Finally, multiple regression analysis showed that two personality traits, conscientiousness and openness to experience were the strongest predictors of the flow state. The implications for future flow-related research in the field of applied linguistics are discussed.Teaching is one of the professions that creates opportunities for individuals to experience flow, a state of complete absorption in an activity. However, very few studies have examined ESL/EFL teachers’ flow states inside or outside the classroom. As such, this study aimed to explore the quality of experience of 75 EFL teachers in flow and also examine the relationships between their emotional intelligence, the Big Five personality traits and the flow state. To this end, the teachers filled out recurrent flow surveys for a week, and also completed emotional intelligence and the Big Five personality questionnaires. It was found that reading was the major flow trigger outside the classroom and teaching and delivering lessons was the most significant flow-inducing activity for the teachers inside the classroom. Furthermore, correlations and independent samples  Recently, increasing attention has been paid to the issue of teacher motivation as an important way of improving the effectiveness of teaching and learning in the English as a Foreign Language (EFL) classroom . There iflow, as coined by teacher flow occurs when a teacher is completely absorbed in the act of teaching. Their attention is fully invested in the task at hand, as they lose their sense of self-awareness. This happens when feedback is ample in the classroom environment, giving the teacher the opportunity to adjust the level of teaching to that of the learners, which subsequently leads to adjustments made on the part of learners to meet the new level of challenge  teachers’ flow state is almost non-existent. In the only study carried out to date, In the neighboring fields of psychology and education, a number of studies have been conducted on primary and high school teachers’ flow states. A few studies have compared the frequency and intensity of flow among teachers with those in other professions . In a stVery few empirical studies of flow have been conducted in the field of applied linguistics to date, but there are signs this might change in the years to come. Firstly, the broadening of the field to include holistic concepts and their interrelations has provided more space for situated studies that examine the bigger picture of the phenomena under study . In lineMost of the existing studies in applied linguistics examine task flow. Emotional intelligence is defined as: “the ability to monitor one’s own and others’ feelings, to discriminate among them, and to use this information to guide one’s thinking and action” , p. 189.Being able to enter flow is emotional intelligence at its best; flow represents perhaps the ultimate in harnessing the emotions in the service of performance and learning. In flow, the emotions are not just contained and channeled, but positive, energized and aligned with the task at hand.However, despite the fact that the connection between emotions and flow is self-explanatory (as stated above), empirical studies investigating the relationship between emotional intelligence and flow are scarce. In applied linguistics, emotional intelligence has been explored with regard to learners’ and teachers’ experiences inside and outside the classroom , teacherWith regard to personality traits, five broad, overarching traits have been found to subsume other lower-order traits and characteristics . These tIn the field of psychology, a few studies have examined the relationship between flow proneness and the big five factors . In thisHowever, findings regarding the rest of the big five measures  are somewhat mixed . ExtraveTaking into account the importance of teachers’ flow states in creating optimal classroom environments and enhancing the growth and well-being of their students, the uniqueness of teaching EFL compared to other subjects and the fact that more research investigating the connections between flow, the Big Five and emotional intelligence is needed, this study seeks to answer the following research questions:(1)What is the quality of experience of “a purposeful sample of Iranian” EFL teachers inside and outside the classroom?(2)What is the relationship between the EFL teachers’ flow state and their Big Five personality traits?(3)What is the relationship between the EFL teachers’ flow state and their emotional intelligence?Seventy-five EFL teachers teaching adult classes in the city of Mashhad, in Northeastern Iran participated in this study. The participant sample comprised of 54 female and 21 male teachers . The teachers taught in four language schools and testing centers across the city and had higher-intermediate to advanced language proficiency as measured by the proficiency tests they had taken in their teaching institutions. All of the teachers were L1 speakers of Persian/Farsi. As communicative language teaching/learning is not the primary objective of higher educational institutions in Iran, a sizable population of young adults attend private language schools and testing centers to learn conversational English or prepare for international exams such as IELTS and TOEFL. The teachers who participated in this study taught in four popular schools within this context. They were mostly undertaking their higher education studies in Iranian universities and were teaching part-time in the language schools. All of the participants were in their twenties or thirties.At the outset of the study, a 90-minute informational session was arranged with the teachers, where the researcher explained the main objectives of the study and provided training on the concepts included in the questionnaires and the ways of filling them out. All 75 teachers gave written consent to (a) participating in this study, (b) filling out the questionnaires, and (c) receiving multiple text messages a day as per the design of the study. Two of the questionnaires were completed in the language schools and one was filled out multiple times at home.In this study, flow was measured through the multi-time Experience Sampling Method ESM; . The ESMThe ESF used in this study consisted of 38 items, 30 of which could be numerically coded and consisted of Likert-type scale items on affect , activation , cognitive efficiency , and motivation  , p. 38. In this study, a Persian adaptation, which is a shorter 90-item version of BAR-On EQ-i , 2004, wA Persian adaptation of the 60-item NEO Personality Inventory was used in this study. The reliability of this questionnaire has been measured by As per the ESM , every pAt the end of the week, the researcher collected the ESFs and administered an EQ-i and a revised NEO Personality inventory. The former took approximately 30 minutes while the latter took 40 minutes to complete. To ensure confidentiality and anonymity, each participant had been assigned a code that they wrote on their ESFs, EQ-i, and NEO Personality questionnaires.More than 4,000 ESFs were coded numerically, and the data were entered on SPSS 19. As per the previous studies , responst-tests were run to investigate the relationships between flow and EQ and flow and the Big Five. For the t-tests, the teachers were divided into the high flow (autotelic) and low flow (non-autotelic) groups based on their flow scores throughout the sampling week. The t-tests indicated the difference between the means of the autotelic and non-autotelic groups for the EQ-i scales and the Big Five personality traits. To find out the best predictors of the flow state, multiple regression analysis was run.Correlations and independent samples The open-ended sections of the ESFs increased the reliability of the quantitative section by providing qualitative data about the kinds of activities the participants were engaged in at the time of receiving the text message. Data about these activities were coded by hand by the researcher. The emerging categories were identified, and percentages based on the frequency of occurrence of each activity in the data were calculated.Overall, around 21% of the ESFs completed indicated that the participants were in the flow state. Approximately, 12% of the ESFs revealed that the flow state had occurred outside the classroom and 9% signaled the occurrence of flow inside the classroom. The most prominent flow triggering activity outside the classroom was reading textbooks see . Inside Other activities such as attending university classes, talking to family members and loved ones and pursuing hobbies (happening outside the classroom), and having positive interactions and answering questions and doing exercises (occurring inside the classroom) were less often reported as flow triggering by the participants in the sample.With regard to the extensiveness of the two most frequently reported flow-inducing activities across the sample, 85% of the participants reported being in flow at least once while reading outside the classroom and 87% reported being in flow at least once while teaching during the sampling week.r = 0.428, p = 0.00) and neuroticism had a significant reverse relationship with flow . As seen, the correlation between agreeableness and flow was statistically insignificant .With regard to correlations between the Big Five and the teachers’ flow state, it can be seen that all Big Five factors except agreeableness had a statistically significant relationship with flow see . Conscier = 0.397, p < 0.0001), and the weakest was in the case of intrapersonal .As it could be seen in t-test indicated that the difference between the means of high flow (autotelic) and low flow (non-autotelic) groups was significant for all personality traits except for agreeableness  and low flow (non-autotelic) groups for each EQ-i subscale. As it could be seen in The independent samples R2 values, conscientiousness and conscientiousness and openness to experience were the best predictors of the flow state. It can be stated that teachers’ scores on conscientiousness predicted 22% of the variance in flow scores and their scores on conscientiousness and openness to experience predicted 33% of the variance in flow scores. The effect size for conscientiousness is medium, f2 = 0.28, and for conscientiousness and openness to experience is large, f2 = 0.49.To find out the best predictors of the flow state, multiple regression analysis was run see . FiguresThis study examined a sample of 75 EFL teachers’ quality of experience in flow and the existing relationships between their flow experiences, their emotional intelligence and their Big Five personality traits. With regard to the first research question, it was found that the teachers’ quality of experience did not involve too much variation and complexity within the week they were sampled. Outside the classroom, “reading textbooks” (with the aim of preparing for university courses), and inside the classroom, “teaching and delivering lessons” were the two most frequently reported flow-triggering activities. Hobbies and interacting with their family members, loved ones, friends and colleagues did not seem to make a significant difference in their recurring flow experiences. The teachers’ age range and their educational status might help shed light on this. They were in their twenties or thirties and were teaching part-time while pursuing their higher education studies on a full-time basis (at the time this study was conducted). Therefore, the two main professional activities in their lives, i.e., studying and part-time teaching seem to have triggered the majority of their flow experiences whereas other activities did not seem to create too much flow. Moreover, the percentages of the teachers’ flow experiences inside and outside of the classroom, especially the percentages of their main flow triggers  both inside and outside the classroom, and it is high time that future studies explore flow proneness in other language teaching contexts to increase the understanding of the field of the nature of flow-triggering activities undertaken by language teachers around the world.Secondly, two Big Five personality traits, namely, conscientiousness and openness to experience were the strongest predictors of the flow state. This shows that teachers with greater self-discipline, attentional focus and goal orientation and stronger imagination, curiosity and inquisitiveness might experience more flow and also create the conditions for their students to be in the flow channel more frequently than teachers who do not possess these qualities. Finally, it was found that all emotional intelligence facets correlated significantly with the flow state which highlights the importance of teachers’ emotional stability and emotional regulation for entering and sustaining the flow state. Overall, the more the conditions for experiencing teacher flow are explored and the teachers’ inner psychological states, as well as task characteristics and contextual elements are examined, the higher the possibility that the flow state will be recreated in the language classroom, leading to increased opportunities for the growth, engagement and well-being of learners and their teachers.This study has several implications for language teaching. Firstly, it is important for language teachers to continually increase their knowledge of flow theory and seek to recreate the flow state in the classroom given the benefits of the flow state for themselves and their students. One way they can achieve this is through the administration of tasks that challenge (but do not overwhelm) their learners , 1990. TMoreover, although personality traits have traditionally been treated as relatively stable constructs in psychology , recent Finally, in this study, emotional intelligence was found to be correlated with the flow state. Therefore, it might be helpful for EFL teachers to practice emotional regulation and stress management strategies to enable themselves (and their learners) to more easily and frequently experience flow. In this regard, mindfulness might help teachers regulate their emotions and enhance their well-being . MoreoveThis study has a few limitations. Firstly, personality was measured based on Moreover, it is commonly assumed that when learners are in flow, language learning is happening, but that assumption needs to be tested more extensively . One dirIt was suggested that teachers practice conscientiousness and openness to experience in order to enhance the frequency and intensity of their flow experiences. To this aim, the usage of metacognitive strategies such as mental contrasting, if-then scenarios and episodic future thinking were recommended. A direction for future studies to take in this respect would be to explore whether teachers  can enhance their flow proneness by utilizing the above-mentioned strategies. As such, it would be interesting to see whether the introduction of these strategies in teacher workshops could increase teachers’ flow scores especially those who consistently score lower in their ESFs .Finally, it is recommended that future studies consider the whole picture when it comes to investigating language teachers’ flow state. If the aim is to study teachers’ behavioral patterns, it might be a good idea to explore the interactions of their personality traits and the characteristics of the classroom tasks they assign as well as the qualities of the learning context that trigger teacher and learners’ flow states. Clarifying the nuances of these relationships will help the flow state be better understood and recreated within language learning classrooms in the future.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Participants provided written informed consent to participate in the study.The author confirms being the sole contributor of this work and has approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Coping with difficulty conceiving and the ensuing fertility treatments is a stressful experience that impacts many aspects of women’s lives. On the basis of Lazarus and Folkman’s model of stress and coping and Schaefer and Moos’s model of personal growth, and in view of the sparse literature on cultural aspects of infertility and personal growth, this study examined the relationship between stress on the one hand and personal growth and life satisfaction on the other among Arab and Jewish Israeli women. Furthermore, it investigated the moderating role played by perceived stigma, coping flexibility, cultural orientation , and ethnicity. Two hundred five Arab and Jewish Israeli women undergoing fertility treatment completed self-report questionnaires. The results show that Arab women reported higher levels of personal growth and individualism than Jewish women. In the whole sample, a linear negative relationship was found between stress and life satisfaction, and a curvilinear relationship was found between stress and personal growth. In addition, perceived stigma, collectivism, individualism, and coping flexibility were found to moderate the association between perceived stress and personal growth. The findings provide further understanding of personal growth in the context of infertility, showing that personal resources and perceptions are more important than cultural differences in this regard. Coping with difficulty conceiving and the ensuing fertility treatments is a highly stressful experience that impacts various aspects of a woman’s life. Even after successful treatment, self-image, familial and social relationships, and perceptions of life may be adversely affected ,2. AccorThe current study draws on both Lazarus and Folkman’s  model ofThe inability to conceive or failure to carry a baby to term after at least one year of regular and unprotected sexual intercourse is challenging and stressful in most societies . Israel Couples coping with fertility problems often report emotional distress . The senPersonal growth , also caRecent studies reveal the complex curvilinear relationship between perceived stress and growth. They show that intermediate levels of stress are related to higher levels of personal growth . Rozen aIn recent years, researchers have begun to examine personal growth following a variety of stressful, although nontraumatic, life events, including fertility problems . AlthougLife satisfaction reflects the way in which the individual perceives and values their life  with resAlthough research indicates links between fertility treatment and both personal growth and life satisfaction, the factors that contribute to these positive outcomes are still unclear. Tedeschi and Calhoun  contend Studies demonstrate that the ability to be flexible, that is, to utilize different strategies as specific situations require, constitutes a resilience factor for coping with stress-related events . It has Studies conducted among women undergoing fertility treatment show that those who act in a more flexible way by employing several strategies of active coping report less stress and more positive (re)thinking . FurtherThe repercussions of fertility problems frequently result from social constructions rather than from the medical problem itself , indicatThe biblical commandment “be fruitful and multiply” is central to Judaism. Consequently, considerable medical and financial efforts are invested in bringing children into the world, both on the national and the individual level. Moreover, similar to the situation in many Western countries, Jewish Israeli society tends toward individualism, with the family generally characterized by democratic relationships and relatively permissive parental control. This reflects the belief that life experience, hardship, and adversities shape one’s personality, an attitude that encourages tackling challenges, confronting problems, and choosing an active and direct way of coping ,31.On the other hand, the Arab population in Israel , is in transition from a traditional to a more modern society. Despite the process of modernization, the family and collective are still favored over the individual . This teAmong Muslim couples, a woman’s infertility can serve as legitimate grounds for divorce, or for the taking of a second wife by the husband, which is permitted by Islamic law . When itA stigma is a negative perception that differentiates a person from others. It includes three interdependent components: cognitive (the stereotype); emotional (prejudice); and behavioral (discrimination). Negative beliefs and feelings toward an individual or group may lead to discriminatory behavior, which, in turn, preserves and inflames existing stigmas and prejudices . ResearcThis problem may be even more severe in Arab society, where parenthood is generally expected to follow immediately on marriage and motherhood is viewed as the most meaningful experience in a woman’s life . Thus, A(1)A negative linear relationship would be found between level of stress and life satisfaction, so that the higher the level of stress, the lower the satisfaction with life.(2)A curvilinear relationship would be found between level of stress and personal growth, so that moderate levels of stress would be associated with higher levels of growth and high or low levels of stress would be associated with lower levels of growth.(3)Coping flexibility would be positively associated with both life satisfaction and personal growth, so that the higher the level of coping flexibility, the higher the satisfaction with life and growth.This study examined the associations between stress and personal growth and life satisfaction among Israeli women undergoing fertility treatment, comparing Jewish and Arab women and exploring the moderating role of several personal and cultural factors. In light of the literature, we hypothesized the following:(1)Is there a difference in the levels of stress, personal growth, and life satisfaction between Arab and Jewish women?(2)Is the cultural orientation associated with personal growth and life satisfaction?(3)Is the perceived stigma attached to fertility treatment associated with personal growth and life satisfaction?(4)What is the unique and combined contribution of the study variables to personal growth and life satisfaction?(5)Do coping flexibility, cultural orientation , perceived stigma, and ethnicity  moderate the association between stress on the one hand and personal growth and life satisfaction on the other?In addition, given the lack of previous findings on which to rely, the following questions were investigated exploratively:The sample consisted of 205 women aged 18–40 from throughout Israel who were undergoing fertility treatment. Of these, 105 were Arab and 100 were Jewish. Most were married and did not have children. The distribution of the participants in both groups on the categorical and continuous sociodemographic variables is presented in Perceived Stress Scale (PSS) [le (PSS)  includesle (PSS)  and 0.84Posttraumatic Growth Inventory (PTGI) [y (PTGI)  was usedSatisfaction with Life Scale (SWLS) [e (SWLS)  consistsCoping Flexibility Questionnaire (COFLEX) [(COFLEX)  containsIndividualism–Collectivism Scale (ICS) [le (ICS) , used tole (ICS) . In the Stigma Scale for Receiving Psychological Help Questionnaire (SSRPH) [ (SSRPH) , adapted (SSRPH) , consist (SSRPH)  and 0.67A sociodemographic questionnaire was used to obtain data regarding the participants’ personal and familial characteristics, including age, spouse’s age, education, years of marriage, religion, level of religiosity, period of infertility, cause of infertility, and stage of treatment.After receiving the approval of the University Review Board, the data were collected by posting a request in Hebrew and Arabic on social media and Internet parenting forums along with a link to the questionnaire. The criteria for inclusion in the study were being a woman of 18 or older with fertility problems who was currently undergoing treatment. The women were assured that participation was voluntary, that they could stop completing the questionnaire whenever they wished, and that no identifying information would be collected. Due to the method of data collection, the response rate cannot be assessed. A total of 225 questionnaires were received. After exclusion of those that were not fully completed or were submitted by women who did not meet the study criteria, 205 questionnaires were included in the analysis.p < 0.001), a multicollinearity test indicated that no problem was created by using both of these independent variables. Perceived stress was entered in Step 2, and coping flexibility, cultural orientation, and perceived stigma were entered in Step 3. In Step 4, moderation was examined by five interactions: stress X perceived stigma; stress X coping flexibility; stress X individualism; stress X collectivism; and stress X ethnicity. Finally, the possibility of a curvilinear relationship between stress and personal growth (Hypothesis 2) was examined by means of a 3-step hierarchical regression, with background variables entered in Step 1, a linear relationship between stress and growth in Step 2, and a quadratic relationship between these variables in Step 3.All analyses were conducted using IBM SPSS version 27. First, one-way ANOVAs were conducted to compare the research groups (Research Question 1). Next, Pearson correlations were calculated to examine the relationships between the variables (Hypotheses 1 and 3 and Research Questions 2 and 3). Then, the unique and combined contribution of the study variables to personal growth and life satisfaction (Research Question 4) and the moderating role played by coping flexibility, cultural orientation, and stigma (Research Question 5) were examined by means of two hierarchical regressions. Where significant interactions were found, their source was examined by PROCESS, a procedure for examining direct and indirect effects . In bothp = 0.073; Jewish: chi-square = 104.41, df = 86, p = 0.086).In a preliminary stage, the missing data were completed by a process of multiple imputation. To ensure that the data completion remained unbiased, we examined the missing values template. Dividing the sample between the two populations showed that values were missing completely at random  in both The means and standard deviations of the variables in the two study groups, along with the results of the ANOVAs comparing the groups (Research Question 1), are presented in The results of the Pearson correlations between the study variables for each study group for the whole sample appear in Two four-step hierarchical regressions were conducted to examine the unique and combined contribution of the independent variables to personal growth and life satisfaction (Research Questions 4 and 5). The results are presented in The regression for personal growth showed that the variables explained 40.3% of the variance in this outcome. In Step 1, the background variables contributed 15% to the explained variance, with being an Arab and higher economic status both associated with greater growth. Stress in Step 2 contributed a further 5.4% to the explanation of the variance, so that the higher the level of stress, the lower the level of personal growth. In Step 3, coping flexibility, stigma, and cultural orientation  added 11.9% to the explained variance, with higher coping flexibility and collectivism significantly associated with higher personal growth. In Step 4, with an additional 8% of explained variance, four interactions between stress on the one hand and stigma, coping flexibility, individualism, and collectivism on the other were found to be significant. The interaction between stress and ethnicity was not significant.The PROCESS procedure  was thenWith respect to life satisfaction, the independent variables explained 47.2% of the variance. In Step 1, the background variables accounted for 21.7% of the variance, showing that the better the woman’s economic status and the fewer treatment cycles she had undergone, the higher her life satisfaction. Stress in Step 2 contributed an additional 18.8% to the explained variance, with higher stress associated with lower life satisfaction. Step 3 added 5.6% to the explanation of the variance: higher coping flexibility and collectivism were associated with higher life satisfaction. None of the interactions entered in Step 4 were found to make a significant contribution to explaining the variance in life satisfaction (Research Question 5).A further hierarchical regression was performed to examine Hypothesis 2 concerning the association between stress and personal growth. The results of this analysis appear in As The current study sought to examine the implications of the stress evoked by fertility treatments on the personal growth and life satisfaction of Jewish and Arab women and investigate the moderating role played by perceived stigma, coping flexibility, cultural orientation, and ethnicity. Although the psychological consequences of infertility have been discussed extensively ,14,15, cThe findings indicate a greater inclination toward individualism, perceived stigma, coping flexibility, and personal growth among Arab women in fertility treatment than among Jewish women. The fact that Arab women perceived themselves to be more individualistic than did the Jewish participants is surprising given that Jewish society as a whole is considered more individualistic than Arab society, which is typically described as collectivist ,53. HoweFurthermore, difficulty conceiving may undermine an Arab woman’s sense that her life is clearly mapped out, dictated by the norms of procreation and family expansion, which are seen not only as supreme values , but alsThis explanation is supported by the finding that Arab participants reported higher perceived stigma than Jewish women. As the demand for procreation is anchored in religion and tradition, any deviation from the norm is negatively perceived . This fiWithin this complex social reality, the Arab participants in our study also reported greater growth than the Jewish participants, most of whom defined themselves as secular. Research shows that the resources of religion and religious belief moderate the negative influences of stressful life events in general and coping with fertility problems in particular ,60. ThusAnother possible explanation for the higher level of personal growth reported by Arab women lies in the claim that individuals with limited resources tend to experience greater growth . Those wOn the other hand, no difference was found here between the Arab and Jewish participants with respect to the level of stress. This is consistent with a study of female victims of domestic violence, which found that Arab and Jewish participants reported similar levels of mental distress . Both grIt is important to note that the associations between stress and both personal growth and life satisfaction were not moderated by ethnicity. In other words, notwithstanding the differences between Arab and Jewish women in the level of their reported perceptions, both their reported level of stress and the associations of stress with the dependent variables were similar.As predicted by Hypothesis 1, a significant negative linear relationship between level of stress and life satisfaction was found in the sample as a whole and was not moderated by ethnicity. This general finding is consistent with previous studies ,67 suggeIn confirmation of Hypothesis 2, a curvilinear relationship was found between stress and growth, indicating that the greatest growth was associated with moderate levels of stress. This finding, reflecting the complexity of this relationship, is in line with the results of previous studies  and suppAs predicted (Hypothesis 3), coping flexibility was found to directly contribute to personal growth, in line with previous research ,70. ThisFurthermore, coping flexibility was found to play a moderating role in the relationship between stress and personal growth, showing that only among women with lower coping flexibility was greater stress associated with less growth. It is possible that women dealing with infertility who demonstrate little coping flexibility repeatedly employ the same coping strategy, which may not always be suitable for the situation . Such woThe cultural orientation of collectivism was also found to directly contribute to growth among all participants (Research question 2). People oriented toward the values of the collective tend to see themselves and their life goals as integral to their family and community, and therefore involve themselves in social life and rely on it at times of hardship . The litIn addition, both collectivism and individualism were found to moderate the relationship between stress and personal growth, but in different directions. Thus, only among women with a low sense of collectivism was greater stress associated with a lower level of growth, and only among women reporting high levels of individualism was there a negative relationship between stress and personal growth. The sense of failure and inferiority that often accompany the need for fertility treatment is heightened by social norms that threaten the woman’s sense of identity and femininity and may lead to a sense of alienation and isolation from society .This reality may lead to constant tension between the desire to maintain privacy and the desire to share in order to receive support and comfort from the social group . InevitaNo direct relationship was found here between perceived stigma and personal growth. This corresponds with the trend in the research that views growth as a product of a combination of factors, including internal resources and environmental variables ,20. ExamTaken together, the findings concerning the moderating role of the cultural aspects may indicate that more vulnerable and sensitive contexts, such as a perceived social atmosphere of stigma and lower regard for communal needs, as reflected in a lower assessment of collectivism and a higher sense of individualism, heighten stress to a degree that makes it difficult to experience personal growth. In other words, there may be some circumstances in which stress and growth are unrelated and others in which they are inversely related. Considering this option against the background of the curvilinear relationship found between stress and personal growth suggests a complicated association whereby there may be different “segments” of relations between stress and growth: women who experienced a moderate level of stress during their fertility treatments reported the greatest personal growth; very low levels of stress were unrelated to growth and became more relevant as the level of stress rose to moderate levels; and higher levels of stress were associated with lower personal growth. This study therefore provides hints of circumstances or contexts that may trigger, or alternatively hinder, the experience of growth among women undergoing fertility treatment. As this is only initial evidence, more research is needed to validate this suggestion and explore additional conditions that may enable personal growth.In further confirmation of Hypothesis 3, a positive relationship was found between coping flexibility and life satisfaction. This is consistent with the results of a study conducted among people being treated for inflammatory bowel disease, where coping flexibility was found to enable patients to adjust more quickly to their new reality, and therefore report higher levels of life satisfaction, than those with little flexibility .In contrast, no direct relationship between perceived stigma and life satisfaction was found. This runs counter to the findings of a previous study reporting a negative relationship between perceived stigma and quality of life among HIV patients . HoweverA positive relationship was also found between collectivism and life satisfaction. People with a sense of community belonging who perceive their support system to be available feel comfortable relying on it in a crisis. Not only does it provide them with practical aid and assistance in problem-solving, but it also serves as a reminder of their strength in difficult times. Such support has been found to contribute to psychological health and increase the individual’s life satisfaction . Thus, iHowever, none of the three factors was found to play a moderating role in the relationship between stress and life satisfaction. This suggests that the relationship between these variables is affected more by external, objective, and quantitative factors  and lessSeveral background variables were found to contribute to the two outcomes. First, the more treatment cycles the participants had undergone, the lower the sense of life satisfaction they reported. This is in line with the extensive literature pointing to the negative implications of fertility treatment, which is often perceived as traumatic . The lenIn addition, higher economic status was associated with both higher growth and higher life satisfaction. This is probably due to the fact that fertility treatment represents a heavy financial burden stemming from expensive medical tests and medications, lost workdays, and other costs that are not subsidized . Women wCertain limitations of the study should be noted. First, it relies on self-report questionnaires, a subjective measure that may lead to a social desirability bias. Secondly, the data were collected at a single point in time, which did not allow for an examination of changes over time. Future longitudinal studies might reveal the trajectory of growth and life satisfaction over the course of fertility treatment. Thirdly, convenience sampling does not allow us to collect extended medical data on participants. Future studies may combine data from women with information collected from medical records to allow a fuller picture of the physical condition of women in fertility treatments. Finally, the study employed a quantitative methodology, which provides a broad picture but does not enable us to draw causal inferences. Qualitative studies using in-depth interviews might enable a deeper understanding of the multidimensional phenomena of personal growth and life satisfaction among women in fertility treatment. Future studies might also engage the women’s spouses to reveal their point of view in this challenging process.The current study is, to the best of our knowledge, the first to examine the personal growth and life satisfaction of Arab and Jewish women undergoing fertility treatment. The differences found in the pattern of the independent variables associated with the two outcomes support the claim in the literature that they are distinct constructs. Whereas personal growth is the result of an internal process involving introspection and the ability to look to the future, life satisfaction is associated with current feelings and perceptions.The major contribution of this study lies in the differences found between Arab and Jewish participants in personal growth, as well as the added value in the findings that Arab women report on higher coping flexibility and individualism. The findings further our understanding of the relationship between stress, personal growth, and life satisfaction. These findings also promote the development of a unique body of theoretical and empirical research that explores the role of culture in coping with fertility problems. This knowledge can be used to design culturally sensitive interventions for different populations of women undergoing the same stressful experience, through the understanding of the available resources which each culture provides its members with.


Bilingualism has been shown to induce neuroplasticity in the brain, but conflicting evidence regarding its specific effects in grey matter continues to emerge, probably due to methodological differences between studies, as well as approaches that may miss the variability and dynamicity of bilingual experience. In our study, we devised a continuous score of bilingual experiences and we investigated their non-linear effects on regional GM volume in a sample of young healthy participants from an immersive and naturalistic bilingual environment. We focused our analyses on cortical and subcortical regions that had been previously proposed as part of the bilingual speech pipeline and language control network. Our results showed a non-linear relationship between bilingualism score and grey matter volume of the inferior frontal gyrus. We also found linear increases in volumes of putamen and cerebellum as a function of bilingualism score. These results go in line with predictions for immersive and naturalistic bilingual environments with increased intensity and diversity of language use and provide further evidence supporting the dynamicity of bilingualism’s effects on brain structure. First, a matrix of correlations was estimated between the 41 bilingualism items in our questionnaire, using yzed see . The Kaiyzed see  verifiedpromax), obtaining three factors and its factor loadings  package . GAMMs a package —i.e., th package , allowinIn a first-level analyses, we used GAMMs in which we fitted a regression spline for the main effect of bilingualism score on GM volume of each ROI, with participant as a random effect, and also considering the main effect of TIV in order to control for the different head sizes of our participants. We examined the interaction effect of bilingualism score and age on GM volumes, due to the large age range in our sample and accounting for non-linear brain changes related to age and bilingualism that have been previously reported . We alsoIn a second-level analyses, we analyzed the main effect of bilingual score on GM volumes collapsed across hemisphere, due to the lack of significant interactions with this variable at the first level, and including age, hemisphere and TIV as covariates. We also included participant as a random effect.p < 0.05 as a threshold of significance, after correcting for family-wise error rate (FWE) using the Bonferroni correction.For all our results, we considered p-values above the 0.05 significance threshold there were obtained, and the k-index was in all cases close to or above 1, which suggests that there were no significant or missed patterns in the residuals of the models , cerebellum  and IFG . Specifically, putaminal and cerebellar volumes showed linear increases as a function of increasing bilingual experiences. For GM volume in the IFG, bilingualism emerged as a non-linear predictor that showed an initial decrease, followed by an increase in the middle part of the bilingualism spectrum, and a final decrease at the end of the continuum, resulting in an “S” shaped distribution (see p < 0.05, FWE corrected; see In the second-level analyses, bilingualism score emerged as a significant predictor of GM in three structures: putamen (In the present study, we investigated the effect of quantified bilingual experiences on regional GM volumes. To do so, we focused on a healthy sample of bilinguals living in a society where both Spanish and Catalan are actively used, in contrast to environments where languages are used in more compartmentalized manner . Due to The IFG is one of the core cortical areas implicated in language control , and itsOur results also showed an unexpected increase of IFG volumes in the middle of the bilingual experience spectrum, right after the initial decrease, which itself was followed by a decrease at the highest levels of bilingual experience. This effect might be caused by a change in the nature of the cognitive demands that bilingualism poses after the first stages of bilingual experience, and before reaching full efficiency , such asOur results further corroborate suggestions that bilingualism increases the volume of the putamen , and thaSimilar to the putamen, our results also corroborate previous evidence showing GM volume increases in the cerebellum of immersed bilinguals . The cerSome major cortical regions that lacked significant changes in our results were ACC and inferior parietal cortex. The inferior parietal lobule is thought to be crucial for the integration of semantics and phonology of recently learned vocabulary , a proceTo summarize, in this study we investigated the dynamic effects of bilingualism on GM volumes of healthy participants with a wide variety of bilingual experiences, living in a naturalistic and immersive bilingual environment. We reported a non-linear relationship between IFG and bilingualism score, a pattern that largely goes in line with predictions for effects in environments with high bilingual immersion, increased diversity and intensity of language use. We also reported linear putaminal and cerebellar GM volume increases as a function of bilingualism, which might reflect a growing need to control for motor programmes and grammatical processing. Our results further support the dynamic nature of bilingualism’s effects on brain structure and show that this dynamicity is also present in immersive environments.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethics Committee of the Universitat Jaume I. The patients/participants provided their written informed consent to participate in this study.VC, CÁ, and CP contributed to conception and design of the study. VC and LM-M organized the database. LM-M performed the statistical analysis and wrote the first draft of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Cardiovascular disease is consistently ranked high among the causes of death on a global scale. Monitoring of cardiovascular signs throughout the course of a long period of time and in real time is necessary in order to discover anomalies and begin early intervention at the appropriate time. To this purpose, a significant amount of interest among researchers has been directed toward the creation of flexible sensors that may be worn or implanted and are capable of constant, immediate observation of a variety of main physiological indicators. The real-time readings of the heart and arteries' pressure fluctuations can be reflected directly by mechanical sensors, which are one of the many types of sensors. Potential benefits of mechanical sensors include excellent accuracy and considerable versatility. Capacitive, piezoresistive, piezoelectric, and triboelectric principles are the foundations of the four types of mechanical sensors that are discussed in this article as recent developments for the purpose of monitoring the cardiovascular system. The biomechanical systems that are present in the cardiovascular system are then detailed, along with their monitoring, and this includes blood and endocardial pressure, pulse wave, and heart rhythm. In conclusion, we examine the usefulness of the use of continuous health monitoring for the treatment of vascular disease and highlight the difficulties associated with its translation into clinical practice. Cardiovascular disease (CVD) and the complications that might arise from it are regarded as one of the primary causes of death on a global scale . FurtherElectrocardiograms (ECG), Doppler ultrasounds, arteriography, computed tomography (CT), and other imaging techniques, among others, are commonly used in clinical settings to evaluate cardiovascular disease (CVD), all of which are able to identify the disease accurately –9. In adAdditionally, due to issues with durability, mobile connectivity, longevity, and reliability, it is challenging to maintain a long-term collection of clinical grade individual health indicators in traditional healthcare systems –13.Consequently, to date, the need for low cost, wearable biomedical devices that reliably provide meaningful guideline health data have been a major roadblock in the promotion of the value of technology provided by the Internet of Things (IoT) in the individualized healthcare system. Significant advancements in wearable pressure sensors have been noticed over the course of the past several decades. These advancements have made it possible for these sensors to continuously and noninvasively monitor human physiological and pathological signals , 15. TheTo collect cardiac-related physiological data, biomechanical sensing devices have been the subject of substantial research . Using aRecent research has shown that wearable sensors can be directly connected to the skin surface or integrated with clothes, which is more practical and has adequate patient compliance. These investigations were conducted by a number of different researchers. In contrast, implantable sensors necessitate surgical trauma, but they offer advantages that cannot be replicated for the detection of minute forces in deep tissues. The main problems that prevent clinical applications of implantable and wearable pressure devices for diagnostics are inaccuracies in measurement and a lack of long-term durability. Additionally, in order to obtain conformal contact with the surfaces of organs and soft tissues, the biocompatibility and flexibility of the sensors need to undergo further development –20.Consequently, there is still a lot of room for growth and development in the use of biomechanical sensors for cardiac activity monitoring, notwithstanding recent optimization efforts in this area. Miniaturization in production and transmission via wireless means sensors can be implanted in the body in a less invasive fashion or worn on the body continuously to monitor a wide range of biomarkers and decrease in the need to recharge implantable sensors through the use of energy harvesting and conversion methods.Diagnostic precision was increased with the use of multimodal signals such as microvascular flow; to address the demands of personalized medication and remote monitoring in healthcare, cutting-edge technologies like machine learning and cloud computing are being coupled with real-world physiological data to create novel monitoring systems. As a result of the efforts of scientists all around the world, there is hope that chronic illness monitoring in the cardiovascular system can be accomplished with the use of implantable and wearable sensors.Latest developments in mechanical sensors for the cardiovascular system are summarized in this review. First, the characteristics and operation of four common mechanical sensors are outlined. After that, various techniques for keeping tabs on a patient's vital signs are covered, and details about the cardiovascular system's physiomechanical workings are provided. Furthermore, from an energy point of view, the potential application shift from battery-powered to self-powered sensors is considered. To wrap things up, a brief summary of why existing cardiovascular system monitoring needs to be improved is provided. The goal is to bridge the gap between mechanical sensing and the acquisition of physiological signals for the protection of cardiovascular health.There are arteries, capillaries, and veins that make up the cardiovascular system. The heart stands out among the body's organs as being unusually consistent in its form and function. The heart's powerful beating pumps enough blood to the body's tissues and organs to supply their metabolic demands. Because of this, the heart can be thought of as a series of unidirectional pumps. Based on this trait, the heart must generate adequate force to pump out blood it takes in; change the blood supply in response to the needs of the body pumped out per unit of time and guarantee a one-way flow devoid of reflux. The heart's physiological activity stems from its role as a biological pump. Reduced efficiency or, in the worst scenario, the full stoppage of physiological function will follow if any component of the pump is structurally weakened or malfunctions. The reasons of cardiovascular disease can be better understood with a more in-depth comprehension of the pumping function of the heart. Inner, middle, and exterior structures often make up a vascular wall, which is a tube that is hollow and has a structure that is made up of multiple layers of composite material that can bear the pressure of blood and is bound by extratubular tissues. Smooth muscle, elastic fibers, and collagen fibers are all the components of smooth muscle that are located in this layer, and they are largely responsible for the vessel's mechanical qualities. Vascular wall compliance is a key clinical measure of the elasticity or stiffness of the vascular system's cushioning function . In geneWearable or implanted strain sensors and pressure sensors are the primary stretchable sensors used in mechanical approaches for monitoring cardiovascular physiological parameters. These sensors rely on a variety of different fundamental sensing methods, including piezoresistive, piezoelectric, triboelectric, and capacitive , 23, 24,The principle of the piezoresistive effect is at the core of the piezoresistive sensor. The piezoresistive effect describes the modification of the output electrical impulse caused by the pressure variation in the resistivity of pneumatically materials. Another technique of detection relies on the shift in electrical resistance brought about by architectural changes caused by increased pressure of dielectric materials. Piezoresistive impact sensors are powered by external pressures that bend the dielectric substantial, which in turn changes the distribution and contact state of the internal conductive filler and, consequently, the dielectric material's resistance .Pressure sensors based on piezoresistive strain gauges have the benefit of being extremely durable. The consistency of both their functioning and their calibration may be relied upon over time. The straightforward design results in both lower costs and increased longevity. The sensors have a high level of durability, making them resistant to shock, vibration, and variations in dynamic pressure. Readout circuits are quite straightforward, which paves the way for high-resolution measurement. In most cases, the response time is less than one millisecond, and the output varies linearly with the pressure. They are capable of measuring pressures ranging from around 3 psi all the way up to about 20,000 psi; therefore, their applications are rather diverse (21 kPa to 150 MPa). Additionally, the output is consistent over time. There is the possibility of fusing the resistive elements to the diaphragm. This is a tried and tested method that has been put to good use for a considerable amount of time, but complications might arise when the adhesives are subjected to high temperatures or excessive pressure. A further possibility is to construct thin film resistors directly on the membrane itself. These are able to function well in temperatures that are higher and are better suited for use in severe environments .Incorporating the piezoelectric phenomenon, piezoelectric sensors transform mechanical forces into electrical impulses. Piezoelectric are a type of noncentrosymmetric dielectrics. The electric fields imbalance between the upper and bottom electrodes is caused by the internal detachment of positive and negative charges caused by the material deformation that occurs under stress or strain. The pattern of the potential difference is supported by this mesoscopic dipolar in the crystal lattice, which is caused by the opposite movement of the positive and negative charge centres. As a result, the potential difference can be used as a proxy for atmospheric pressure .Since piezoelectric materials convert mechanical energy into an electrical signal, they can be used to monitor a wide variety of physiological signals. They work particularly well for tracking variations in pressure over time, as many vital signs, such as the heart rate and breathing rate, are cyclical processes. Sound waves and tactile sensing both operate at pressures in the low pressure range (1 Pa–10 kPa). Intraocular pressure and cranial pressure are at the upper end of that spectrum. Blood pressure readings and some bodily motions fall into the range of systems with pressures 10–100 kPa. In order to achieve the desired pressure range and quality, piezoelectric sensors can be adapted structurally or materially .By combining the triboelectric effect and electrostatic induction, a triboelectric sensor has the capacity to provide an electric signal to pressure stimulation. The triboelectric phenomenon happens when the surfaces of two materials with different triboelectric characteristics come into touch with each other and create different polarity. The magnitude of the cost is proportional to the dissimilarity in triboelectric characteristics of the two friction materials. Triboelectric characteristics generate a potential difference proportional to the quantity of opposing charge on each surface. Electrostatic induction causes inductive charges on the electrodes, which are generated by the applied pressure. Electrical output for sensing is generated when charge moves between electrodes and eventually reaches balance through an open load .Triboelectric sensors, which can function as a self-powered device, are a rapidly developing field of technology. Triboelectric sensors are able to accurately monitor heart rates because of their excellent signal-to-noise ratios, pressure sensitivity, and high-voltage outputs achieved by turning mechanical energy into power. In addition to being lightweight because of their compact design, they also come in a wide range of materials from which to choose, including synthetic polymers, silicone rubber, silk, and cotton. Furthermore, triboelectric sensors are a practical everyday wearable gadget because of their diminutive size. Additionally, triboelectric sensors are rapidly developing with the purpose of gathering energy from human movement to power other devices. Several different types of wearable heart rate monitors based on triboelectric sensors have already been created .In order to measure the felt mechanical load, capacitive sensors alter the capacitance value of the device and capacitance, in the context of a conventional parallel plate construction. The capacitance of a capacitor can be altered by applying a specific amount of force to its electrode plates. In light of this, pressure sensing is an achievable goal based on this approach .As such, capacitive sensors use two electrodes and a compressible dielectric material to measure electrical fields. Applying force causes the gap to close and the capacitance to increase. In contrast to resistive technology, the two electrodes are separated at all times. Therefore, capacitive sensors can withstand repeated loads with minimal risk of damage.Superior stability in terms of repeatability and longevity, as well as the ability to accurately monitor low pressure levels, are just two of the benefits of capacitive sensor technology over resistive. Integration of pressure (using arrays measuring thousands of points of force) and force sensors (measuring discrete points) with consumer electronics, robotics, ergonomics, medicine, and automobiles are only few of the uses being investigated .Despite the intricacy of cardiovascular physiology, the primary function of this system is quite straightforward, to supply oxygenated blood to critical organs and tissues. Important to this process is the heart's role as a pump. Everything that happens between the start of one ventricular systole and the start of the next is called “the cardiac cycle.” Consequently, the monitoring of the biomechanical processes are taking place in the cardiovascular system, such as blood pressure and endocardial pressure, pulse wave, and heart rhythm , 30.Pressure exerted per unit area by blood against the vessel wall is what we call blood pressure. The three most important parameters in determining blood pressure are the amount of blood pressure, the pace at which blood is pumped into and out of the arteries, and the elasticity of arterial walls . SystoliGenerally speaking, a person's blood pressure will be higher in the morning (or while awake) and lower during the night (or during sleep). Stroke, heart failure, and kidney failure are just some of the cardiovascular events that may be linked to a person's blood pressure readings before and after these two periods , 32. ComHeart and blood vessel hemodynamic are intrinsically linked to blood pressure. To a large extent, blood is turbulently viscous in the flexible capillaries (aorta); therefore, most of the energy transfer occurs along the vessel walls . The preR2 = 0.78). When adopting a core shell packing method, the monitoring capabilities remain at a high level for up to 72 hours after the chest has been sealed. The in vivo biocompatibility of the device is assessed after two weeks of implantation to prove its clinical efficacy.Blood flow rate was calculated using a distinct arterial pressure tube and 17.8 mV/mmHg sensitivity, as reported by Ma et al. ; neverth−1) and strong linearity (R2 = 0.9985). Furthermore, the hierarchical structures controlled by pore size, plasma bias, and MXene concentration are confirmed to play a vital role in enhancing the sensing performance through both experimental characterisation and finite element simulation. More evidence of the created flexible pressure sensor's potential in wearable biomonitoring and health evaluation is provided by its shown ability to measure human radial pulse, as well as to detect finger tapping, foot stomping, and object identification.Using helium plasma irradiation, Wei et al.  produced−1. Over a wide range of external pressures, the device also shows increased sensitivity in comparison to an unstructured PDMS layer. The device's ultra-low detection limit of pressure is 1 Pa, and it displays a wide operating pressure range (1 Pa to 100 kPa), good working stability, quick reaction (110 ms), and high sensitivity. Also investigated was blood pressure monitoring, with tests showing that multiple oscillometric waveform signatures were produced by the devices for varying blood pressures. Thanks to its high performance characteristics, the flexible pressure sensor that was manufactured can be integrated into wearable blood pressure monitors and employed in biological settings.Using a porous dielectric layer (PDMSDIW), Kumar  demonstrFang et al.  demonstrA wireless, continuously operating blood pressure monitoring device was created by Yi et al. . IntegraUsing self-powered ultrasensitive pulse sensors (SUPSs) located at several arterial pulse locations, Xu et al.  proposed−1, and ultrafast response time of less than 5 ms are all made possible by plasma etching of PTFE to introduce surface nanowires. One hundred participants, ranging in age from 24 to 82 years and in varied states of health, had their real measurements used. The BP value was computed in real time by an enhanced genetic algorithm, and PTT was determined by subtracting the timestamps of the peaks in the fingertip and ear signals. WCSPS blood pressure readings varied by between 0.87 and 3.65 percent from those obtained using a commercial cuff-based device. All of these things prove that it is possible to have a real-time monitoring system for the cardiovascular system that is both effective and affordable.According to Meng et al. , a flexiBattery-free, wireless monitoring of arterial blood flow was recently reported by Boutry et al. . The pre−1) were achieved through the combined efforts of potassium sodium niobate (KNN) particles and a polyvinylidene fluoride (PVDF) polymer matrix. Due to the sinusoidal structure and 3D printing of the ferroelectric material, the mechanical modulus is close to the vascular level, enabling sensitive sensing of pressure changes . (11.25–225.00 mmHg). Sensitive pressure sensors can identify even the smallest changes in blood vessel motion, allowing for early diagnosis of partial occlusions (like thrombosis) and reducing the risk of implant failure.A wireless stent system incorporating soft sensors was created by Herbert et al. to suit insertion and manipulation needs in their vascular electronic system . Two str−1, and its output voltage correlated well with aortic systolic blood pressure (R2 = 0.971). Yorkshire swine adults were implanted with the PETF to monitor their blood pressure and provide a visual alert if they were showing signs of hypertension in real time. For further development of both implanted and external medical devices, the manufacture of electromechanical coupling biopolymers is essential. The first portable thrombus detector was announced in 2019 by Li's team O3 (PZT) to create an ultrathin conformal piezoelectric sensor that allows for conformal contact between the sensor and skin. Coating high quality PZT films onto a sapphire substrate, annealing the substrate, and then peeling off the PZT films to transfer them to an ultrathin polyethylene terephthalate (PET) substrate (4.8 m) is a common technique for creating thin, flexible electronics. Afterwards, gold forked finger electrodes were made and placed on top of the thin PZT substrate. Bandaging the wrist held the piezoelectric sensor that wirelessly transmitted the measured pulse signal to a nearby smartphone. With a friction layer made of nanostructured metallic copper and polymer film and an encapsulating layer of flexible polydimethylsiloxane (PDMS), Ouyang et al. [−1 and a response time of less than 4 ms, with an output voltage 7 and 2.7 times higher than the nonmicrostructured and single nanowire microstructured PTFE, respectively. At a static force of 1500 mN, the sensitivity was still up to 0.15 mV Pa−1. The UFS's superior qualities allow it to pick up on pulse pulses as tiny as those coming from a fingertip. What is more, by incorporating the UFS into mobile devices, this study has effectively provided a proof of concept for a healthcare system.To keep tabs on vitals like HR and BP in real time, Fan et al.  designedearchers . This seearchers  used Pb[g et al.  developeg et al.  is made Central to the monitoring of hemodynamically unstable patients in intensive care and surgical settings is cardiac output (CO), the volume of blood evacuated per minute from one ventricle. Some of these techniques are the clinical gold standard, intermittent pulmonary thermodilution using a pulmonary artery catheter, while others, such as ultrasonography Doppler, bioimpedance, and pulse wave analysis, are less intrusive. Patients who are hemodynamically unstable are closely monitored in the operating room and intensive care unit by measuring the volume of blood drained from a single ventricle per minute. Invasive periodic pulmonary thermodilution with a pulmonary artery catheter, noninvasive and minimally invasive ultrasonography with Doppler, and pulse wave modelling are all methods that can be used to assess cardiac output , 58.The pulmonary thermodilution method of CO monitoring is the gold standard in clinical practice since it allows for a full evaluation of cardiovascular function. However, noncardiac surgery patients with low or intermediate risk are rarely good candidates for this procedure. Transthoracic echocardiography (TTE) using ultrasound Doppler technology is now a standard monitor in cardiac operating rooms and intensive care units. TTE is a well-established method of clinical hemodynamic assessment. However, there are a few restrictions, such as the need for an appropriate ultrasound window, the reliance on an operator, and the moderately real-time monitoring. Contrarily, pulse wave analysis enables constant, real-time monitoring of CO variations. Additionally, it can be utilized for goal directed hemodynamic therapy during the perioperative period. All pulse wave monitoring techniques start with the assumption that the pressure wave has a known and consistent relationship with the measured quantity . Since tPacemakers, cardiac resynchronization treatment (CRT) devices, and defibrillators are all examples of cardiovascular implanted electronic devices (CIEDs) that play an important role in decreasing disease and death by observing, restoring, and controlling heart function , 61. EndImprovements in real-time medical monitoring will come from self-powered sensors that require little to no external power but still have good performance while monitoring physiological signals . Long term in vivo cardiac implant safety was assessed by Li et al. using an implantable nanogenerators (i-NG) system made of soft and flexible nanogenerators . Pigs haIn patients with heart failure and reduced cardiac function, monitoring changes in endocardial pressure (EP) by a minimally invasive method is of critical clinical importance. For continuous EP monitoring, Liu et al.  presentePart of the next frontier in medicine is the use of implantable medical electronics that can both monitor and treat disease. Dong et al.  suggesteLi et al.  describePulse waves, blood and endocardial pressure, and heart rhythms are the primary uses of mechanical sensors that hold improvement for use in evaluating cardiovascular health. In conclusion, mechanical sensors have the potential to improve cardiovascular health monitoring. Depending on the application, wearable sensors can be sewn into garments or adhered to the skin itself. The second option is preferable due to the fact that it is more practical and has sufficient patient compliance. Implantable sensors, on the other hand, require surgical trauma in order to be placed, but they offer benefits that cannot be imitated and are particularly useful for the detection of minute forces in deep tissues. Implantable and wearable pressure devices that are employed in diagnostics face the primary issues of ensuring accurate measurement and maintaining their functionality over an extended period of time. These are the obstacles that must be overcome before these gadgets can be used in clinical settings. In addition, there is a requirement for further improvements to be made to the sensors' adaptability and cytocompatibility in order to accomplish conformal contact with the surfaces of soft tissues and organs. As a consequence of this, the use of biomechanical sensors in the monitoring of CVD still faces a great deal of difficulties and a substantial amount of opportunity for development, and there is a tendency toward optimization.A cardiac monitoring system needs to be able to function for many years in a highly dynamic environment, where it is constantly deformed and undeformed, contacted and uncontacted, in order to be therapeutically transferable.It is crucial to think about mechanical biocompatibility; some designs are not healthy for the human body because they put too much pressure on the organs or the musculoskeletal system. This is especially crucial for heart adjacent devices; therefore, it is common practice to test them in animal models using no power to ensure they do not interfere with operation. Analysing the adhesion and delamination of the electrodes, as well as the responses between the materials in the body and the components of the cardiac monitoring system, are all areas that need more study. Taking into account a wide variety of drive frequencies, including frequent changes between low and high, is particularly important for cardiac sensing devices to maintain reliable operation.One of the key drivers behind the advancement of the cardiac monitoring system is the provision of sustainable energy to construct implantable medical devices that can be used for a lifetime. Since the device will be implanted and remain in the body for years or perhaps decades, it must pass stringent in vivo evaluation requirements for biocompatibility, implantation method and site, and long-term endurance. As it stands, there are no unified evaluation criteria or methodology in place, and these assessments are neither systematic nor comprehensive. The surgical technique must be standardized appropriately. There are several potential locations for implanting a device; they include the heart, lungs, diaphragm, and aorta; therefore, it is important to establish the optimum implantation site and fixation approach.Using energy collecting and transformation systems, we can achieve the autocharging detecting system, which significantly decreases the required charging time for implantable sensors. One of two targets, low energy sensing or self-powered sensing, will get the job done. A more complete extraction of information from multimodal signals, such as microvascular flow, is necessary for the continuous monitoring of several physiological parameters. The efforts of researchers from all over the world have led to the development of sensors that can either be worn or implanted. These sensors show a great deal of promise as potential tools for the continuous monitoring of cardiovascular disease and have been the result of the efforts of researchers from all over the world.


Sickle cell anemia is still a significant public health issue in underdeveloped and developing countries. Sickle cell disease is one of the most common inherited diseases in Brazil. It affects mainly the mixed race population. Approximately 1 African-Brazilian child is affected with sickle cell disease for every 37,400 children born alive. Hearing loss has been considered one of the main clinical manifestations, especially in children. However, to date, there are just a hand full of studies in Brazil and the Brazilian state of Bahia has the largest African-descended population, attempting to establish the frequency of this event.To analyze the major studies associated with the subject, published in the last twenty years in the main indexed databases.To use MEDLINE to identify the main papers published in English in medical literature, between January of 1989 and January of 2009; associating sickle cell anemia and hearing loss, with its clinical outcomes.Given that it is always possible to attempt to prevent disabilities, understanding hearing loss in children with sickle cell anemia enables to maximize quality of life and provides for a broader school attendance. Sickle cell (SC) anemia is a hereditary hemoglobin disorder associated with a very specific molecular lesion, which is the exchange of glutamic acid for valine in the 6th residue of the hemoglobin beta chain, originating the S hemoglobinSickle cell anemia is still a public health issue in underdeveloped and developing countries. The sickle cell disease includes a group of genetic alterations characterized by the predominance of the S hemoglobin, which causes red blood cells to have the shape of a sickle. The main clinical manifestations of sickle cell anemia are a chronic anemia caused by the destruction of red blood cells (hemolytic type) and thrombotic events. Despite a variable disease severity, individuals affected require regular health care from childhood all the way to adult ageS) reaches the frequency of 7.6% in the population from the Brazilian northeast, made up of 82% of blacks and brownsThe S hemoglobin gene is highly frequent throughout the Americas, and in Brazil it is more frequent in the southeast and the northeastHearing deficit is described as one of the symptoms which happen because of the cochlear high sensitivity to vessel occlusion, causing ischemia and cochlear anoxia, because of the sickle cells which preclude blood flow to the cochlear epitheliumThe concern with the early diagnosis of hearing impairment has been a constant issue, since the loss caused by such impairment, often times is irreversible, affecting not only oral language, but also the child's global development and school performanceAlthough sickle cell anemia has been broadly studied in Brazil in terms of population frequency and clinical manifestation, its public health issues associated with child-youth hearing loss has not received proper attention in our country.In the present paper we reviewed the literature on sickle cell anemia and its clinical-audiologic repercussions in children and adolescents, analyzing how the specialized literature discusses the topic in different methodological approaches.To use the literature from the past two decades to analyze which are the main findings on the dual: sickle cell anemia and hearing loss, and the later repercussions in individuals with sickle cell anemia.sickle cell disease; hearing loss; auditory dysfunction; stroke; prevalence; audiological evaluations; auditory electrophysiological assessments, used alone or in combination in our study. Based on the analysis of a list bearing one hundred and fifty-seven (157) references of relevant publications and review papers, we selected fifty-eight (58) papers which were the most relevant concerning the topic at hand.Using the MEDLINE database, we studied papers in the English language, published in the medical literature between January of 1989 and January of 2009, which reported associations between sickle cell anemia and hearing deficit, and its clinical repercussions. We reviewed Medline, Scielo, and Caribbean and Latin-American Literature on Health Sciences, with the following keywords: Sickle cell anemia has an unknown origin, but it very likely started in Africa, millions of years ago. It protects people against malaria, a common and severe ailment of warm weather countries. The first case described in contemporary medicine literature happened in 1910, by J. Henrick, and since then, numerous associations between the disease conditions and its complications have been describedThe disease started in Africa, and it was brought to the Americas by the forced immigration of slaves. In Brazil, it is heterogeneously distributed, being more frequent where there are higher numbers of African descendants (northeast). Besides Africa and the Americas, it is today found all over Europe and in large regions of AsiaIn the USA, sickle cell anemia is considered a significant public health problem; one in every 400 African-Americans is treated for sickle cell anemia in the public health care systemSickle cell anemia, as clinical expression of the homozygosis of the S hemoglobin gene, is an important genetic abnormality in Brazil, especially in the regions which received large numbers of African slaves. In our country it is estimated that 3 for every 500 Brazilian-Africans have sickle cell anemia trace and one for every 500 blacks in Brazil is born with some form of the disease. Although there is a higher prevalence in African-descendants, the Caucasian population, especially those from the Mediterranean , Middle East, India, have many cases of sickle cell diseaseIn our country, the disease was considered predominant among blacks and browns; nonetheless, new studies have shown that although the disease predominates among African-descendants, the growing mixture of races is opening the borders of this disease, unbundling it from ethnic linksIn the state of Bahia, it was estimated that 5.5% of the general population bears a sickle cell trace, reaching 6.3% of the African-descended population2 causes morphological polymerization of the red blood cell, and it takes on an anomalous form, looking like a sickle. The elongated deformed red cells, not always can cross through small vessels, blocking them and preventing blood flow in the vicinity areas. The disease's course is variable; there are patients who have severe problems with greater frequency and others who have only sporadic health problems.The decrease in the levels of OIn general, besides chronic anemia, the different forms of sickle cell diseases are characterized by numerous complications which may affect almost all organs and systems, with relevant morbidity, reduction in work capacity and in life expectancy. Besides chronic anemia manifestations, the clinical picture is dominated by osteocartilaginous pain episodes, abdominal pain, pulmonary infarctions and infections, growth and sexual maturation delays, stroke and chronic involvement of multiple organs, systems or body aparatusesUsually, it is during the second half of the first year of the life of a child that the first symptoms of the disease manifest, except for the cases in which the blood test – to detect the disease, was carried out at birth or when the baby is in the nursery. It is common for the disease to manifest itself by the time the child reaches school age, and it is rare when this does not happen.As per institutional policy, sickle cell anemia started to be “appreciated” in 1996 through the Sickle Cell Anemia Program of the Ministry of Health (PAF-MS) which intends, within its general goals, to “promote educational actions, aiming at educating the population about the disease; to train health care professionals for prevention, diagnosis and treatment of the disease, and also to promote the active search for affected people”2 levels causes the morphological polymerization of the red cell and it takes on an anomalous form resembling a scythe or sickle. The morphological change associated with the physiological change in the structure of the red cells drastically reduces the capacity to transport O2 through the body. Some authors report that the hearing deficit concurrent to sickle cell anemia is not associated with the classic symptoms, but rather to its pathogenesis.Sickle cell anemia is a world-wide disease, especially present in countries with blacks and mixed populations, where the SS sickle cell form is very common. A reduction in OThe relationship between sickle cell anemia and hearing loss has been clearly documented. There are numerous investigations correlating the peripheral sensorial hearing deficit with a large variety of results. The prevalence of hearing deficit reported in the literature describes losses of mild to profound levels. Most of the cases have bilateral hearing loss; unilateral hearing loss is rarely described.19A metanalysis study carried out on the hearing of individuals with sickle cell reported that the ischemia caused to the stria vascularis leads to hypoxia in the organ of Corti, especially in individuals with a large number of painful spells, which would indicate a significant risk for the entire hearing system.Some studies have reported that the cochlear lesion is caused by the deformation of the red blood cell, which prevent proper blood supply to the high metabolic activity required to maintain the delicate ionic and electrical balance of the endolymph, and that the anoxia caused to the organ of Corti would cause extensive and progressive cochlear damage, which would justify the lack of otoacoustic emissions in individuals with sickle cell anemia.There are authors who have analyzed distortion product otoacoustic emissions (DPOAE) in two groups of twenty African-American children with and without sickle cell anemia, and concluded that the DPOAE were changed in children with sickle cell, especially in relation to an increase in DPOAE amplitude.A case-controlled study carried out in the USA, stratifying groups with different types of hemoglobin diseases  for hearing assessment using Brainstem Auditory Evoked Potential (BAEP) to study the threshold, showed that the SS form had 80% of the individuals with a level of hearing impairment varying from mild to profound.Numerous studies (between 1988 and 2004) used different methodologies to determine the hearing impairment in individuals with sickle cell, from conventional audiologic evaluation , central auditory processing assessment, brainstem auditory evoked potential and otoacoustic emissions. The results obtained had different percentage values of hearing deficit incidences, varying in the population groups studied between 12 and 66% among individuals with sickle cell anemia. One of the most employed techniques was the study of otoacoustic emission amplitudes, which showed a considerable increase in the amplitude of otoacoustic emissions, bearing a considerable increase in response amplitude from children with sickle cell anemia.28In African countries, such as Congo, with a predominance of black individuals, a study reported sudden hearing loss in individuals with sickle cell. The pathophysiology of the hearing loss was found to be associated with the fact that the vascular occlusion caused obliteration of the internal artery of the auditory terminal, thus causing ischemia and cochlear anoxia. The high sensitivity of the cochlea towards anoxia and its great fragility concerning external factors require an accurate and early audiological diagnosis, and also specialized care. The authors stress the need for regular audiological follow up in patients with sickle cell anemia.In Europe, there was a study carried out in Spain, with the Mediterranean population, describing two cases of sudden hearing loss in patients with sickle cell anemia, stressing the high cochlear sensitivity to arterial occlusion caused by the malformation of the red cells. The authors stress the need for prevention, diagnosis and treatment of the hearing loss caused by vascular occlusion led by sickle cell disease; and also the need for public health policies which support the rehabilitation of sickle-cell individuals with sensorineural hearing lossA case-control study carried out in Nigeria, investigated the hearing function of 62 individuals at an age range between 7 and 30 years, with sickle cell anemia, found a sensorineural hearing loss above 30 dB in 40% of the individuals evaluated and in 5.5% in the control group. Hearing impairment installed progressively along the disease course, bilaterally and it reached speech frequencies. The authors stress the need for prevention, diagnosis and treatment of the hearing loss caused by the vascular occlusion which happens in sickle cell anemia, and also the need for public health policies which support the rehabilitation of sickle cell individuals with sensorineural hearing lossIn Ghana, they carried out a study to establish the prevalence of sensorineural hearing loss in patients with sickle cell disease. Twenty-nine percent of the patients with sickle cell anemia had moderate sensorineural hearing loss, especially in the frequency range between 4 and 8 KHz. In the study, the authors stress the need for studies with populations from different geographical areas for prevalence analysis.A case-control study carried out to assess hearing in patients with sickle cell anemia in Nigeria, showed that the hearing impairment reaches more the speech frequencies, and that the hearing deficit happens predominantly in the inner ear, having seen that tympanometric curves are normal, ruling out this type of problem in the middle ear (otitis), which could cause the hearing impairment34In Kenya, a retrospective study was carried out with 360 patients in the age range between 7 months and 21 years, with bearers of the SS form of the sickle cell disease, who were submitted to neurological assessment. Numerous neurological sequelae were found: 67% of the patients had already had a stroke; 33%, seizures, visual disorders and hearing impairment, besides cerebellar degeneration, mental confusion and hallucinations. Multiple neurologic complications were described in 4 patients. The authors ratify that in Kenyan patients, there is the need for longitudinal audiological and neurological follow up in individuals with sickle cell anemia.Considering the major racial mix in Bahia, with a predominance of the black population, it is extremely relevant to know about and react early on concerning hearing impairment, especially concerning the pediatric population, in order to install prevention and diagnostic measures early on so as to avoid learning deficits and late schooling.35.According to estimates from the World Health Organization, every year in Brazil we have about 3,500 children born with sickle cell disease. Twenty percent of them will not reach five years of age, because of complications directly associated with the disease itself. Only early diagnosis and proper treatment can change this scenario. According to data from APAE-Salvador, from August of 2000, when the “foot test” started, neonatal screening for hemoglobin diseases, allowed us to know the true incidence of such disease: 1,655 live newborns with sickle cell anemia and 1 child with sickle cell trace for every 17 birthsBased on the analysis of studies carried out to date, we can see that knowing the magnitude of sickle cell disease, with many analysis variables and sequelae, hearing impairment in children and adolescents, often times is ultimately missed or underdiagnosed, which impairs early specialized intervention, especially in children acquiring oral language or in those starting school.Different diagnostic methods confirmed the great variety in the degree of hearing loss in patients with sickle cell disease; nonetheless, the sensorineural hearing loss type predominated in the studies considered, confirming the damage caused to the cochlea and the auditory nerve, caused by hypoxia stemming from the sickle shape of the red cells.Thus, we emphasize the early detection of hearing loss through otoacoustic emission tests, which can be carried out together with the PKU test, contributing to a reduction in severity and facilitating early and systematized intervention.36.The Sickle Cell Anemia Program, developed by the Department of Health, with a very active participation of African-Brazilian activists as of the late 90's, has tried to conceptualize that sickle cell anemia is much more than a disease, under to auspices of medicine aloneIn the state of Bahia, in June of 2003, a program was installed for the prevention, diagnosis and integral medical care and education to people with sickle cell disease and other hemoglobin diseases, including the Brazilian Public Health system – SUS - in this program we can guarantee that it will cover the diagnostic tests for hemoglobin diseases for newborn children, as well as specific treatments for the sickle cell disease.Therefore, as it is guaranteed by law, we believe it to be of fundamental importance to inform the families of these patients about their rights guaranteed by law which are often times unknown to them, and its clinical repercussions and sequelae so as to provide early and efficient treatment in order to minimize the repercussions it has on the linguistic and cognitive development of children with sickle cell anemia.Having said this all, based on the literature review carried out, it is clear the need to prevent, diagnose and systematically follow up these children with sickle cell anemia, because hearing loss, when underdiagnosed or diagnosed very later on, may cause irreparable damage to the sickle-cell-affected individual's linguistic, biopsychosocial and emotional developments.