Anemia is a serious complication of chronic kidney disease (CKD) with a significant adverse outcome on the burden and progression of the disease. Hence, the study intended to assess the pooled prevalence of anemia and its predictors among CKD patients in Sub-Saharan African nations.2) tests were employed to evaluate the heterogeneity across the included studies. Due to substantial heterogeneity among the studies, a random-effects meta-analysis technique was employed to estimate the pooled prevalence of anemia. Subgroup analysis, sensitivity analysis, and meta-regression analysis were carried out to search the possible bases of heterogeneity. Funnel plot symmetry, Begg’s test, and Egger’s regression test were employed to assess the existence of publication bias. In addition, factors associated with anemia among CKD patients were examined. All statistical analyses were carried out with STATA™ Version 14 software.To identify the relevant studies systematic searches were carried out in Medline, EMBASE, HINARI, Google Scholar, Science Direct, and Cochrane Library. From selected studies, data were taken out with a standardized data extraction format prepared in Microsoft Excel. Inverse variance . Stage of CKD (3–5) (pooled odds ratio (POR) = 5.33, 95% CI:4.20–6.76), presence of diabetes mellitus , hemodialysis history , and female sex  were significantly related with anemia.A total of 25 studies with 5042 study participants were considered in this study. The pooled prevalence of anemia among CKD patients was estimated to be 59.15%  with a substantial level of heterogeneity as evidenced by IMore than half of CKD patients were suffering from anemia. Stage of CKD, presence of DM, hemodialysis history, and being female sex were factors associated with anemia among CKD patients. Chronic kidney disease (CKD) is an emerging global public health issue that places a significant financial burden on both the patients’ families and the healthcare delivery system. CKD is a major basis of morbidity and mortality in both developed and developing nations, affecting more than 10% of the worldwide population in 2015 . Al. Al18]. To ascertain all eligible literature that reports the prevalence of anemia and its predictors among patients presenting with CKD in sub-Saharan African nations, a systematic exploration of the literature was conducted by three authors  through Medline (PubMed), EMBASE, HINARI, Google Scholar, Science Direct, CINAHL, Popline, Cochrane Library African Journals Online (AJOL), and grey literature. Additionally, the reference lists of each retrieved article were also searched manually for search optimization. The search was carried out using the following key search terms and phrases: “anemia”, “anaemia”, “associated factors”, “risk factors”, “chronic renal impairment”, “chronic kidney injury”, “chronic renal insufficiency”, “chronic kidney disease”, “Sub Saharan Africa”, and “names of each the sub-Saharan Africa countries”. Boolean operators like “AND” and “OR” were used to combine search terms. The search of the article was limited to full texts, free articles, and published in peer-reviewed journals in the English language. Then, based on the eligibility criteria, two authors (TTT & FAG) independently reviewed all potential article titles, abstracts, and full-text quality. Finally, the screened articles were compiled together.All studies in sub-Saharan African countries that reported the prevalence of anemia and its predictors among CKD patients were illegible for the study. However, the studies that did not report our outcome of interest  or if it is not possible to calculate from the available data; studies which were not fully accessible even after e-mailing the primary author twice; and studies having a low-quality score in accordance with the given quality assessment criteria were excluded from this study.The selected articles were thoroughly and independently examined by the other two authors (STM & BTA), and the necessary data for the review were collected and summarized using a straightforward data extraction spreadsheet format prepared in Microsoft Office Excel software. If inconsistencies among data extractors were detected, a third author acted as the final arbiter. In instances of incomplete data, emails were sent to the corresponding author twice in an attempt to get further information, or calculations were conducted using the available information.The data extraction tool comprises the name of the first author, publication year, country where the study was conducted, design of the study, sample size, the prevalence of anemia with 95% confidence interval (CI), dialysis status, and each specific factor (factors if two or more studies considered them as predictors of anemia among CKD patients). For every associated factor, in order to calculate the odds ratio, the data from the primary studies were extracted by three authors  in the form of two by two tables.The methodological quality of each incorporated study was evaluated by two authors  independently, using the Newcastle-Ottawa scale (NOS) quality valuation tool that was adopted for the quality evaluation of cross-sectional studies . The tooAdditionally, the risk of bias in selected studies was evaluated using the Hoy et al.  risk of 2 test and its p-values, with I2 values of below 25, 25–75, and above 75% demonstrating low, medium and, high heterogeneity, respectively [2 = 98.1%, P-value 0.001).For statistical analysis, the extracted data were imported into STATA version 14 software . The heterogeneity across the recorded studies was evaluated by using the heterogeneity Iectively . The tesAs a result, a random-effects meta-analysis model was applied to estimate the pooled prevalence of anemia among CKD patients. Using a forest plot, the pooled prevalence with a 95% CI was produced and displayed.Furthermore, subgroup analysis and meta-regression were employed to detect the probable cause of heterogeneity. In addition, sensitivity analysis was conducted to evaluate the relative effect of each study on the overall estimate by omitting each study one by one. Besides, the possibility of publication bias was also evaluated by using funnel plot symmetry, Egger’s regression test, and Begg’s test. Finally, the different factors associated with anemia among CKD patients were presented using pooled odds ratios (PORs) with a corresponding 95% CI.A total of 3644 records concerning the prevalence and predictors of anemia among CKD patients in sub-Saharan African regions were collected from the databases of PubMed, HINARI, EMBASE, Science Direct, Google Scholar, Cochrane Library, and grey literature. Of these studies, 1852 articles were removed due to repetition. After assessing the title and abstract, 1695 articles were removed from the remaining 1792 studies as they were found to be non-applicable for this systematic review and meta-analysis. The remaining 97 studies were then assessed for eligibility based on the pre-defined criteria, which resulted in the further exclusion of 72 studies. Finally, 25 studies that satisfied the eligibility criteria were considered in the analysis .A total of 25 original articles that revealed the prevalence and predictors of anemia among 5042 CKD patients in sub-Saharan African regions which were published between 2010 and 2021 were incorporated in this systematic review and meta-analysis. These studies were carried out in South Africa (5 studies) , 22–25, 2 statistic , indicating a great variability in the prevalence of anemia among patients presented with CKD across the studies. Hence, a random effect model was employed to determine the pooled prevalence of anemia among CKD patients in sub-Saharan African regions  with a substantial level of heterogeneity as evidenced by I regions .To pinpoint the source of heterogeneity, subgroup analyses based on the study area, year of publication, sample size, dialysis status, and bias risk of the included studies were conducted. Based on the subgroup analysis, the pooled prevalence of anemia in the included studies ranged between 37.8% in Uganda and 83.30% in Cameroon, 54.76% among studies published after the years of 2015, and 81.63% up to the year 2015, and 65.51% among studies with moderate risk of bias and 51.00% among study with low-risk of bias.Another subgroup analysis based on the sample size showed the highest prevalence (67.68%) of anemia was detected among the studies with a sample size of less than 150; whereas the lowest (50.04%) was observed among the studies with a sample size of 150 and above. Furthermore, the pooled prevalence of anemia in studies among dialysis and pre-dialysis patients was 71.01 and 55.42%, respectively . In addiA leave-one-out sensitivity analysis was also conducted to determine the cause of heterogeneity. The results of the random-effects model’s sensitivity analysis indicated that no single study had an impact on the overall prevalence of anemia among CKD patients .The publication bias was evaluated with a funnel plot, Beggs’ and Eggers’ tests. The funnel plot  was symmIn this systematic review and meta-analysis stage of CKD, the presence of diabetes mellitus (DM), female sex, and history of hemodialysis were recognized as factors significantly associated with the presence of anemia among CKD patients. For each identified factor except sex, sensitivity analysis was also carried out by excluding each study one by one, but the result showed that there was no strong evidence for the effect of a single study on the overall result.Five studies , 33, 36 This systematic review and meta-analysis deliver evidence of an estimated pooled prevalence of anemia among CKD patients in Sub-Saharan African countries. Based on the review, the pooled prevalence of anemia was 59.15% 95% CI, 50.02–68.27). The finding is in line with the studies conducted in Turkey (55.9%) , Malaysi.02–68.27These wide discrepancies in the burden of anemia among CKD patients might be explained by the differences in the socio-economic status, the definition of anemia, the study population, methodology, inclusion and exclusion criteria of the study, the stage of CKD, and the quality of healthcare services.Sub-group analysis of this study indicated that the prevalence of anemia among dialysis patients 71.01% (95% CI: 47.48–94.55) was higher than their counterparts, 55.42% (95% CI: 45.26–65.59). It is not surprising to see anemia more commonly among dialysis patients than non-dialysis patients in this study, as the various studies revealed that erythropoietin deficiency and losing blood, either through blood tests or during dialysis were common among dialysis patients , 31, 32.Predictors of anemia were also assessed in the present systematic review and meta-analysis. History of hemodialysis was identified as a predictor of anemia among CKD patients in which CKD patients with a history of hemodialysis were three times more likely to be suffered from anemia than those patients without a history of hemodialysis. This is most likely because hemodialysis-requiring patients were those with a long duration of the disease, advanced renal disease, and comorbidities, in which the presence and severity of anemia were prevalent , 32.In this finding, the sex of the study participants was significantly associated with the presence of anemia in which being female is stated to be a non-modifiable risk factor for the occurrence of anemia among CKD patients, yielding a similar result to a study carried out in Turkey , MalaysiThe study also showed that the stage of CKD was significantly associated with the occurrence of anemia among CKD patients. It was found that the risk of anemia was gradually increased as the CKD advanced, which corresponds well with the results of earlier studies conducted in South Korea , MalaysiFinally, CKD patients with DM had an approximately two-fold increased risk of anemia than those without DM. Likewise; an increase in the risk of anemia among CKD patients with DM has been reported by various studies carried out in the United States , Greece There are a few potential significant limitations to this systematic review and meta-analysis. First of all, there is no uniformity of CKD definitions and anemia cut-off points in the included studies that may affect the estimation of the combined prevalence. Second, it might be challenging to apply the conclusions from a small number of sub-Saharan African nations included in this meta-analysis to all CKD patients in that region. Third, most of the studies incorporated in the review were cross-sectional in nature. As a consequence, a cause-effect relationship cannot be established. Hence further study with a strong study design and by considering other causes of anemia should be conducted. Additionally, there has been a substantial heterogeneity among the included studies and the cause/s for the heterogeneity thus remains elusive, which could make it difficult to interpret the findings.Almost three out of five CKD patients in Sub- Saharan African countries were suffering from anemia, which revealed that anemia is highly prevailing in patients with CKD. Its prevalence varies across the region with the highest prevalence in Cameroon. It was also found that stage of CKD, presence of DM, being female sex, and history of hemodialysis were significantly associated with the presence of anemia among CKD patients. Consequently, a high index of suspicion for anemia should be implemented among CKD patients particularly in patients with advanced CKD stage, history of hemodialysis, comorbid condition of DM, and female sex to improve their outcomes.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.


To explore the effect of inter-pregnancy interval (IPI) and micronutrients on depression in the third trimester of pregnancy.A total of 5,951 eligible pregnant women were included in this single-center retrospective cohort study. Variables with potential effects on third-trimester depression were collected. These variables included: maternal factors , previous delivery outcomes , and micronutrients in early pregnancy . Univariate and multivariate analyses were used to screen the factors affecting the occurrence of depression. Based on these factors, the nomogram model was established. At the same time, the interaction between IPI and micronutrients was verified.The incidence of depression in the third trimester of pregnancy was 4.3%. Univariate and multivariate analysis showed that there were five independent risk factors for third-trimester depression: gravidity, previous cesarean section delivery, folic acid, and vitamin D levels in early pregnancy and IPI. According to the multivariate logistic regression analysis, the prediction model and nomogram were established. The prediction cut-offs of the corresponding factors were calculated according to the Youden index. Finally, the synergistic effect of short IPI and micronutrient deficiency was verified.There is a synergistic effect between short IPI and micronutrient deficiency in early pregnancy, which can aggravate the occurrence of depression in late pregnancy. Depression is a common complication during pregnancy and postpartum . In deveInter-pregnancy interval (IPI) refers to the period between the birth of the previous child and the conception of the index child. Evidence suggests that short IPI and some micronutrient deficiencies may cause the development of depression through psychoneuroimmunology mechanisms. Women of childbearing age are particularly vulnerable to malnutrition because pregnancy and lactation are the main sources of nutritional stress in the body. In fact, during pregnancy or lactation, the demand for many nutrients will reach the highest level in a lifetime. High demands combined with insufficient intake often lead to nutritional deficiencies during pregnancy and breastfeeding . ContinuThis retrospective cohort study was conducted at the International Peace Maternity and Child Health Hospital (IPMCH), a tertiary first-class obstetrics and gynecology hospital in Shanghai, China. We collected the data of pregnant women who gave birth in IPMCH twice in a row and the second delivery time was from April 2014 to March 2020. After excluding cases that did not meet the inclusion criteria or had missing data, we finally included 5,951 cases. The ethics committee of the International Peace Maternal and child health hospital approved the study procedure (Reference Number: GKLW 2021–23). All participants provided written informed consent, and the ethics committee approved the consent procedure.Women who met the following criteria were included: (1) singleton pregnancy; (2) women with both first and second births at the IPMCH; (3) regular obstetrics with available first-trimester serology; (4) third trimester Edinburgh score available; and (5) delivery gestational age ≥ 28 weeks.Exclusion criteria were: (1) multiple pregnancy; (2) women with a history of depression or taking antidepressants before pregnancy; (3) parity ≥ 3; (4) stillbirth or miscarriage; (5) delivery gestational age < 28 weeks. (6) lack of serological markers or Edinburgh score; and (7) incomplete data. Ultimately 5,951 pregnant women participated in the study.Several studies have shown that screening can improve pregnancy outcomes in depressed mothers , 13. OveIPI refers to the period between the birth of the previous child and the conception of the subsequent pregnancy. Gravidity is defined as the number of times that a woman has been pregnant. Parity is defined as the number of times that she has given birth to a fetus with a gestational age of 28 weeks or more, regardless of whether the child was born alive or was stillborn. Premature birth is defined as labor that happens before the 37th week of pregnancy. BMI (body mass index) is a person’s weight in kilograms divided by the square of height in meters. The EPDS is a set of 10-item self-report questions to screen women for symptoms of emotional distress during pregnancy and the postnatal period.All data during the two deliveries of participants were recorded by designated personnel and archived electronically, including age, gravidity, BMI, education level, place of residence, personal and family history, pregnancy interval, pregnancy complications, mode of delivery, and pregnancy outcome. Each participant had a regular prenatal examination in our hospital. The examination items in the early pregnancy included serum nutrients . During the late pregnancy, they completed the EPDS questionnaire to obtain the Edinburgh score.Fasting blood samples were collected from each woman after one night of random fasting (11–12 weeks of pregnancy) to detect micronutrients. Peripheral blood samples were collected in a BD vacuum container between 8 a.m. and 10 a.m. for treatment within 90 min. Plasma and serum aliquots were stored at –80°C for subsequent analysis.The primary outcome measure is the occurrence of depression in the third trimester of pregnancy. All participants filled in the Edinburgh questionnaire within 2 weeks before delivery in the third trimester of pregnancy to obtain the EPDS score. The diagnostic threshold for depression in pregnancy is 11 points , 11 poinThe secondary outcome measures included peripheral blood micronutrient levels during early pregnancy  and IPI. Maternal factors, previous delivery outcomes, and delivery mode were also collected. Maternal factors include age, IPI, BMI, BMI change, gravidity, native place, education, smoking, and alcohol consumption. Previous delivery outcomes included preterm birth, preeclampsia, ICP, GDM, and FGR. The pregnancy outcomes were recorded after delivery. IPI is defined as the period between the birth of the previous child and the conception of the index child. BMI changes represent the difference in weight between two consecutive early pregnancies.1 Quantitative data were tested for normality. Those in line with the normal distribution were expressed as mean ± standard deviation and compared by independent sample t-test. And those not in line with the normal distribution are represented by the median and interquartile space. Qualitative data were expressed as ratios and compared by the chi-square test. The receiver operating characteristic (ROC) curve and the Youden index was used to determine the predictive cutoffs for each risk factor. Univariate logistic regression was used to find the related risk factors of depression during pregnancy. Multivariate regression analysis was used to adjust for confounding variables known to independently affect depression. In addition, we used a linear model to understand the interaction effects among the risk factors. Risk ratios (ORs) with 95% confidence intervals (CI) were calculated to identify risk factors and evaluate their impact. The nomogram was established based on the results of the multivariate logistic regression analysis using software R 3.0.3 by using the “rms” package. P-value < 0.05 is considered significant.SPSS version 21.0  and R software version 3.6.1 .P < 0.001). In terms of micronutrients in early pregnancy, the levels of vitamin D, folic acid, and calcium in the depression group were significantly lower than those in the non-depression group (P < 0.05). In addition, the IPI in the depression group was significantly shorter than that in the non-depression group (P < 0.001). There was no significant difference between the two groups in age, native place, education level, smoking, alcohol consumption, complications of previous pregnancy, BMI, BMI change, vitamin B12, and serum ferritin in early pregnancy.P < 0.05), while there was no difference in other pregnancy outcomes.The incidence of third-trimester depression was 4.3% in this study. The risk factors in the two groups were compared, and the results were shown in p < 0.001). The Youden index was used to calculate the pregnancy specificity and regional cutoff values of vitamin D, folic acid and pregnancy interval associated with the incidence of depression. According to the maximum value of the Youden index, the cut-off value of vitamin D in early pregnancy was 40.75 nmol/L, the cut-off value of folic acid was 25.55 nmol/L, and the IPI cut-off was 23.5 months.We used a receiver-operating characteristic (ROC) curve to determine the relationships between the risk factors and the occurrence of depression . The levP < 0.001). gravidity ≥ 4  and previous cesarean delivery  are risk factors, while vitamin D ≥ 40.75 nmol/L , folic acid ≥ 25.55 nmol/L , and IPI ≥ 23.5 months  are protective factors.Based on the above cut-off values, the levels of vitamin D and folic acid in early pregnancy, pregnancy interval, pregnancy times, and the mode of previous delivery were divided into two groups for univariate and multivariate logistic regression analysis. The analysis results and forest plots were shown in P < 0.05). When IPI < 23.5 months, the levels of vitamin D, and folic acid in early pregnancy significantly affected the occurrence of depression (P < 0.001). On the contrary, when IPI ≥ 23.5 months, vitamin D and folic acid levels had little effect on depression (P > 0.05). Therefore, short IPI and deficiency of micronutrients in early pregnancy had a synergistic effect on depression, and the interaction effect was shown in To explore the interaction effects between IPI and micronutrients in influencing depression, we established a linear model. The results were shown in The incidence of depression in the third trimester of pregnancy in Shanghai was found to be 4.3% in this study. In previous studies, parity was found to be correlated with perinatal depression and nutrition , 18. YouPrevious studies have shown that depression is associated with adverse reproductive events, such as cesarean section . Women eAdequate nutrients are necessary for many aspects of normal brain function  and the The role of vitamin D in calcium regulation and bone health has long been recognized, but its role in cell proliferation and development has been a subject of increasing attention , especiaSome studies have shown that extending IPls may have beneficial effects, including reducing the risk of depression. Shorter IPIs may affect postpartum mood through two different mechanisms. The first is the social role and physical discomfort caused by frequent childbirth . Second,Although screening is important for the detection of perinatal depression, the screening itself is not enough to improve results unless there are appropriate strategies to respond to positive screening results and further treatment and follow-up. If pregnancy spacing and micronutrient deficiency are identified as causal mechanisms for our findings, this will support the extension of pregnancy spacing and the promotion of dietary supplements in the postpartum and perinatal period , especiaIn this study, we found the five independent risk factors of third-trimester depression were gravidity, previous cesarean section delivery, folic acid, and vitamin D levels in early pregnancy and IPI. At the same time, we also proved the synergistic effects of short IPI and micronutrient deficiency on depression. Based on these findings, we recommend strengthening pre-pregnancy education to prolong and optimize pregnancy interval and emphasize the importance of perinatal nutritional assessment and appropriate intervention, and promote micronutrient supplements, when necessary, especially in pregnant women with short IPI.The major advantage of this study is that it uses a female pregnancy-related cohort with detailed clinical information. The included subjects required that both deliveries were in our hospital, so the data variables, including maternal demographic information and delivery information, were reliably recorded in the medical archives. The sample size of the study is large, and the effects of parity and prenatal depression history were excluded. However, this study is a clinical retrospective cohort study, so it is difficult to avoid selection bias when selecting research objects. The research object of this study is limited to the research of specific ethnic groups of Chinese people, and the results should be carefully considered, because they cannot be extended to the whole population. We do not have information on postpartum factors such as postpartum examination, use of postpartum contraceptives, or breastfeeding, which may confuse the estimated impact of IPI and nutrients on adverse pregnancy outcomes , 51. In The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by the Ethics Committee of the International Peace Maternity and Child Health Hospital (reference number GKLW 2021-23). The patients/participants provided their written informed consent to participate in this study.WG participated in research design, data collection, interpretation, and manuscript revision. JL participated in the design of the study, analyzed the data, and drafted the manuscript. YZ was responsible for collecting and interpreting data. WG and JL conceived the study and reviewed the manuscript. All authors contributed to the article and approved the submitted version.


Results: In bivariate and multivariate logistic regression models with avoidance of sex and perceived negative impact of endometriosis symptoms on sex life as DVs, higher endometriosis symptom frequency, dyspareunia, and sexual distress were associated with greater avoidance of sex and higher perceived negative impact of endometriosis symptoms on sex life. With a two- and three-fold increase in the odds of avoiding sex and reporting a negative impact of endometriosis on sex lives, respectively, for each point increase in dyspareunia. Similarly, there was a 7% to 11% increase in avoidance of sex and the negative impact of endometriosis on sex lives, per one-point increase in symptom frequency and sexual distress. Conclusions: The results highlight the considerable impacts of endometriosis symptomatology on women’s sex lives and wellbeing. Better medical and counselling services may be needed to ameliorate the negative impact of endometriosis on women’s sex lives.Background: Endometriosis affects approximately 10% of women and is associated with a range of symptoms including pelvic pain, abnormal bleeding, and painful sexual intercourse. However, very little is known about the relationship between endometriosis-related symptoms and sex. Methods: Women with a diagnosis of endometriosis ( Endometriosis is a chronic non-communicable condition affecting approximately 10% of women of reproductive age, with approximately 176 million women diagnosed worldwide . AbnormaThere are three general forms of endometriosis-related pain: dysmenorrhea, dyspareunia, and non-menstrual chronic pelvic pain . DysmenoGeneral endometriosis-related pelvic pain has also been found to have a negative impact on women’s psychological health and wellbeing ,15,16. SDespite the adverse impact of these endometriosis-related sexual problems on women’s psychological, social, and physical wellbeing and quality of life, the field has largely ignored their importance to women. Notably, the 10th World Congress on Endometriosis 2008) established priority issues for research which largely ignored the reduced quality of sex life in women with endometriosis 08 establ. Althougn = 2060) completed an online questionnaire. The majority of the sample were surgically diagnosed (87.8%) with 12.2% diagnosed by a medical practitioner. The mean age in the sample was 30.49 years (SD = 7.25), with participants’ ages ranging from 18 to 62 years. Most participants (75.1%) were in a committed relationship and identified as heterosexual (89.6%), were sexually active (95.3%), and were engaging in sexual intercourse on average 5.52 times per month (SD = 5.81). Most of the sample (88.9%) were from Australia (n = 1478), Europe (n = 182), and New Zealand (n = 172). The participant characteristics are detailed in Women with a diagnosis of endometriosis (n = 18) entered the study but did not provide answers on key demographic characteristics and measures, leaving a final sample of 2060 participants.The present study is part of a larger study examining women’s experiences of PCOS, endometriosis, and a combination of both. More comprehensive details of the sample are available in previous research . The totn = 144), the total minimum sample size required was 1104.Participant inclusion/ exclusion criteria were as follows; participants must be aged 18 years or above, have a formal diagnosis of endometriosis, and have English language competency. For the current study, women reporting a diagnosis of both endometriosis and Polycystic Ovarian Syndrome (PCOS) were excluded from our analysis. The minimum required sample size for the larger study was calculated using the standard rule of thumb adopted in mainstream epidemiology research whereby 20 participants are required per cell and level of the variable included in the analysis  . AccordiThe study was advertised via peak endometriosis organizations in Australia, New Zealand, and the United Kingdom via their social media pages  and associated word-of-mouth/snowballing. The advertisements included a link to the questionnaire hosted by the Qualtrics research platform. On average, the questionnaire took 25 min to complete. Participants were informed at the start of the study that completing the questionnaire represented their consent to participate in the study. Ethical approval was granted by the University Human Research Ethics Committee.Along with demographic characteristics , the questionnaire assessed endometriosis symptomatology, dyspareunia, female sexual distress, avoidance of sex, and the negative impact of endometriosis symptoms on sex life.To measure endometriosis symptom frequency, participants were presented with a list of common endometriosis symptoms the authors had devised after consulting various medical sources and asked to indicate which symptoms they generally experienced. Consistent with previous research , a symptThe Pelvic Pain Subscale of the B&B scale assesses three pain symptoms; pelvic pain not related to the menses, dysmenorrhea (painful menstruation), and dyspareunia . Each of the three types of pelvic pain are rated on a 4-point rating scale ranging from 0 = absent to 3 = severe, and these three items can be summed to form a single score . BecauseThe FSDS-R is a screening instrument which consists of 13 items for measuring sex-related personal distress in women. The fixed-choice response format offered a five-point response scale ranging from 0 = never to 4 = always, with items summed to create a total score ranging from 0 to 52. Severe sexual distress is sometimes defined by an FSDS-R cut-off score of 11 or greater. However, for the present study, we used the total score as a linear variable . CronbacWe developed two questions assessing the impact of endometriosis on the avoidance of sex, i.e., “Do you avoid sexual intercourse because of your endometriosis?” (avoidance of sex), and on sex life, i.e., “Do your endometriosis symptoms have a negative impact on your sex life?” (perceived negative impact on sex life). Participants simply answered yes (coded as 1) or no (coded as 0) for each of the items.p-values for all statistics.Spearman’s Rho was used to examine bivariate relationships between endometriosis symptom frequency, dyspareunia, sexual distress, avoidance of sex, and perceived negative impact of endometriosis symptoms on sex life. Multivariate logistic regression models were used to examine multivariate relationships between the variables of interest and the dependent variables avoidance of sex and perceived negative impact of endometriosis symptoms impact on sex life. A priori tests revealed no significant differences between heterosexual and non-heterosexual participants (≈10%) on any of the variables of interest in pre-analyses. Accordingly, we reported the combined results for heterosexual and non-heterosexual women. We reported means (M) and standard deviations (SD), proportions (%) for descriptive statistics, and r’s, beta’s (B) and standard errors (SE), adjusted odds ratios (adjORs) with 95% confidence intervals, and associated Women on average experienced 10.87 (SD = 4.81) endometriosis symptoms. The mean dyspareunia (B&B) score for the sample was 1.67 (SD = 0.91), with approximately twenty per cent of women (20.4%) reporting severe dyspareunia, 35.6% reporting moderate dyspareunia, and 34.4% reporting mild dyspareunia. Only 9.6% reported no dyspareunia. Mean sexual distress (FSDS-R) scores were high . Using the clinical cut-off score of ≥11, 68.3% of the sample reported having severe levels of sexual distress.Eighty per cent (80.3%) of participants reported that they believed their endometriosis symptoms have had a negative impact on their sex life and 67.5% reported avoiding sexual intercourse due to their endometriosis.There were significant bivariate relationships between most of the variables of interest see . Notably2  = 567.41, p ≤ 0.001).Multivariate logistic regression models found several significant relationships between the independent variables and avoidance of sex and the perceived negative impact of endometriosis symptoms on sex life see . Age, en2  = 567.98, p ≤ 0.001).For the perceived negative impact of endometriosis symptoms on women’s sex lives, endometriosis symptom frequency, dyspareunia, and sexual distress were all associated with women reporting a perceived negative impact of endometriosis symptoms on their sex life. Again, the largest association was between the level of dyspareunia and the perceived negative impact of endometriosis symptoms on sex life with a 176% increase in the odds of reporting endometriosis having a negative impact on their sex life. There were also smaller but significant increases (7% and 11%) in the odds of women reporting a negative impact of endometriosis symptoms on their sex life for each 1-point increase in symptom frequency and sexual distress, respectively. The overall model was also significant (XThere is a paucity of research examining the role of endometriosis symptomatology (symptom frequency and dyspareunia) and associated sexual distress on the avoidance of sex and the negative impact of endometriosis symptoms on women’s sex lives. In the present sample, eight out of ten women reported that their endometriosis symptoms had a negative impact on their sex lives, 68.3% reported experiencing severe sexual distress, and over two-thirds (67%) said they avoided sex because of their endometriosis symptomatology. In both bivariate and multivariate analyses endometriosis symptom frequency, dyspareunia, and sexual distress, were associated with more avoidance of sex and the reporting of a greater negative impact on their sex lives. The impact of dyspareunia was particularly strong and concerning, with a two- and three-fold increase in the odds of avoiding sex and reporting a negative impact on sex lives, respectively, for each point increase in dyspareunia. This points to the need for better options for the management of pain during and after sex. The overall results highlight the need for better medical and counselling options to support women and their partners in having a sex life, and importantly an enjoyable one.Although we examined several novel relationships between endometriosis-related variables and outcomes, the general findings appear to be in line with previous research in the area. For example, previous studies have found similarly high rates of dyspareunia and sexual distress in women with endometriosis and noted the severe impairments that endometriosis causes to women’s sexual functioning ,25. For The results are also supported by conceptual models, such as the Fear Avoidance Model (FAM) ,29, whicWhile large, our sample is one of convenience and caution needs to be taken in the interpretation of the results. In particular, prevalence estimates cannot and were not made, and the numbers of women reporting avoidance of sex and other scores across measures may not represent those of the theoretical population of interest. However, it is reasonable to assume the pattern of the relationships identified in this study will be similar in other samples of women with endometriosis. Additionally, the findings are consistent with the existing body of research on endometriosis, sexual concerns, and distress. The present sample was recruited online through endometriosis organizational webpages and support groups. This may have resulted in a sample with more severe endometriosis symptomology and therefore a greater need to seek out information and support. Our advertised study criteria stated we were seeking women with a formal diagnosis of endometriosis, which means that women with endometriosis-related symptoms who have not had a formal diagnosis were excluded from the sample. How this affects the results is uncertain, however, if the symptoms experienced by those without a diagnosis are similar to those reported here, there is reason to expect a similar pattern or results. Further, in this paper we report on women who have a self-reported diagnosis of endometriosis, meaning that the reported diagnosis was not accompanied by a medical report independently confirming the veracity of the self-reported diagnosis; consequently, this may result in some women who have not been formally diagnosed completing the survey, for example, women who are in the process of being diagnosed or women who believe they have endometriosis, but not clinically confirmed. However, the self-report data on endometriosis have been found to be highly accurate in studies where medical register data are not available . FinallyNotwithstanding the limitations, the present study provides preliminary evidence on the often-considerable extent of women’s sex-related problems and distress due to their endometriosis symptomatology. Better medical and counselling services may be needed to ameliorate the negative impact of endometriosis on women’s sex lives. In the absence of a cure for endometriosis, approaches for reducing and managing dyspareunia and distress are needed, if only in the form of short-term pain relief. The impact of dyspareunia on women’s sex lives not only affects their physical and mental wellbeing but impacts on intimate relationships and family. More research is needed in this understudied area. Work that seeks to understand the impact of endometriosis-related pain on partners and family is needed, as wellbeing is further compromised if personal relations suffer. Additionally, research on pain-reduction treatments that can allow women to have and enjoy sex with their partners if even for limited periods, appear to be urgently needed.


To analyze the development process of small incision lenticule extraction (SMILE) surgery in a 12-year period.We conducted a literature search for SMILE research from 2011 to 2022 using the Science Citation Index Expanded (SCIE) of the Web of Science Core Collection (WoSCC). The VOS viewer, and CiteSpace software were used to perform the bibliometric analysis. Publication language, annual growth trend, countries/regions and institutions, journals, keywords, references, and citation bursts were analyzed.A total of 731 publications from 2011 to 2022 were retrieved. Annual publication records grew from two to more than 100 during this period. China had the highest number of publications (n = 326). Sixty-five keywords that appeared more than four times were classified into six clusters: femtosecond laser technology, dry eye, biomechanics, visual quality, complications, and hyperopia.The number of literatures has been growing rapidly in the past 12 years. Our study provides a deep insight into publications on SMILE for researchers and clinicians with bibliometric analysis for the first time. Small incision lenticule extraction (SMILE) is the newest laser vision correction procedure, where the refractive lenticule cut by a femtosecond laser is extracted through a small corneal incision . The basBibliometrics involve scientific summarization of the literature through intuitive charts, which makes it easy to understand the countries, institutions, authors, journals, and hotspots of related disciplines. This study aimed to analyze the research progress in SMILE surgery over the last 12 years through bibliometrics.We conducted a literature search for SMILE research from 2011 to 2022 using the Science Citation Index-Expanded (SCIE) of the Web of Science Core Collection (WoSCC) to identify SMILE-related publications, limited to “article” and “review”, over the past 12 years (from 2011 to 2022) with no language restriction. Our search strategy was as follows: Topic = . All retrieved records were downloaded on May 14, 2022.2).The annual number of publications, type of documents, and languages on SMILE studies were analyzed using CiteSpace 6.2.1 . The impact factors of the journals were provided by the 2021 Journal Citation Reports . Elements of SMILE research, including countries/regions, keywords, journals, and main co-cited journals, were identified via VOS viewer 1.6.15 . A publication was assigned equally to all participating countries/regions or institutions when it was completed by collaborations between more than one country/region or institution. Network maps for countries/regions, institutions, journals, and the main co-cited journals were generated by the VOS viewer in addition to cluster analysis and density maps for high-frequency keywords. On the bibliometric maps generated by the VOS viewer, different nodes represent elements, and the larger the size of the node, the higher the number or frequency of elements is. A line, which connects two nodes, reflects the relationship between different elements, and its thickness indicates the strength of the relationship. Nodes of different colors represent different clusters. Parameters of the VOS viewer were set as follows: fractional counting at the counting method, ignoring documents with too many authors (maximum number of authors per document: 25). Microsoft Office Excel 2019  was used to manage data. The correlation between the year and the number of articles was expressed by the linear correlation coefficient . A significant correlation between the number of studies and the year of publication was found with a high coefficient of determination (R2 = 0.62).Outputs of the annual publication with an upward trend are shown in The top 10 countries or regions, and institutions among the 604 institutions in 45 countries are shown in n = 326), followed by the United States (n = 140), Germany (n = 81), India (n = 68), and France (n = 58). As shown in A total of 45 countries/regions contributed to SMILE research. China published the highest number of papers , followed by the Journal of Cataract and Refractive Surgery (n = 98), and BMC Ophthalmology (n = 48). Among 1144 co-cited academic journals, five had more than 1000 citations, and all of them were from the United States. The Journal of Refractive Surgery had the most co-citations (n = 4427), followed by the Journal of Cataract and Refractive Surgery (n = 3928), Investigative Ophthalmology & Visual Science (n = 1252), Cornea (n = 1217), and Ophthalmology (n = 1155).Seventy-seven scholarly journals published papers on SMILE research. Over 250 papers were published in the top two journals, both of which were published in the United States . The JouJournals  with a publication number greater than or equal to three (T = 3) were used to construct the citation network map, which can be divided into five clusters with different colors .Journals  with co-citations greater than or equal to 25 (T = 25) were used to construct the co-citation network .A total of 686 hotspot keywords for SMILE research were extracted with a frequency of occurrence of 1720. Subsequently, 65 keywords that appeared more than four times were included and classified into six clusters on the map , includiThe top 10 co-cited references in SMILE research are listed in The top 25 citation bursts pertaining to the development of SMILE were identified from 2011 to 2022 . The incBibliometrics is helpful for understanding the evolutionary process of a discipline. Through keyword analysis, we found that the research keywords for SMILE surgery can be classified into six clusters: femtosecond laser technology, dry eye, biomechanics, visual quality, complications, and hyperopia. These keywords reflect the main concerns of clinicians and researchers regarding the development of SMILE surgery. Thus, we have discussed the development of SMILE in the following order: basic information and six clusters.Journal of Refractive Surgery and Journal of Cataract and Refractive Surgery ranked first and second in the lists of the most productive and co-cited journals, respectively.Studies on SMILE surgery peaked in 2020. The number of articles published in various countries is mostly on the rise, indicating the rapid development of SMILE. Among them, China has the largest number of papers. This may be due to an early start of SMILE surgery in China. Currently, SMILE has become the most common corneal surgical method for myopia correction in China, and more than three million SMILE surgeries have been completed in China. Therefore, it is not surprising to find that Chinese research institutions occupy the top four of 10 seats with good international collaboration. The United States is potent enough to mention here, as SMILE surgery was approved by the United States Food and Drug Administration (FDA) in 2016 . In addiin situ keratomileusis (LASIK) flap making. Thereafter, the FLEx  , 33, OcuThe visual quality of SMILE surgery has been widely studied. Aberration is the most commonly used method for evaluating visual quality. Many studies have shown that a smaller spherical aberration was induced by SMILE compared to LASIK , 38, 39,Astigmatism is another important research topic. Unlike LASIK, in which an infrared-guided pupil tracking system is used during the surgical process, SMILE mainly depends on the surgeon’s judgment. Consequently, the comparison of astigmatism vector analysis between the two surgeries has attracted much attention. Although there is no unified conclusion at present, it is reported that there is slight inferiority and more under-correction during SMILE than during LASIK when treating low-to-moderate astigmatism, and a comparable rate of under-correction when treating high astigmatism , 46. ComComplications of SMILE are a constant concern, especially postoperative complications such as corneal ectasia. Other common postoperative complications include dry eyes and diffuse lamellar keratitis .Initially, intraoperative complications gained more attention than postoperative ones, as a certain learning curve is required for surgeons performing SMILE. In 2014, Ivarsen et al.  publisheThe main highlight of SMILE is the characteristic small incision. Compared to the approximately 20 mm incision in LASIK, a small incision design guarantees a reduction in flap-related complications, such as flap loss and flap displacement. In addition, it also reduces damage to the corneal nerves. Compared with LASIK, the recovery time of corneal sensation and dry eye symptoms after SMILE has been proved to be shortened through clinical research and experimental research , 51.Treatment of hyperopia with SMILE is not easy. The result of the earliest attempt using FLEx was not satisfactory. By enlarging the transition zone in SMILE, its stability is improved, and the refractive outcomes are similar to those of LASIK , 53. At For correction of hyperopia, an important and attractive surgical correction is the transplantation of lenticules obtained from the SMILE procedure . LenticuThe number of literature has been growing rapidly in the past 12 years. Our study provides a deep insight into publications on SMILE for researchers and clinicians with bibliometric analysis for the first time.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.TH and XZ: conceptualization. LZ: data curation. TH and LZ: writing original draft preparation. All authors: reviewing and editing.


Syzygium aromaticum (clove) has been used as a dental analgesic, an anesthetic, and a bioreducing and capping agent in the formation of metallic nanoparticles. The main objective of this study was to evaluate the antimicrobial effect in oral microorganisms of biogenic silver nanoparticles (AgNPs) formed with aqueous extract of clove through an ecofriendly method “green synthesis”. The obtained AgNPs were characterized by UV-Vis (ultraviolet-visible spectroscopy), SEM-EDS (scanning electron microscopy–energy dispersive X-ray spectroscopy), TEM (transmission electron microscopy), and ζ potential, while its antimicrobial effect was corroborated against oral Gram-positive and Gram-negative microorganisms, as well as yeast that is commonly present in the oral cavity. The AgNPs showed absorption at 400–500 nm in the UV-Vis spectrum, had an average size of 4–16 nm as observed by the high-resolution transmission electron microscopy (HR-TEM), and were of a crystalline nature and quasi-spherical form. The antimicrobial susceptibility test showed inhibition zones of 2–4 mm in diameter. Our results suggest that AgNPs synthesized with clove can be used as effective growth inhibitors in several oral microorganisms. Candida albicans [streptococci, which constitute 47–85% of the cultivable cells found during the first four hours after professional tooth cleaning); as plaque oxygen levels fall, the proportions of Gram-negative microorganisms tend to increase [Streptococcus, Lactobacillus, Lactococcus, Enterococcus, Staphylococcus, Corynebacterium, Veillonella and Bacteroides stand out for being responsible for various oral conditions [Syzygium aromaticum (Clove) is employed in Indian ayurvedic medicine, Chinese medicine, and western herbalism, while in dentistry, its essential oil is used as an anodyne (painkiller) for emergencies. Clove oil is a pale-yellow liquid with a characteristic odor and taste. It consists of 81–95% phenols (eugenol with about 3% of acetyl eugenol), sesquiterpenes , and small quantities of esters, alcohols, and ketones [The ideal properties of an antibacterial coating include prolonged activity, high levels of bactericidal and bacteriostatic activity, ability to act against a wide spectrum of bacteria, biocompatibility, and low in vivo toxicity ,2,3,4,5.albicans , Recentlalbicans . Regardialbicans . The foralbicans ; these ralbicans . Moreovealbicans . Over 70albicans . This mealbicans ,41. The albicans . The bacincrease . In the nditions . Silver nditions ,46. Syzy ketones ,50,51,52 ketones , which iHerein, AgNPs were synthesized using aqueous clove extract, as a reducing and stabilizing agent, taking advantage of the AgNPs antimicrobial properties in synergy with the clove dental applications as an analgesic and anesthetic. The green-synthesized AgNPs were characterized by ultraviolet-visible (UV-Vis) spectrometry, scanning electron microscopy–energy dispersive X-ray spectroscopy (SEM-EDS), transmission electron microscopy (TEM) and ζ potential. The antibacterial activity of the AgNPs against Gram-positive and Gram-negative microorganisms and yeast were tested by the disc-diffusion method.The reduction of silver ions and formation of AgNPs occurred after silver nitrate solution was placed in contact with the clove aqueous extract, followed immediately by a change in color of the suspension, from colorless to yellow. This process was carried out under ambient conditions. It is relevant to mention that no stabilizing or capping agent was used.The spectra were recorded when both the color and absorption intensity of the colloidal samples remained constant, as shown in The characterization technique was consistent with the EDS analysis. AgNPs generally showed absorption peaks at approximately 3 keV .TEM was employed to characterize the size, shape, and morphology of the synthesized AgNPs, which resulted to be quasi-spherical, with sizes ranging 4–16 nm, with a mean size of 10 nm and a standard deviation of 4.27 nm .The electrostatic stabilization of the AgNPs was estimated by measuring their ζ potential values, which were found to be in the range of −15.7 to −16.2 mV.Candida albicans, which turns out to be really important. In The biogenic AgNPs were tested for antimicrobial activities against Gram-positive, Gram-negative bacteria and yeast, presenting similar inhibition zones in all cultures. The inhibition zones produced by the AgNPs displayed halos of 2–4 mm in diameter. The control group (clove extract) did not show any antibacterial effect only antifungal effect . This laE. coli, where the antibacterial activity is completely inhibited until the last treatment.Through this study, we were able to determine both the maximum effective concentration (MEC), as well as the minimum inhibitory concentration (MIC), where we can observe the effectiveness of the NPs at different concentrations against the different microorganisms mentioned above . SpecifiEnterococcus faecalis. Meanwhile, Mansourian and Rana used clove extract against C. albicans and compared it to nystatin. In both cases, the results obtained with the clove extracts were more effective than the substances they were compared to. The most probable pathway for AgNPs biosynthesis is that the flavonoids, from the clove buds, act as reducing agents when they encounter Ag+ ions. The electrons are transferred and the reduction process occurs, leading to the formation of AgNPs. It is well known that flavonoids also prevent agglomeration and stabilize the AgNPs in aqueous solution [Clove is one of the most valuable of all spices, and it has been used for centuries as a food preservative and for medicinal purposes, as an analgesic and antispasmodic, with eugenol being the main compound responsible for this activity. This plant represents one of the richest sources of phenolic compounds such as eugenol, eugenol acetate, and gallic acid (75–77%) ,55,56,57solution ,22,23,58solution ,59. Uponsolution , Deshpansolution , and Bajsolution  producedsolution ,49.According to UV-Vis spectroscopy results, in the first 20 min of reaction, there was an incipient reduction in which the SPR could already be observed. This may be attributed to the high availability of reducing agents such as eugenol in the aqueous extract. During the next six hours of reaction, the SPR was clearly observed at 447 nm, indicating the formation of AgNPs. After six hours of reaction, SPR with a defined shape appears at 447 nm, indicating that the NPs now have a defined shape and size, compared to plasmons at 431 nm at short reaction times, indicating incipient nanoparticle formation. Measurements were made approximately once every five minutes to verify the AgNPs kinetics of formation.EDS analysis of the AgNPs confirmed the presence of metallic Ag see , accordiThe HR-TEM image in Streptococcus mutans, the main causal agent of tooth decay and periodontitis, is found in 70–90% of the population. Meanwhile, Staphylococcus aureus is found in patients with bacterial endocarditis and cellulite. Enterococcus faecalis is present in most failed root canal treatments. Escherichia coli has been isolated from salivary gland infections, while Candida albicans is found in one in every 1000 patients attending dental consultation and also in stomatitis associated with the use of dental prostheses. Taken together, these bacteria are responsible for various opportunistic infections in immunocompromised patients. In this study, the antibacterial activity of AgNPs against four types of bacteria and one yeast was investigated. The inhibition zones were similar in all cell cultures. Biological tests of AgNPs against test strains showed that they have a significant effect on the growth of Gram-positive and Gram-negative bacteria. The latter have a layer of lipopolysaccharides at the exterior, while underneath lies a thin layer of peptidoglycan. Thus, a potent antimicrobial effect can be determined in the microdilution in broth study that emphasizes the antibacterial and antifungal effectiveness of the AgNPs as shown in Escherichia coli having microbial effect until the last concentration of NPs. On the other hand, we observed bacterial growth of the Streptococcus mutans strain from the third highest concentration, and also the following Staphylococcus aureus and Enterococcus faecalis; on the other hand, we see that the antifungal effectiveness of the AgNPs against Candida albicans is low but not null. Several studies indicate [The microorganisms selected in this study for microbiological tests are part of the normal and pathogenic microflora of the oral cavity. indicate ,65,66 thindicate ,68. This3) . The AgNPs were directly synthesized with the clove  extract using a simple green synthesis procedure. Initially, various concentrations were tested until the optimum conditions were established.In this experimental study, the chemical precursor used was silver nitrate ; the reaction was completed within a few minutes.A 10 mM solution of AgNOThe UV-Vis analysis was performed using a spectrophotometer , which was operated at a resolution of 1 nm at room temperature. The spectral range was 300–800 nm. In this way, the kinetics of the reduction were followed until stable NPs were obtained.The final product was sonicated for 30 min to break up larger nanoparticle agglomerates; then, the particles were dried in a vacuum at room temperature (20 °C) prior to analysis. The NPs were attached to aluminum stubs with conductive tape, coated with carbon, and observed under SEM  with secondary electrons at ×100, ×500, and ×3000 magnification that was operating at 20 kV. EDS analysis was developed.TEM was obtained via a JEOL JEM-2100 microscope . Samples for the TEM examination were prepared by placing a drop of the suspension on a copper grid (300 mesh) coated with carbon film, and allowing it to dry under ambient conditions.Zeta potential measurements were determined using the Zetasizer 2000 . The voltage applied to drive the electrodes of the zeta cell was 150 V capillary electrophoresis. The sample was prepared by injecting approximately 2 mL solution into the cell.Staphylococcus aureus, Streptococcus mutans, Enterococcus faecalis) and Gram-negative microorganisms (Escherichia coli) and yeast , which are commonly present in the oral cavity and are responsible for important conditions in oral health. The experiments into antimicrobial activity were carried out as proscribed by the Clinical and Laboratory Standards Institute [The bacterial strains used in this study were obtained from the stock culture collection of the Biochemistry laboratory at the School of Dentistry within the National Autonomous University of Mexico (UNAM). The strains were originally collected from clinical samples of the oral cavity of patients from the previously mentioned institution. These strains are native to central Mexico, having all been characterized through a set of culture media assays and biochemical tests. They included Gram-positive  plates using sterile cotton swabs. The sterile paper discs were saturated with 10 μL of AgNPs (0.849 mg/mL) that had been prepared 24 h previously. In addition, three tubes with AgNPs that had been prepared 7, 14, and 21 days before the antimicrobial tests were used to saturate the paper discs and placed on agar plates. The disc impregnated with extract of clove was used as a positive control. After 24 and 48 h of incubation at 37 °C, the microbial susceptibility was determined through the measurement of any noticed inhibition zones. The assays were performed in triplicate .The research protocol was reviewed and approved by the Ethics Committee of the Center for Research and Advanced Studies in Dentistry.5 CFU/mL) excluding controls. Subsequently, 100 μL of AgNPs (0.849 mg/mL) were placed at the beginning and seven serial microdilutions were made from the 100 μL of AgNPs. These assays were performed in triplicate in four wells for each concentration and strain. Inoculated microplates were incubated at 37 °C with continuous shaking at ~200 rpm for 24 h. The presence or absence of turbidity in each well was presented to the naked eye. The minimum concentration in the wells is taken as the MIC and the maximum effective concentration of MEC was identified by determining the lowest concentration of antimicrobial agent that reduces the viability of the initial bacterial inoculum by 99.9% or a log reduction in inoculum count [The antimicrobial capacity of AgNPs were determined following the dilution method of the broth . Selectium count .Sizygium aromaticum show strong antibacterial activity. It is important to highlight that the nanoparticle generation method does not represent a strong environmental impact, it is very easy to carry out and, above all, very economical. In addition, this research has shown that AgNPs synthesized by this method are effective against the five most common microorganisms present in the oral cavity, these microorganisms are responsible for many oral health disorders, and we are sure that this research can contribute to the development of new antimicrobial agents for dental health or medical use, the routes of administration and cytotoxic assays will be exposed in future research because the expectations of this material are very high.AgNPs synthesized from aqueous extracts of


SD = 1.68; range: 18–36). They were asked to complete self-report questionnaires measuring FA, personality traits (Big Five), self-esteem, narcissism, self-efficacy, social anxiety, loneliness, and well-being indicators. Due to the low content, factorial, and clinical validity, the first three items were excluded from the Polish version of the mYFAS. The six-item mYFAS demonstrated measurement invariance, allowing for meaningful comparisons between genders and yielded almost identical prevalence rates for men and women. The hierarchical multiple regression analysis showed that, narcissism, and social anxiety predicted FA in both genders, whereas important gender differences in antecedents were also noted. In addition, FA was associated with body mass index (BMI) and most of the well-being indicators, even after controlling for relevant variables. The findings suggest that our modified analytical approach allows researchers to measure FA using a valid, useful, and simple tool.The Yale Food Addiction Scale (YFAS) is the most commonly used scale for measuring food addiction (FA). The previous approach to the YFAS and its subsequent versions assumed dichotomization of items, separating addiction symptoms and clinical significance items, and factorial validity testing on a subset of items. In this paper, we discuss the drawbacks associated with these procedures. In addition, we present a different analytical approach to investigate the validity of the modified YFAS (mYFAS) along with an alternative scoring method that overcomes limitations related to the previous approach. After establishing the structure of the mYFAS, we investigated the potential antecedents and consequences of FA separately for men and women. The sample consisted of 1182 Polish undergraduate students  with a mean age of 20.33 years ( Despite a lack of conceptual clarity on food addiction (FA) and an explicit and agreed definition of this concept , FA is gThis abnormal pattern of excessive consumption is also defined as hedonic eating behavior involving consuming highly palatable foods in quantities beyond homeostatic energy requirements  to obtaiThe concept of FA remains controversial. Some researchers question whether food or eating can be addictive if it is necessary to human survival and whether there are particular foods that are “addictive” and, therefore, akin to drugs of abuse , while oIn the recent meta-analysis  conductePrevious results on the gender-related prevalence of FA have been inconsistent, with some reporting higher FA among women ,24,25, oThere are few data on the relationships between personality traits (Big Five) and FA. In a non-clinical sample of Asian university students, lower agreeableness and higher extraversion were correlated with addiction-like eating . In a stAs for other psychological variables related to FA, Omar et al.  noted thRegarding the impact on psychological functioning, FA may lead to functional negative consequences, associated distress, and cause a risk to psychological well-being . It is aThe YFAS is the most commonly used scale for measuring FA . It was There are a few challenging issues with the YFAS that could be addressed with a different analytical approach. Firstly, the items are divided into addiction symptoms and clinical significance indicators. Some psychopathologies are diagnosed in such a way, e.g., schizophrenia which requires the presence of certain symptoms such as delusions (criterion A) and clinically significant impairment (criterion B)  (p. 99).In the case of the YFAS, items measuring symptoms with a frequency scale are subsequently dichotomized to provide diagnostic thresholds based on the analysis of the relation between scores on the YFAS items and increased risk for broadly defined eating pathology, including binge eating disorder (BED), anorexia nervosa (AN), bulimia nervosa (BN). The YFAS factor analyses are usually conducted on these dichotomized items ,52. SuchThis latter phenomenon is well documented in the literature, as women interpret similar overeating behaviors differently, reporting more loss of control than men . It likeIn addition, dichotomization narrows down the variance of scores reducing the precision of measurement. Specifically, in the YFAS and the mYFAS clinical significance items were measured as dichotomous answers “yes” or “no,” differently to symptoms’ items which were measured on a frequency scale. This has been modified in the YFAS 2.0  to creatWhen developing the YFAS and its subsequent versions, clinical significance items measuring a harm component were not included in factor analyses . MoreoveThe practical consequences of the above-described approach to the YFAS scoring are that: (1) measurement and scoring are complex; (2) symptom count scores instead of total scale scores are used for correlational analyses, which is related to a few problems. The most important one is that this score does not represent FA because, according to the scoring method, clinical significance (harm) should also be present. Moreover, because thresholds are based on comparisons with a wide range of eating pathology and factor analyses are conducted on dichotomized scores, this score likely does not represent pure FA but may capture other non-addictive eating pathologies or even non-pathological overeating habits or perceptions. Finally, the variance of scores is substantially limited, affecting any advanced statistical analyses.The objective of this study was two-fold: (1) to test the validity and reliability of the Polish version of the mYFAS among female and male students, including its factorial structure and measurement invariance between genders, as well as criterion validity separately for women and men, and (2) to compare FA between female and male students, including its prevalence, potential risk factors and consequences. To overcome the aforementioned limitations of the YFAS and its modifications, in this study, we modified the response scale in the mYFAS clinical significance items to be the same frequency scale as other symptoms (similarly to the YFAS 2.0). Subsequently, we assumed that all items measure one latent construct of FA without division into symptoms and clinical significance items. This is congruent with (1) the theoretical assumption that one construct representing addictive disorder is measured; (2) the way addictive disorders are diagnosed in DSM-5; (3) the theoretical assumption that items with a Likert-type scale measure continuous variables representing the frequency of particular behaviors characteristic for FA; and (4) harm dimension should permeate to some level most of the items. Apart from improving measurement validity, such assumptions also have considerable practical significance because they (1) simplify measurement and scoring; (2) allow the use of a total score on the mYFAS in more advanced statistical analyses; and (3) have a higher variance of scores, enabling more precise and nuanced analyses of associations with other variables. This way, a simple, valid, and useful measure can be obtained. Our approach assures that the measurement is congruent with the addiction framework and allows for valid differentiation between addictive and non-addictive problematic eating behaviors (such as BED) or non-problematic eating habits or perceptions. A recently developed FA scale used procedures congruent with our approach to measuring this problematic behavior .We formulated the following hypotheses: Hypothesis 1 (H1).The Polish version of the mYFAS will yield a single factor solution representing one construct of FA, and the items will be invariant between genders. Hypothesis 2 (H2).Women will show higher prevalence rates of FA than men. In addition, our study examined the potential antecedents and consequences of FA.Based on the previous studies on the associations between psychological variables and FA ,37,39,40Hypothesis 3 (H3).Narcissism, social anxiety, and loneliness will be positively associated with FA, whereas emotional stability, agreeableness, conscientiousness, self-esteem, and self-efficacy would be negatively associated with FA.Since previous studies noted gender differences in the symptoms of addictions , Big FiHypothesis 4 (H4).There will be some differences between genders in terms of the antecedents of FA.Regarding the consequences of FA and considering the results of previous studies on predictors of well-being ,67,68, wHypothesis 5 (H5).Higher levels of FA would be associated with lower levels of the general quality of life, health quality, sleep quality, and higher levels of perceived stress, general anxiety, hopelessness, and BMI, even after controlling for age, Big Five personality traits, self-esteem, narcissism, self-efficacy, social anxiety, and loneliness.n = 515, 43.6%), Technological University of Gdańsk , and Gdańsk University of Physical Education and Sport . Most students were from first  and third  year of study, with similar number of students from second  and fourth  year, and minority of fifth  year students; 3 students (0.3%) did not declare the year of study. Students were from the following courses of study: law , physical exercise , administration , electronics, telecommunications and informatics , construction , ocean engineering , automatics and robotics , economic analysis , biomedical engineering , medical biology , biology , German philology , transport , Russian studies , and other .The sample consisted of 1182 undergraduate students  from three major universities in the Pomerania region: University of Gdańsk . The average BMI for those who were sampled was 22.42 kg/m2 . Of the 1157 participants, 852 (73.6%) were of normal weight ; 94 (8.1%) were underweight (BMI < 18.50 kg/m2), and 211 (18.3%) were overweight (BMI ≥ 25 kg/m2). Inclusion criteria were undergraduate student status and at least 18 years of age. Exclusion criteria were not being a student or being underaged.Data from 25 participants (2.1%) were removed due to missing data exceeding 30%. The final sample comprised 1157 full-time students . The mean age of the participants was 20.33 years   to measuTo measure the Big Five personality traits , we used the Polish version of the Ten Item Personality Inventory (TIPI) . Each peSelf-esteem was measured with a single item developed based on an item from the World Health Organization Questionnaire of QOL (WHOQOL-BREF) . The itePerceived narcissism was measured with the Single Item Narcissism Scale (SINS) , which cSelf-efficacy was measured with two items based on the General Self-Efficacy Scale (GSES) : “I can Social anxiety was measured with a short Polish version of the Liebowitz Social Anxiety Scale , based oLoneliness was measured with the Three-Item Loneliness Scale (TILS) . The TILThree aspects of quality of life were measured in the current study: general quality of life, health quality, and sleep quality. We used three ultra-brief scales developed by Atroszko  based onPerceived stress was measured using the Perceived Stress Scale-4 (PSS-4), which is the short form of the PSS-10 . PSS-4 cGeneral anxiety was measured with a short anxiety scale developed for the Health and Retirement Study . The scaHopelessness was measured with a Polish version  of the S2.BMI was measured by asking respondents to report their height and weight and using the following formula: BMI = kg/mData were collected using convenience sampling during the winter term in 2016. The research team member (P.A.A.) contacted lecturers via email and asked them to disseminate the survey among the students during their own lectures or classes. Before completing the questionnaires, each student was informed about the purpose of the study, the anonymous and voluntary participation, and the right to withdraw from the study at any point without any consequences. While giving participants sufficient information about the research project and the voluntary participation, all research participants gave their permission to be part of a study by completing the questionnaires and turning them back to the researchers. Completing questionnaires took about 15–20 min. No incentives were given to participants.Non-probability sampling was used in the present study. However, relatively large, diverse in terms of course fields and years of study, and balanced in terms of gender the sample of students took part in the study, assuring high statistical power and relative generalizability of the results. The advantage of the sampling method was that almost all students from a particular course participated in the study, thus limiting bias from non-responders which in practice is relatively high even in randomly drawn or stratified samples.The study was approved by the institutional review board at the Institute of Psychology at the University of Gdańsk . The study was part of a multiphase research project on behavioral addictions that consisted of subsequent data collections for the six-year period from 2013 to 2018. All procedures performed in our study were in accordance with the 1964 Helsinki declaration  and its later amendments or comparable ethical standards.The analysis started with the imputation of missing data using the expectation-maximization (EM) algorithm  implemenn1 = 579) and (n2 = 578), using the Select Cases function implemented in IBM SPSS [2 test for gender (p = 0.80) and of the t-test for age (p = 0.25) showed no demographic differences between the two samples. The first sample was used to determine the factor structure of the mYFAS using confirmatory factor analysis (CFA) with the maximum likelihood estimation with robust standard errors (MLR). All nine items were included in the analyses. A single-factor model representing one latent construct of FA was assumed. The second sample was used to test if the findings would replicate. A model with a single latent factor was tested. The following model criteria were employed: χ2 divided by degrees of freedom (χ2/df), Comparative Fit Index (CFI), Tucker–Lewis Index (TLI), Root Mean Squared Error of Approximation (RMSEA), and Standardized Root Mean Square Residual (SRMR). The model fits the data well when: χ2/df ≤ 3, CFI and TLI ≥ 0.95, RMSEA < 0.06 and SRMR < 0.08 [2/df ≤ 5, CFI and TLI ≥ 0.90, RMSEA < 0.08 and SRMR < 0.1 [In the next step, the sample was randomly divided into two parts  and 2 (“I worry about cutting down on certain foods.”), and poor model fit with item 3 (“I feel sluggish or fatigued from overeating.”), which also showed lower factor loadings than other items, these three items were removed from the scale. The remaining six-item model showed a good fit. Very similar and high (>0.70) item loadings were observed. Based on that, a tau-equivalent model was subsequently tested alongside a congeneric model in the validation subsample. It assumes equal item loadings, which supports the notion that all items measure FA with the same and high precision.2, which is overly sensitive to sample size [, modification indices were inspected to identify the noninvariant items and to refine the structural models [After establishing the structure of the short Polish version of the mYSAS, we performed a multi-group CFA (MGCFA)  in the fple size ,99. MI wple size ,99. If ml models . If the l models ,97. CFA l models .Next, the prevalence of FA based on different approaches to establishing cut-off scores was calculated. First, we calculated the prevalence of FA for nine items using the original cut-offs . To meetIn the last step of the analyses, the potential predictors and outcomes of FA were tested. Considering the substantial differences between genders in terms of patterns, predictors, and consequences of behavioral addictions ,102 and r between 0.1 and 0.3) or moderate (r between 0.3 and 0.5) at most, whereas correlations of items 4–9 were mostly strong (r > 0.5).For men, higher scores than for women were noted for items 5, 7, and 9, whereas women scored higher than men on items 1 and 2. An inspection of descriptive statistics of the mYFAS items, including in particular the values of means, skewness, kurtosis, and correlation coefficients, suggested that items 1–3 might measure a different construct than the remaining items.2/df = 7.71, CFI = 0.864, TLI = 0.818, RMSEA = 0.108  suggested that the model with a single latent factor composed of nine indicators did not fit the data well. Moreover, the standardized factor loadings for items 1–3 were 0.20, 0.37, and 0.51, respectively, being lower than other items in the scale and lower than the recommended threshold of 0.60–0.70 [2/df = 1.92, CFI = 0.989, TLI = 0.981, RMSEA = 0.040  and high and very similar standardized factor loadings . The model fit the data well: χ2/df = 2.68, CFI = 0.979, TLI = 0.965; RMSEA = 0.054 , and SRMR = 0.024. All standardized factor loadings exceeded the value of 0.7 , and SRMR = 0.045), with each item loading of 0.77. Cronbach’s alpha coefficient for the six-item mYFAS was 0.89 in the first subsample and 0.87 in the second subsample.To further support the six-item mYFAS structure, CFA was repeated in the second sample ( 0.7 see . Moreovep = 0.069).The results of MGCFA suggest that latent mean values obtained from men and women may be compared meaningfully . To compThe prevalence of FA based on different approaches to establishing cut-off scores is presented in Means, standard deviations, percentages, and correlation coefficients of the study variables for both genders separately are presented in p < 0.001; women: β = 0.16, p < 0.001), extraversion , narcissism , and social anxiety . Moreover, among men, FA was negatively associated with self-efficacy , whereas among women it was negatively associated with agreeableness , conscientiousness , and self-esteem , and positively with loneliness .The results of regression analysis for FA showed that the predictors explained a total of 15.7% of the variance of FA for men and 11.2% of the variance of FA for women . In the p < 0.001; women: β = −0.11, p = 0.008), general anxiety , and hopelessness  for both genders. Moreover, after adjusting for other variables, FA predicted perceived stress  among men, and sleep quality  among women. The explained variance of well-being indicators ranged from 18% for sleep quality to 44% for hopelessness among men and from 12% for health quality to 37% for hopelessness among women. FA was also a significant predictor of BMI , even after adjusting for other variables. The explained variance for BMI was 7.5% for men and 6.5% for women.The objective of the study was to investigate the validity and reliability of the Polish version of the mYFAS among female and male students, including its factorial structure and measurement invariance between genders, as well as criterion validity separately for women and men. Moreover, the aim of this research was to compare FA between female and male students, including its prevalence, potential risk factors and consequences. To the best of our knowledge, it is the first study to provide a very detailed psychometric analysis of the mYFAS and the first to analyze potential similarities and differences in FA between genders comprehensively.The mYFAS response scale was somewhat modified to evaluate its factorial structure and psychometric properties more adequately. The original structure of the scale did not yield an acceptable factorial solution. The short version of the scale showed a very good model fit, including a tau-equivalent model with the assumption of the equality of loadings on all items. Moreover, scalar measurement invariance allowing for meaningful comparisons between genders was supported (H1 substantiated). Arguably, the removed items also showed the lowest content validity as they measure eating patterns that are not always pathological and can be relatively frequent in the general population. In fact, they were originally designed this way by authors to assess behaviors that could plausibly occur occasionally in non-problem eaters. However, while all items that originally were rated on the frequency scale were described this way, CFA showed that the three first items, in fact, very poorly capture problematic eating and may not be diagnostic at all. Importantly, women scored significantly higher on the first two items (removed), while men scored significantly higher on items 5, 7, and 9, measuring clinically relevant symptoms such as withdrawal or functional impairments.Consequently, the prevalence analyses showed that FA rates were 1.5 times higher among female students than male students when estimated using the original scoring method and based on the original 9-item scale see . This fiSubsequently, the short version of the mYFAS was used in a series of regression analyses in which FA was a potential outcome and a potential cause of deteriorated well-being. These analyses were conducted separately for female and male students because a considerable body of evidence has suggested that addictive disorders function differently between genders . A receNotably, however, there were differences in potential specific antecedents of FA between female and male students (H4 substantiated). Among women, low agreeableness, conscientiousness, and self-esteem, together with high loneliness, were significantly related to FA. On the other hand, among men, none of these were related to FA in the final model; instead, self-efficacy stood out as showing the relatively strongest association. While self-esteem was negatively related to FA among men in the penultimate step of the analysis, self-efficacy likely explained this covariance when it was added in the last step. This was not the case among women. These results suggest a clear distinction between socially oriented communion variables and an agentic variable , differeOn the other hand, men addicted to food may use eating as a coping mechanism with their sense of low generalized self-efficacy and hopelessness. These findings are congruent with previous analyzes showing that the female profile of addictions includes more socially oriented behaviors, particularly those associated with social perception by others, such as SNUD, study addiction, and shopping addiction . Women tIn both genders, FA showed significant zero-order correlations with all indicators of deteriorated well-being and health . This supports the criterion validity of the short version of the mYFAS. However, both for women and men, it was related only to lower health quality and higher general anxiety, hopelessness and BMI above and beyond relevant personality traits and psychosocial variables . Moreover, there was a statistically significant relationship with perceived stress above and beyond other variables in the model among men and sleep quality among women. The mean difference in betas from the last step of regression analyses across all well-being indicators (0.12) showed that generally, the associations were relatively stronger for men, particularly in terms of health quality and perceived stress.Consistent with previous research ,53,54, fThere are two most important theoretical and practical implications of the current study. First is that the measurement of FA can be simplified, and at the same time, it may improve its validity and usefulness, including the availability for advanced and nuanced statistical analyses. The second is that there might be no differences in the prevalence of FA between genders; however, there are different potential risk factors of FA among women and men, and the potential severity disparities in the disorder need further clarification.This has crucial importance since, thus far, most research on FA has tended to analyze both genders together. Such practice clearly creates more confusion and bias in the way FA is understood. While there are some common risk factors for all addictions , women and men clearly differ in how they become addicted, how addictions develop and are maintained, in relapse risks and treatment outcomes ,113,114.In terms of strengths, to the best of our knowledge, this is the first study to investigate in detail the psychometric properties of the mYFAS with a different theoretical and analytical approach. Commonly used valid and reliable psychological questionnaires were applied. A relatively large, diverse and balanced in terms of gender sample of students took part in the study, assuring high statistical power and relative generalizability of the results. It may lay a foundation for future developments of the YFAS and diagnostic criteria for FA, as well as studies on gender differences related to this problematic behavior.Regarding the limitations of the present study, the sample was not representative of the general population of undergraduate students. Moreover, all the data collected were self-reported, which is related to typical weaknesses of such data, e.g., common method bias. The data were cross-sectional, which precludes any conclusions about causal relationships among the variables. In addition, the data can be considered relatively old since they were gathered in 2016. Nonetheless, the discussed limitations did not seem to prevent identifying the most important and expected effects.It can be concluded that the short six-item version of the mYFAS is a valid and reliable measure of FA risk, invariant between genders, and therefore allowing for meaningful comparisons between men and women. It is the first study to examine in detail the theoretical implications of the psychometric properties of the mYFAS analyzed with a different scoring method. It showed that the original version of the scale may be problematic due to the low content, factorial validity, and clinical validity of the first three items. Measurement of FA can be considerably simplified, and at the same time, its validity and usefulness for advanced and nuanced statistical analyses may be improved.FA may show similar prevalence rates between genders among undergraduate students. The higher prevalence and seemingly higher severity of FA among women found in previous studies may stem from using non-diagnostic criteria/items used to measure its risk. These may overestimate disordered eating behaviors due to the tendency of women to perceive common non-pathological eating habits or perceptions as problematic. It is likely related to cognitive biases driven by cultural standards of a slim body image. At the same time, addictive eating among men and its consequences may be systematically neglected as more studies are conducted on women.FA has common risk factors among women and men . Importantly, however, there are clear differences in specific risk factors. Communal variables such as low agreeableness and high loneliness together with low self-esteem and conscientiousness are significantly related to FA among women. On the other hand, the agentic trait of low self-efficacy is associated with FA among men. This has crucial importance since, thus far, most research on FA has tended to analyze both genders together. Such practice clearly creates more confusion and bias in the way FA is understood.Moreover, in both genders, the six-item mYFAS was related to all indicators of deteriorated well-being and health , and it was related to most of the indicators above and beyond other personality traits and variables previously found to be consistently associated with deteriorated psychosocial functioning . The associations tended to be somewhat stronger among men.While it may complicate research, future studies should analyze FA and likely most of the addictive behaviors separately for men and women. More representative samples from the general population, and longitudinal studies, including detailed analyses of common and specific risk factors, clinical manifestations, and developmental trajectories, are warranted. Prevention and treatment programs accounting for gender differences in FA are highly needed. More research on FA among men is needed. More advanced analyses of the psychometric properties of FA scales may allow for the development of valid criteria for diagnosing FA and measures based on them.