollution threats.The score of social and economic conditions reflects the occupancy of social resources. The higher the social vulnerability score is, the fewer social resources the village requires. The population of MS needed the fewest social resources among 16 villages, with the highest SEC composite score of 0.31. The indicators of receptor behavioral characteristics represent the social life stress of the local population. The higher the score is, the greater the pressure they are under. The population of SW was burdened by the heaviest social stress among the 16 villages with the highest BE composite score of 0.28.In fact, the correlation analysis of each index score in the social vulnerability evaluation system could roughly reflect the local population and social characteristics. SPSS was used to analyze the correlation of each index, and results were shown in p = 0.034 < 0.05). This result is consistent with the research of Tachibanaki [p = 0.048), which is consistent with the finding that age and gender are both risk factors for chronic diseases [p = 0.007 < 0.05). There was significant positive correlation between the proportion of women and the proportion of vulnerable age groups (p = 0.020 < 0.05). These two phenomena are related to the survey area. Because the survey area is rural, and its geographical location is remote, local adult males may go out to work more, so the proportion of females and the number of vulnerable age groups in the 16 surveyed villages was higher. In Chinese rural areas, there are many people engaged in heavy manual labor in harsh working environments.The correlation of some indicators related to our research was consistent with the results of large sample data analysis in many studies. As a result, a significant positive correlation was found between the proportion of people with a low educational background and the proportion of people with income lower than the local average income , WW (0.36), LQ (0.35), GT (0.26), WJZ (0.21), CL (0.14), ZS (0.12), HJ (0.10), YQ (0.08), SW (0.07), TN (0.06), CG (0.05), FD (0.05), SZ (0.04), MS (0.04), and WD (0.03).Soil and vegetable pollution data were obtained through experimental detection, and population and social characteristic data were obtained through investigation, with the environmental health vulnerability evaluation performed with the tentative comprehensive evaluation method. Results indicated that the average physical vulnerability values of the population in the polluted and reference areas were 3.99 and 1.00, respectively. For villages with sampling sites, WW had the highest physical vulnerability value of 8.55. Considering exposure pathways, vegetable intake is the exposure type that should be paid more attention, as it contributes more than 90% to physical vulnerability among the four exposure pathways. Arsenic and cadmium should be the priority pollutants, with average physical vulnerability value contributions of 63.9% and 17.0%, respectively. According to the social vulnerability assessment, LQ had the highest social vulnerability with a value of 0.77. Comprehensive environmental health vulnerability assessment showed that five villages near mining activities  and two villages (ZS and YQ) far from the mine-affected area are urgent areas in environmental risk management, with high physical and social vulnerability.For environmental health risk, there is an entire solving structure presented by EPA or CDC authorities in the U.S., which is widely recognized in the era of scientific research to receive hazard index of physical pollutants. We omitted the process and focused more on introducing social rather than physical aspects. Social and physical vulnerability contribute to the population’s environmental health risk. On the basis of the results, social and physical vulnerability in research of heavy-metal exposure leading to environmental health risk are not significantly related with each other. Considering divergent factors of population vulnerability in a certain area, population distribution, regional development, and mining activities are likely to influence these two types of vulnerability. Our previous study showed that heavy-metal exposure in soil is a cause of environmental health risk, particularly in a long-term mining city such as Daye, China.From our research, we learned that risk and vulnerability likely band with each other, even in the aspect of environmental health risks. The result shows that social and physical vulnerability cause significant population environmental health risk. It is appropriate not to add social to physical vulnerability to solve the calculation of the environmental health risk modelling, but to combine the two types of vulnerability and calculate each type individually as presented above. Furthermore, population environmental health risks, which focus the research subject on a group of people or residents in a certain place, need to be carefully considered with the social conditions and characteristics of the group.It is innovative to create a systematic approach with social and physical vulnerability to deal with population environmental health risk that uses the hazard index for the evaluation of physical vulnerability and creates a novel social vulnerability index system to evaluate the later vulnerability on the basis of a large-scale of door-to-door survey of residents of 24 villages in the research area. Therefore, the research would not assume individuals to be one subject, but consider a number of local residents to be a population. The critical problem lies in the fact that it is inadvisable to ignore population distribution and characteristics in the research of population vulnerability and the environmental health of local residents.Results indicated that long-term mining activities may influence a percentage of the population and in a large range of areas. According to the researching dimension, village-scale areas are specific and with significant differences, which helped us to confirm the suitability of geographic division between the polluted the reference areas.By filtering the results of physical vulnerability assessment in the case study, villages in the polluted area are more likely to be exposed to environmental health risk than the ones in the reference area. Sample analysis and health risk calculation revealed that the adjacent contiguous villages of WW, WJZ, JQ, and LQ, had a high value of HI (HI > 3.50). The adjacent contiguous villages of MS, FD, and WD, on the other hand, had a lower value of HI (HI < 1.00). An adjacent–contiguous feature indicates a spatial characteristic of physical vulnerability.Regarding social vulnerability, the adjacent contiguous villages of SW, ZS, MS, and FD in the reference area had a higher assessment value (score > 0.59). The adjacent contiguous villages of LQ, TN, and JQ in the reference area had a higher assessment value (score > 0.45). However, the difference between physical and social vulnerability is that the former one is specific and the latter is universal, with or without the environmental health risk problem. The population’s social vulnerability widely exists according to the result (score > or =0.19), but comprehensive population vulnerability is more meaningful with both the social and the physical aspect. Furthermore, when considering population social vulnerability, there is an adjacent–contiguous feature that indicates a spatial characteristic of social vulnerability without zoning differences, and this feature was notable in both the reference and the polluted area.There is a continuous and cumulative risk of heavy-metal exposure in mining areas that can be obtained both from sample analysis and questionnaire survey. Social vulnerability indicates people’s livelihood, population effects, group behaviors, and population differences under a certain stress or risk or multiple sources, which should not be neglected in environmental health risk assessment activities. The cohorts, as a large number of residents living locally in the two studied areas, considering exposure to environmental health risk of heavy-metal exposure, had significantly different social vulnerability. A nonrandomized control study of the polluted and reference areas by the village-scale zoning is applicable.Different environmental protection measures and risk management control strategies should be adopted more meticulously for different vulnerability characteristics. Social vulnerability is related to many more factors, and some cannot be entirely obtained, such as the local educational background structure, income level, the proportion of people in industries with large opportunities of direct contact with pollutants such as mining, construction, and agricultural planting.The research area in the case study belongs to rural areas of the city of Daye, where the economic development level is lagging behind that of cities and towns. In addition, a major feature of the local rural areas is that there have been more mining activities resulting in a higher proportion of the local population with industrial employment and mining as the main occupation. The reasonable distribution of industries in rural areas and their improvement need to be considered.On the basis of sample analysis and field investigation of heavy-metal pollution in soil and vegetables, and population and societal survey data in Daye, China, physical and social vulnerability were modeled, and the comprehensive environmental health vulnerability of the area was analyzed with each village as an evaluation unit. The significant result of comprehensive environmental health vulnerability assessment on heavy-metal exposure showed that study areas could be divided into four categories according to the evaluation of environmental health vulnerability. Physical vulnerability indicates the extent of exposure to heavy metals, which is mainly impacted by pollution degree of environmental media and ways for residents to contact pollutants according to the method for calculating physical vulnerability. Areas with high physical vulnerability may be more polluted or more frequently exposed to pollutants by local residents. Therefore, pollution control strategies should be adopted, and education for personal protection awareness and health monitoring should be strengthened. Regions with low physical vulnerability should pay attention to environmental planning and personal protection guidelines. Social vulnerability represents the ability and sensitivity of communities to respond to pollution threats.The priority control of contaminated areas and pollutants should be effectively identified. According to the analysis of physical vulnerability, the physical vulnerability of villages near mining activities is significantly higher than that of areas far away from mining-affected areas. The physical vulnerability of 10 villages near mining activities and some villages far away from mining activities, such as YQ and SZ, was higher than the acceptable level, which should be listed as the focus of environmental health risk management. In addition, arsenic, cadmium, and copper are the main pollutants in the area, which greatly contribute to physical vulnerability.In order to promote environmental risk management, it is necessary to give priority to effectively and accurately identifying and controlling pollution areas. Moreover, accuracy means identifying vulnerable populations on the village scale. Furthermore, it is necessary to appropriately adjust the industrial structure and cooperate more to form a complete economic zone.


Uveal melanoma (UM) is a rare form of melanoma originating in the eye. Unlike cutaneous melanoma (CM), the role of ultraviolet radiation (UVR) in UM aetiology is still unresolved. UM has a high incidence in Australia. Epidemiological analyses revealed heterogeneity in UM incidence between two eastern Australian states, Queensland (QLD) and Victoria (VIC). It was found that QLD has a 21% higher incidence of UM than VIC and, in fact, has one of the highest incidences in the world. A weak south-to-north trend in incidence along the eastern Australian coast is seen, and rural areas have a 24% greater burden than major city areas in both the states. The two states are similar demographically, but differ socially, industrially and latitudinally. This is important because it could indicate a minor UVR role in UM incidence, especially in QLD. Preventative measures by sun-protective behaviours may be important, especially in the northeastern Australian demographic. Uveal melanoma (UM) is the second-most-common melanoma in humans and has a high age-standardized incidence rate (ASR) in Australia. Regional patterns of UM ASRs in Australia are unknown. The aim of this study was to determine and compare UM ASRs in two geographically disparate eastern states, Queensland (QLD) and Victoria (VIC), by using cancer registry data that was obtained from 2001 to 2013. World-standardized UM ASRs and incidence-rate ratios (IRRs) were calculated. Higher UM ASR was also observed in anterior UM compared to posterior UM ASR. UM ASR remained unchanged from 2001 to 2013 in QLD but decreased in VIC. A south-to-north latitude trend in UM ASR along the east of Australia is weakly evident, and rural populations have higher UM ASRs than major city populations in both states. Differences in ultraviolent radiation (UVR) susceptibility, indigenous populations, social behaviours, chemical exposure, and socioeconomic status could all be contributing to differences in UM rates between QLD and VIC and between rural compared to major city areas. It is possible that a minority of cases in QLD and VIC might be prevented by sun-protective behaviours. This is important, because these findings suggest that QLD, which is already known to have one of the highest cutaneous melanoma (CM) ASRs in the world, also has one of the highest UM ASRs. Uveal Melanoma (UM) is the most common intraocular melanoma in humans, arising from melanocytes of the iris, choroid or ciliary body in the eye. UM age-standardized incidence rate (ASR) appears to be elevated in Australia, with world-standardized ASR ranging from 6.2 to 8.0 per 1,000,000 person-years in men and 5.2 to 6.1 per 1,000,000 person-years in women , the UniQueensland (QLD) and Victoria (VIC) are states with the most northern and southern latitudes of the Australian mainland, respectively, and are found at similar longitudes. QLD is 7.5 times the size of VIC ,7, with The comparison of two states with very similar populations, health systems, and governing variables provides a unique setting for the scientific investigation of population-wide factors associated with UM ASRs. Indeed, there already exist substantial differences in cancer burdens between the pair of states: QLD has one of the highest Cutaneous Melanoma (CM) ASRs in the world , and betThe aim of this study was therefore to use the unique characteristics of this state pair to compare UM ASR and incidence-rate ratios (IRR) patterns between 2001 to 2013 and to reflect on possible factors that drive differences in UM ASR. UM data from 2001 to 2013 was obtained from the QLD Cancer Registry (extracted 3 March 2016) and the Victorian Cancer Registry (extracted 8 March 2016). This encompassed all ICD-O-3 C69 sites (eye and adnexa), from 2001 to 2013, with ICD-O-3 morphology 872-879. Information on sex, year of birth, year of diagnosis, postcode inhabitancy at time of diagnosis, and site of origin were provided for both states. In this study, melanomas of the “conjunctiva” (C690) and “lacrimal gland” (C695), which have sometimes been classed as “ocular melanomas” in the past ,15, are In order to assess the relationship between UM ASR, latitude, and remoteness, the data on postcode inhabitancy at the time of diagnosis was used. Cases without postcode information were excluded from comparison statistics involving rurality and latitude. Rurality was based on the Australian Bureau of Statistics (ABS) Remoteness Area (RA 2011) level , i.e., mx-axis points were available as a result of insufficient case numbers (<25) for age standardization, per demographic, sex, time interval, and/or latitude band. Significance of correlations and t-tests were both determined using p values at the 0.05 significance level. The data was further analyzed by Poisson regression models to produce incidence rate ratios (IRRs) for characteristics such as rurality and latitude. Age and sex person-year exposure was included in every model to control for differences between the populations. IRRs were computed using per-sex, per-age-group, per-year population to account for increasing population over time. Statistics were performed using SPSS Statistics 26 or R 4.1.1.ASRs per 1,000,000 person-years and their 95% confidence intervals (95% CI) were calculated for different geographical groups from 2001 to 2013 using annual population data from the ABS , and thep = 0.03) in VIC (62.8 years old) than in QLD (60.9 years old). From 2001 to 2013, there were 432 UM cases in QLD and 434 cases in VIC see . Nine cap < 0.001) and females . When assessing individual sites of origins, QLD had a statistically higher ASR of anterior (ciliary body or iris) melanoma than VIC in both genders . QLD also had a higher ASR of posterior  melanoma in men (5.4) compared to VIC (4.2) per 1,000,000 (p = 0.05) but not in women .Summaries of ASRs in Australia, VIC, and QLD are presented for UM in p = 0.005) higher incidence rate of UM in QLD than VIC when controlling for age, remoteness, and sex (p = 0.018) higher incidence than females when controlling for age and latitude and 17%  higher incidence than females when controlling for age, state, and remoteness  only when the northernmost third of QLD is excluded . When looking at the incidence rate we see that Central Queensland (QLD band 2) has a 74% greater incidence of UM  than in VIC when controlling for age, sex, and year of diagnosis  but decreased in VIC . Comparisons of ASRs for younger and older VIC and QLD populations from 2001–2007 and 2008–2013 are presented in p = 0.03). In contrast, the ASR in older VIC males was lower in 2008–2013  than in 2001–2007 . In younger cohorts (<55 years old), a lower UM ASR was seen in 2008–2013 than in 2001–2007 in QLD females  but was not statistically different in QLD males . In VIC, the UM ASR in younger individuals was not statistically different from 2001–2007 and 2008–2013 in either sex.UM time trends are presented in p = 0.04). This is also seen in VIC . When controlling for age and sex, the ASR of UM was still higher in QLD than in VIC in major city areas  and rural areas . This is largely due to the higher rate of UM in QLD males in major cities and in QLD females in rural areas (see p = 0.002) when accounting for age, sex, and state . The age of diagnosis is also lower (p = 0.03) in QLD (60.9 years old) than in VIC (62.8 years old). These differences in site of origin and age of diagnosis could implicate distinct aetiological drivers of UM in QLD and VIC.This is the first time that the ASRs of UM in QLD and VIC have been directly compared. The (world-standardized) ASR of UM from 2001 to 2013 was higher in QLD  than in VIC . The UM ASR in QLD (but not VIC) is also higher than the Australian average reported previously  observed from VIC (latitude −39.1° to −34.0°) to the more populated parts of QLD (−29.0° to −21.6°) also suggests a role for UVR in pathogenesis. However, UM ASR falls in the remote, most UVR exposed areas of northern QLD. This, surprisingly, could also be argued to be supportive of a role of UVR in UM ASR along eastern Australia. This seems counterintuitive, but while UM ASR has not shown a south to north increase across the entire continent previously [The weak positive correlation (eviously ,36,37. Aeviously , the redeviously , includieviously  and in Qeviously , and lowQLD has a higher ASR of UM than VIC even when considering rural and major city areas. Analysis of the state pairs showed that the ASR of UM is higher in rural areas than in major cities for VIC and for QLD. Higher ASR of UM in rural areas compared to urban areas has been reported in Australia-wide data previously . Differences in ASR between rural and urban areas could be due to differences in UVR, pollution, occupational exposure to carcinogens, or socioeconomic status. In dense urban areas, the increased pollution and built environment can cause the absorption and scattering of UV light, reducing UVR exposure . DiffereThis study observes the ASR of UM in two eastern Australia states, VIC and QLD, from 2001 to 2013 as recorded in the Victorian Cancer Registry and QLD Cancer Registry. These registries are reliable for a number of reasons. Firstly, reporting of all cancer diagnoses is mandatory in all Australian states and territories , and secDespite thorough case reporting, the ASRs of UM reported in this study may still be underestimations of the true values for several reasons. Nine QLD UM cases were excluded from the analyses due to a lack of postcode data, potentially creating a sampling bias in the latitude and rurality IRR investigations. In addition, the current study did not employ methods to investigate possible non-notifications by healthcare facilities. Despite mandatory reporting, 109 unnotified cases were discovered in Australia in the period of 1990 to 1998 , and theThis study relied on postcode at diagnosis for many of its analyses, and information on changes of inhabitancy of UM cases was not available. It can be observed through census data that high turnover or growth was greater in regional and remote areas over the study period than in major city areas, especially in QLD ,51,52, wUnfortunately, data on the molecular profiles and pathological features of the diagnosed UM is not reported in the QLD or VIC cancer registries. This may not be surprising given that, in contrast to most other cancers, UM is frequently diagnosed without a confirmatory biopsy, and, instead, diagnosis and subsequent treatment is solely based on clinical findings . This maOur study benefits from the comparison of two latitudinally polar states with relatively similar demographics, latitude, and healthcare systems. Thus, an association be-tween UVR on UM ASR may be commented on. However, caution must be taken in this ecological study to not overstate the evidence for the relationship between UVR radiation and UM ASR, as this and similar ecological studies can only establish weak evidence towards this finding.Finally, UM’s orphan status means that, statistically, a small change in the number of cases can have a large impact on the rate. Consequently, fluctuations in data should be interpreted with caution and more complicated analyses may not have their assumptions met in many samples of UM. QLD and VIC face different carcinogenic, demographic, and solar UVR burdens but represent grossly similar populations and living styles suitable for demographic comparison. Together, the identified factors may contribute to the higher ASR of UM in QLD, especially in men, in rural areas, and in central QLD. This is significant for 2 main reasons: Firstly, south-to-north latitude trends, higher rural ASR, and the substantially greater ASR of anterior UM in QLD than in VIC may all suggest a relationship between UM ASR and UVR in a proportion of cases. This agrees with anatomical, molecular, and epidemiological evidence that at least a small portion of UM cases are UVR-related . Secondly, rural areas typically have less access to healthcare than major cities. This is particularly a problem in UM, which is usually asymptomatic in the early stages and often diagnosed incidentally by an optometrist . This isOur data has shown that from 2001 to 2013, QLD had a greater ASR of UM than VIC resulting in a 21% greater incidence. The UM ASR in QLD is also higher than average Australian rates and represents one of the highest UM rates in the world. Differences in UVR exposure, occupation, chemical exposure, and rurality could all plausibly contribute to the higher rates of UM in QLD than VIC, in men than in women, and in rural areas than in major city areas of both QLD and VIC. This means that awareness and early detection regimes should be considered, especially for these demographics.