Endovascular thrombectomy (EVT) has become the gold standard in the treatment of acute stroke patients. However, not all patients respond well to this treatment despite successful attempts. In this study, we aimed to identify variables associated with the failure of improvements following EVT.We retrospectively analyzed prospectively collected data of 292 ischemic stroke patients with large vessel occlusion who underwent EVT at three academic stroke centers in China from January 2019 to February 2022. All patients were above 18 years old and had symptoms onset ≤6 h. A decrease of more than 4 points on the National Institute of Health Stroke Scale (NIHSS) after 24 h compared with admission or an NIHSS of 0 or 1 after 24 h was defined as early neurological improvement (ENI), whereas a lack of such improvement in the NIHSS was defined as a failure of early neurological improvement (FENI). A favorable outcome was defined as a modified Rankin scale (mRS) score of 0–2 after 90 days.p < 0.001). Mortality was 7.0% in the ENI group in comparison to 42.1% in the FENI group (p < 0.001). The multiple logistic regression model showed that diabetes mellitus , pre-stroke mRS , last known well to puncture time , modified thrombolysis in cerebral infarction = 3 , and number of mechanical thrombectomy passes  were the predictors of FENI.A total of 183 patients were included in the final analyses, 126 of whom had FENI, while 57 had ENI. Favorable outcomes occurred in 80.7% of patients in the ENI group, in contrast to only 22.2% in the FENI group (Diabetes mellitus history, pre-stroke mRS, longer last known well-to-puncture time, lack of modified thrombolysis in cerebral infarction = 3, and the number of mechanical thrombectomy passes are the predictors of FENI. Future large-scale studies are required to validate these findings. TreatmeMultiple studies have reported that early neurological improvements (ENI) can be used as a surrogate in predicting functional outcomes of AIS patients . For exa2.2.1.We included consecutive patients with AIS who underwent EVT from January 2019 to February 2022 at three academic comprehensive stroke centers in China. We used data from the Big Data Observatory Platform for stroke in China, a prospectively collected data platform registry for stroke patients following EVT and the hospital data platforms. The inclusion criteria were as follows: (1) patients with AIS who underwent EVT; (2) age ≥18 years old at the time of treatment; (3) symptom onset ≤6 h. The exclusion criteria were as follows: (1) pre-EVT NIHSS <6; (2) missing data of follow-up; (3) symptoms onset >6 h.2.2.Patients were divided into two groups according to their evolution of neurological deficits. A decrease of more than 4 points on the National Institute of Health Stroke Scale (NIHSS) after 24 h compared with admission or an NIHSS of 0 or 1 after 24 h was defined as early neurological improvement (ENI), whereas a lack of such improvement in the NIHSS was defined as a failure of early neurological improvement (FENI). We collected the following data: age, sex, vascular risk factors, premorbid modified Rankin scale (mRS), door-to-needle time (DNT), onset-to-needle time (ONT), door-to-puncture time (DPT), last known well-to-puncture time (LKWPT), door to recanalization time (DRT), puncture to recanalization (PRT), site of arterial occlusion, number of thrombectomy passes, and modified thrombolysis in cerebral infarction (mTICI) post-thrombectomy. Successful reperfusion was defined as an mTICI of ≥2B, and complete reperfusion was defined as an mTICI of 3. Experienced attending neurologists measured and recorded the NIHSS of all consecutive patients at the admission, while the interventionist recorded the NIHSS after the EVT. Patients’ outcomes were evaluated by mRS at 90 days. Stroke nurses and/or the attending neurology physicians routinely assessed the mRS during in-person appointments or remotely by telephone during outpatient follow-up. A favorable outcome was defined as an mRS of 0–2 after 3 months, and an mRS of 6 was defined as mortality.2.3.U-test was performed for non-normally distributed continuous data, recorded as medians along with the interquartile range (IQR). Normally distributed variables were reported as means with corresponding standard deviations (SD) and compared using the student’s t-test. Results were considered statistically significant if the p-value was <0.05.IBM SPSS version 26 was performed to analyze and draft the figure. The Mann–Whitney 2.4.The study protocol was approved by the Guangdong Provincial Hospital of Integrated Traditional Chinese and Western Medicine, Guangdong Province, China. Informed consent was not required due to the retrospective nature of the study in compliance with national laws and regulations. All procedures performed in the studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.3.From January 2019 to February 2022, we treated 292 consecutive AIS patients who had large vessel occlusion and underwent EVT. A total of 103 patients were treated with an LKWPT >360 min, four patients were lost to follow-up, one had a pre-EVT NIHSS <6, and one did not have the 24 h NIHSS documented. Therefore, 183 patients were included in the final analysis. Among them, 126 patients had FENI, while 57 had ENI.p = 0.031) and sex (p = 0.214), as well as risk factors, such as hypertension (p = 0.321), diabetes mellitus (p = 0.106), coronary artery disease (p = 0.545), atrial fibrillation (p = 0.641), stroke history (p = 0.791), and chronic kidney disease (p = 0.696). Smoking was less frequent in the FENI group compared to the ENI group . In addition, NIHSS at admission , premorbid mRS , baseline Alberta stroke program early CT score (ASPECTS) , and distribution of target vessel occlusion side (p = 0.11) were similar in both groups.The baseline characteristics of patients in both groups are demonstrated in p = 0.946) between the two groups. Patients with FENI required more attempts during EVT , had longer last-known well-to-puncture time  and door to recanalization time . Successful reperfusion defined by modified thrombolysis in cerebral infarction ≥2B was lower in the FENI compared to the ENI group . Furthermore, symptomatic intracranial hemorrhage (sICH) occurred in 14.5% of patients with FENI, and there were no patients with ENI (p = 0.001) after EVT (The rate of bridging intravenous (IV) thrombolysis before EVT was similar . Furthermore, mortality was 7.0% (n = 4) in the ENI group in comparison to 42.1% (n = 53) in the FENI group (p < 0.001). The distribution of 90 days mRS of FENI and ENI groups is shown in Functional outcome was significantly different between the two groups . Patientp < 0.001) and 90 days mortality (p < 0.001) were present after adjusting for confounding factors, including age, current smoking status, diabetes mellitus, NIHSS pre-EVT, and premorbid mRS , 6.221 (1.421–27.248), p = 0.015], longer last known well to puncture time , lack of modified thrombolysis in cerebral infarction = 3 , and the number of mechanical thrombectomy passes  were predictors of FENI , 2.985 (1.070–8.324),  of FENI .4.This study analyzed the clinical variables for their association with FENI in patients with AIS due to LVO who underwent EVT. We found that diabetes history, pre-stroke mRS, LKWPT, absence of complete (TICI 3) reperfusion, number of MT passes, and ICH were independent predictors of FENI. Predictors of FENI were consistent with predictors of reperfusion without functional independence (RFI), a frequent phenomenon that may occur in the extended time window. Indeed, a multi-center cohort study recently demonstrated that higher baseline NIHSS, higher pre-stroke disability, transfer to a comprehensive stroke center, and a longer interval to puncture were independent predictors of RFI in patients with late presentation AIS . ConversAs previously demonstrated in multiple studies , diabeteFurthermore, longer last known normal to puncture time was an independent predictor of FENI and strategies to optimize treatment time are critical to improving patient outcomes , 23..The limitations of this study are related to the retrospective design. Furthermore, uncertainty might arise because of the imputation of missing values. A confirmation and analysis of independent predictors of FENI can be achieved with larger, multi-center cohort studies. Despite such limitations, our findings can help identify factors that can predict the successful outcome of EVT, which can provide pragmatic points for randomized controlled trials, facilitate surrogacy for patients who are unlikely to follow-up, and establish predictive models for ischemic stroke patients’ outcomes .5.Early neurological improvement was a reliable surrogate to predict 90 days favorable outcomes and mortality. Diabetes, premorbid mRS, longer last known well time to puncture time, absence of mTICI 3, sICH, and more EVT passes predicted the failure of early neurological improvement in the early time window following endovascular therapy. Future randomized controlled trials are required to validate these findings.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving humans were approved by Foshan Sanshui District People’s Hospital in Foshan. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required from the participants or the participants’ legal guardians/next of kin because informed consents were not required due to the retrospective nature of the study in compliance with national laws and regulations.FD, YnC, YL, and HM drafted the manuscript. MM, MA, and TN critically edited the manuscript. EJ, SZ, HS, JH, WY, YgC, MF, JC, JM, and XL analyzed the cases and edited the manuscript. All authors contributed to the article and approved the submitted version.The study was supported by the Foshan Science and Technology Bureau (Grant No. 2220001005022), the Medical Science and Technology Research Foundation of Guangdong Province (Grant No. 20221027164016611), Foshan the 14th Five-Year Plan Key Discipline Foundation, the Guangdong Provincial TCM Bureau Key Discipline Foundation, and the Foshan Brain Heart Co-Therapy Foundation. The Foshan 14th Five-Year Priority Speciality Construction Project, The Foshan Nanhai District 14th Five-Year Priority Speciality Construction Project, Foshan Traditional Chinese Medicine Immune Health Technology Innovation Base.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.The handling editor declared a shared affiliation with the author EJ at the time of review.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.


Prosocial risky behavior (PRB) proposes that individuals take risks for others’ benefits or social welfare, and that this may involve trade-offs between risk and social preferences. However, little is known about the underlying cognitive mechanisms of risk-seeking or aversion during PRB.N  = 88), and it further uncovered the modulation of the risk levels of failure  and peer presence  when helping others.This study adopted the dilemma-priming paradigm to examine the interaction between the risk levels of personal cost and situational urgency on PRB (Experiment 1, In Experiment 1, the participants involved in risky dilemmas made more altruistic choices for strangers in urgent situations compared to those for strangers in non-urgent situations. However, increasing the risk levels of personal cost decreased the frequencies of help offered to strangers in urgent situations. Experiment 2 further established that, similar to the risk of personal cost, increasing the risk levels of failure when helping others also decreased the frequencies of help offered to strangers in urgent situations. Furthermore, in dilemmas involving a low-risk personal cost, Experiment 3 showed that peer presence encouraged the participants to make more altruistic choices when providing help to strangers in non-urgent situations.Individuals demonstrate obvious risk-seeking behavior when helping others and that both non-urgent situations and peer presence weaken the effect of increased risk aversion on PRB in a limited manner. For exaPRB is usually observed in real-life and experimental laboratory situations, whereby individuals assume specific risk costs, such as monetary loss , immediaSocial preferences reflect the tendency of individuals to focus on the benefits of others or the welfare of society . SituatiGenerally, the different types of risks resulting from helping others are complex and interactive, and they usually include the two types of risks associated with both the personal cost and the failure to help others . For exaAdditionally, previous studies have demonstrated that the presence of peers encourages risk-seeking tendencies  and prosIn conclusion, some previous studies have regarded prosocial risky behavior as simple prosocial behavior, focusing primarily on the influence of risk factors. Other researchers regarded prosocial risky behavior as simple risk-taking behavior, mainly focusing on prosocial motivation’s influence. Prosocial risky behavior involves the integrated processing of individual risk and social preferences. In this study, we aimed to examine the influence of situational factors such as levels and sources of risk on PRB and further explain the underlying trade-offs and integration mechanisms associated with the social and risk preferences. Therefore, we first examined whether PRB was affected by the interaction between the risk of personal cost caused by helping others and situational urgency (Experiment 1). 2.Experiment 1 aimed to examine the infulence of risk levels of personal cost and situational urgency on PRB. We hypothesized the following: (1) compared to non-urgent situations, participants would make more altruistic decisions toward strangers in urgent situations, (2) the frequencies of providing help would be higher in situations involving low-risk levels of personal cost, (3) and increased risk levels of personal cost would have a stronger weakening effect on the frequencies of help provided to strangers in urgent situations compared to those in non-urgent situations owing to increased levels of risk aversion.2.1.2.1.1.f = 0.30) according to the study conducted by G* Power 3.1 software was used to calculate the sample size , and the2.2.2.2.1.Twenty everyday helping dilemmas see  were citSpecifically, each dilemma describes a conflict situation in which protagonists must sacrifice their benefits to help strangers in urgent or non-urgent situations. Each dilemma comprises a scenario and two options. The scenario describes a situation in which the protagonist desperately needs help (involving urgent or non-urgent situations) while one is conducting an important deed, and the individual must decide whether to aid the person and give up doing their important deed. The two options describe the outcomes of the decision to help or not: one option describes an altruistic decision that one is going to give up their important goal to help the other person , and the other option describes an egoistic decision that one is going to keep doing their important task, thereby ignoring the other person. Participants were required to choose between the two options. The numbers and familiarities of risky helping dilemmas were controlled and balanced between participants.M = 3.60 ± 0.15) were significantly less than the urgent dilemmas , F = 73.80, p < 0.001, ηp2 = 0.56. This result showed that situational urgency was effective.Meanwhile, before the experiment, 30 participants were recruited to complete the 7-point rating scale item  to assess the degree of threat urgency toward the stranger in every helping dilemma. The results showed that the non-urgent dilemmas  × 2  within-subject design. We recorded the frequencies of helping choices during prosocial risky helping tasks. ANOVA was used to analyze the effect of the two within-subject factors on this dependent variable. SPSS software (version 20.0) was used to perform the statistical analysis of all the data.2.4.t-test indicated that the average helping frequencie was significantly higher than the 50% chance, t(87) = 7.58, p < 0.001, thereby suggesting that participants tended to help the protagonists in risky dilemmas. Moreover, the main effect of the degrees of situational urgency was significant, F = 13.61, p < 0.001, ηp2 = 0.14, thereby suggesting that participants made more altruistic choices for strangers in non-urgent situations  than for strangers in urgent situations . The main effect of the risk level of personal cost was significant, F = 81.14, p < 0.001, ηp2 = 0.48, thereby indicating that participants made more altruistic choices in situations involving low-risk levels  compared to those involving high-risk levels  of personal cost.The overall frequencies of the trials in which participants selected help were 0.65 (SD = 0.18). A one-sample F = 107.45, p < 0.001, ηp2 = 0.55. Further, through simple effect analysis, we established that the participants made more altruistic choices for strangers in urgent situations  as compared to those in non-urgent situations  in situations with low-risk levels of personal cost, F = 102.21, p < 0.001. However, participants made less helpful choices for strangers in urgent situations  compared to those in non-urgent situations  or in situations with a high-risk level of personal cost, F = 24.72, p < 0.001  were lower than those in non-urgent situations , t(87) = −10.37, p < 0.001.Additionally, we calculated the risk-taking tendencies using the helping frequencies of high-risk levels minus those of low-risk levels of personal cost in different urgent situations, which indexed the weakening effect of the increased risk levels of personal cost on social preferences. The results showed that risk-seeking tendencies in urgent situations  in risky situations. This risk-seeking tendency in this study is consistent with that reported in previous studies, indicating that people made highly prosocial decisions for others’ benefits or welfare despite taking the risk of personal cost . However3.Experiment 2 aimed to further examine the way in which both levels of risk, i.e., the risk of personal cost and the risk of failure in helping others, affected the frequencies of providing help to strangers in urgent and non-urgent situations. We hypothesized the following: (1) owing to the increased risk levels associated with the two types of risks, the frequencies of the decisions to provide help to strangers experiencing threats would decrease and (2) the difference between high-risk and low-risk levels of the personal cost would be only observed in situations involving low risk but not at high-risk levels of the failure to help others.3.1.3.1.1.f = 0.30). Therefore, 65 college students  were recruited to participate in Experiment 2. The experiment was conducted in accordance with the Declaration of Helsinki and was also approved by the Ethics Committee of Hunan University of Science and Technology. After understanding the experiment fully, each participant signed an informed consent form.Similar to Experiment 1, G* Power 3.1 software was used to calculate the sample size, and the results showed that this study needed to recruit at least 30 participants to ensure sufficient test efficacy (effect = 0.90) under the premise of a medium effect size  × 2  × 2 (risk levels of failure to help others: high-risk levels vs. low-risk levels) within-subject design. ANOVA was used to analyze the way in which the dependent variable  was affected by the three within-subject factors. SPSS software (version 20.0) was used to perform the statistical analysis of all the data.3.4.t-test indicated that the average helping frequencie was significantly higher than the 50% chance (t(64) = 8.36, p < 0.001), thereby suggesting that participants tended to decide to help protagonists experiencing threats. Moreover, the main effect of the degree of situational urgency was significant, F = 6.98, p = 0.01, ηp2 = 0.10, thereby suggesting that participants made more altruistic choices toward strangers in non-urgent situations  compared to those in urgent situations . Meanwhile, the main effect of the risk level of personal cost was significant, F = 26.38, p < 0.001, ηp2 = 0.29, thereby indicating that help frequencies in situations with low levels of personal cost  were significantly higher than those in situations involving high levels of personal cost . Moreover, the main effect of the risk level of failure when helping others was significant, F = 41.11, p < 0.001, ηp2 = 0.39, thereby showing that help frequencies in situations involving low risks of the failure to help others  were significantly higher than those in situations involving a high risk of failure to help others .The overall frequencies of trials in which participants selected help were 0.63 (SD = 0.12). A one-sample F = 4.92, p = 0.03, ηp2 = 0.07. Through further simple effect analysis, we established that in situations with high levels of personal cost, the participants made more altruistic choices toward strangers in non-urgent situations  compared to those in urgent situations , F = 10.76, p = 0.002. However, this difference was not significant in situations with low-risk levels of personal cost , F = 2.57, p = 0.11  = 4.98, p = 0.03, ηp2 = 0.07. Through simple effect analysis, we established that, in situations involving high-risk levels of the failure to help others, the participants made more altruistic choices toward strangers in non-urgent situations  compared to those in urgent situations , F = 9.93, p = 0.002. However, this difference was not significant in situations involving low-risk levels of personal cost , F = 2.78, p = 0.10  = 0.24, p = 0.63, ηp2 = 0.01.The interaction between the risk levels of the failure to help others and the degrees of situational urgency was significant, p = 0.10 . HoweverM = −0.17, SD = 0.25) was lower than that in non-urgent situations , t(64) = −2.22, p = 0.03. Moreover, the risk-seeking tendencies resulting from the risk of failure to help strangers in urgent situations  was lower than that in non-urgent situations , t(64) = −2.23, p = 0.03.Additionally, the risk-taking tendencies resulting from the risk of personal cost associated with helping strangers in urgent situations  compared to the alone condition, participants under the peer presence condition would make more altruistic choices toward strangers experiencing threats and (2) this promotion effect would be more robust in situations involving low-risk levels (vs. high-risk levels) of personal cost under urgent (vs. non-urgent) situations.4.1.4.1.1.f = 0.30). Therefore, 80 college students  were recruited to participate in Experiment 3. Participants were randomly divided into the peer presence condition  and the alone condition . The experiment was conducted in accordance with the Declaration of Helsinki and was also approved by the Ethics Committee of Hunan University of Science and Technology. After understanding the experiment fully, each participant signed an informed consent form.Similar to Experiment 1, G* Power 3.1 software was used to calculate the sample size, and the results showed that this study needed to recruit at least 66 participants to ensure sufficient main effect test efficacy of the between-subject factor and at least 40 participants to ensure sufficient interaction effect test efficacy (effect = 0.90) under the premise of medium effect size  × 2  × 2  mixed design. ANOVA was used to analyze the way in which the dependent variable  was affected by both the within-subject variables  and the between-subject variable . SPSS software (version 20.0) was used to perform the statistical analysis of all the data.4.4.t-test indicated that the average helping frequencie was significantly higher than the 50% chance (peer presence condition: t(39) = 9.84, p < 0.001; control condition: t(39) = 5.50, p < 0.001), thereby suggesting that participants in the two conditions tended to decide to help the protagonists experiencing threats. Moreover, the main effect of the degree of situational urgency was significant, F = 18.74, p < 0.001, ηp2 = 0.19, thereby suggesting that participants made more altruistic choices toward strangers in non-urgent situations  than those in urgent situations . The main effect of the risk level of personal cost was significant, F = 179.18, p < 0.001, ηp2 = 0.70, thereby showing that help frequencies in situations involving low-risk levels of personal cost  were significantly higher than those in situations involving high-risk levels of personal cost .The overall frequencies of trials in which the frequencies of participants under the peer presence condition and the alone condition selected help were 0.67 (SD = 0.11) and 0.63 (SD = 0.15), respectively. The one-sample F = 16.24, p < 0.001, ηp2 = 0.17. Through further simple effect analysis, we established that in situations involving low levels of personal cost, participants in the peer presence condition made more altruistic choices toward helping strangers in non-urgent situations  compared to participants in the alone condition , F = 10.01, p = 0.002. However, this difference between the two conditions was not significant in urgent situations , F = 2.97, p = 0.09. Meanwhile, there were no other significant differences between the two conditions in situations involving high-risk levels of personal cost under urgent  and non-urgent  situations .The interaction between the three independent variables was significant, 4.5.Through Experiment 3, we further established that peer presence encouraged individuals to make more helpful decisions toward strangers experiencing threats. This result suggests that peer presence weakens individuals’ risk-aversion tendency to make more helpful decisions despite facing the risk of personal cost. This is consistent with previous studies reporting that peer presence promotes individuals’ risk-seeking tendencies, which in turn leads people to engage in PRB despite facing the risk of personal cost . People 5.This study assessed whether prosocial risky behavior was affected by the interaction between the risk levels of personal cost and the degrees of situational urgency, and it further uncovered the modulation of risk levels of failure when helping others and peer presence in this interaction. We found that compared to non-urgent situations, the weakening effect of the increased risk levels of both personal cost and the failure to help others on social preferences in urgent situations were stronger. Moreover, peer presence can promote PRB among strangers in non-urgent situations involving low-risk levels of personal cost. The results suggest that individuals generally show an obvious altruistic risk-taking tendency during PRB and that both non-urgent situation and peer presence weaken the effect of increased risk levels on PRB to some extent.5.1.This study established that participants involving college students showed an obvious altruistic risk-seeking tendency when making prosocial risky decisions, thereby revealing that participants in risky situations were willing to make more altruistic decisions (than 50% of chance) for strangers in urgent situations. Previous studies have reported that individuals under acute stress make increased altruistic decisions during economic exchange games  and whenThe theory of reciprocal altruism offered a possible explanation for PRB and held that, although altruistic behavior resulted in some risks of personal cost to the self, it also resulted in immediate or delayed compensations from others. These compensations might be intrinsic motivations and rewards that can improve an individual’s social reputation or standing during social communication . Moreove5.2.The results showed that increased risk levels had a more robust weakening effect on altruistic decisions for strangers in urgent situations compared to those in non-urgent situations. This finding was supported by a previous study that reported that more frequent helping decisions under distant (vs. imminent) threats toward strangers would suggest that defensive states associated with the engagement of slower and more flexible decision processes facilitate helping behavior under threats . Because5.3.M = 47.75%) in high-risk situations associated with the two risks and the most helping frequencies (M = 77.08%) in low-risk situations associated with the two risks. This finding suggests that the combination of the risk of personal cost and the risk of the failure to help others might not significantly enhance individuals’ additional risk aversion but that risk aversion induced by the two risks alone is enough to affect prosocial tendencies.Similar to the risk of personal cost, increased risk levels of failure in helping others also had a more robust weakening effect on helping decisions for strangers in urgent (vs. non-urgent) situations. This finding supports multiple risk perspectives, which argue that multiple risk factors might undermine prosocial developmental trajectories . For exa5.4.Through Experiment 3, we established that individuals in peer presence compared to those in alone situations made more altruistic decisions in dilemmas involving low-level risks of personal cost in non-urgent situations, but not in other risky dilemmas. This finding suggests that peer presence can prompt individuals to engage in increasingly prosocial risky behavior to some extent. However, this promotion is limited to risky dilemmas. This finding is supported by previous studies reporting that peer presence can promote both risk-seeking tendencies  and altr5.5.This study has some limitations. First, although our study provides some preliminary causal evidence for the interaction between risk and social preferences in PRB, it is not yet possible to quantify the switching point of risk aversion. Future studies should focus on the gain-loss matrices between the self and others in risky helping dilemmas involving multiple risk levels of personal cost. Second, while it was beyond the scope of our study to examine individual differences, i.e., sensation-seeking, social value orientation, or empathy, in the trade-off and integration between risk and prosocial preferences, future studies should explore this possibility because PRB is thought to be related to individuals’ sensation-seeking and empathy abilities . Third, 6.This study aimed to adopt the risky helping dilemma task to provide causal evidence of the interaction between risk levels and situational urgency associated with prosocial risky behaviors and further explore the modulation of risk types and peer presence. The results showed that individuals generally showed an obvious risk-taking tendency during prosocial risky behaviors, whereas the increased risk levels of both personal cost and the failure to help others had a stronger weakening effect on the frequencies of help provided to strangers in urgent situations relative to those in non-urgent situations. Furthermore, peer presence encouraged participants to make more altruistic choices toward strangers in non-urgent situations. However, this promotion effect was observed only in situations involving low-risk levels of personal cost. Our study provides novel and empirical research perspectives for investigating the mechanisms behind the trade-off and integration between risk and social preferences when making prosocial risky decisions and behaviors in risky and vulnerable contexts. Altogether, the findings suggest that individuals generally show an obvious altruistic risk-seeking tendency when making prosocial risky decisions and that both non-urgent situations and peer presence weaken the effect of increasing risk aversion on PRB to some extent.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by the ethics committee of Hunan University of Science and Technology. The patients/participants provided their written informed consent to participate in this study.CL and XX prepared the materials and measures. CL and QP collected and analyzed the data. CL and QT drawn tables and figures. CL wrote and amended the manuscript. YZ reviewed the manuscript. All authors contributed to the article and approved the submitted version.This work was supported in part by grants from the Natural Science Foundation of Hunan Province (2021JJ40196), the Key Project of the Philosophy Social Science Project of Hunan Province (18ZDB011), the Educational Science Planning Program of Hunan Province (XJK19QXL002), the Project of Social Science Evaluation Committee of Hunan Province (XSP20YBZ030 and XSP19YBZ082), and the Postgraduate Scientific Research Innovation Project of Hunan Province (CX20211014).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 diseases (CVDs) remain the leading cause of mortality worldwide. This underlies the need to evaluate different targets, such as diet quality. In this regard, we conducted the present study to find whether the healthy eating index-2015 (HEI-2015) score is associated with a 10-year risk of CVDs based on Framingham Risk Score (FRS) and QRISK3 in different body mass index (BMI) groups.This cross-sectional study was performed based on Shiraz University of Medical Sciences Employees Health Cohort Study (SUMS EHCS) data in April 2020. A total of 764 participants met the inclusion criteria. An expert performed demographic, anthropometric, and dietary evaluations. A semi-quantitative food frequency questionnaire (FFQ) was applied to assess the diet quality, and FRS and QRISK3 were used to evaluate the 10-year risk of CVDs.p < 0.001). However, the consumption of refined grains in higher quartiles showed a decreasing trend (p < 0.001). The consumption of added sugar and saturated fatty acids (SFAs) in higher quartiles revealed an increasing trend (p < 0.001). In addition, lower HEI-2015 scores and lower whole grain consumption were significantly associated with higher BMI (p < 0.05). Also, lower consumption of fruits showed a significant relationship with higher risk scores of Framingham and QRISK3 (p < 0.05). Higher added sugar and SFAs intake was significantly related to lower FRS (p < 0.05). A significant reverse association between HEI-2015 and QRISK3 and Framingham risk scores was seen (p < 0.05).Based on the results, many components of HEI-2015 indicated an increasing trend through quartiles (Our findings support dietary recommendations to increase fruit and whole grains intake to prevent CVD and obesity. Moreover, a significant inverse association between HEI-2015 and QRISK3 and Framingham risk scores was observed. Since the results for added sugars and SFA intakes were controversial, further studies are needed. Cardiovascular diseases (CVDs) are known as the leading cause of premature death globally . Based oMultivariate CVDs risk assessment tools are available to identify individuals at risk for effective preventive interventions including drug administration and lifestyle changes . ObesityDiet quality has been established as a major modifiable risk factor for preventing CVDs and all-cause mortality . In thisSince CVDs have become one of the most widespread and important issues in the last few decades and only a few studies have evaluated the associations between diet quality and CVDs risk, the primary objective of our study was to find whether the HEI-2015 score is associated with a 10-year risk of CVDs based on FRS and QRISK3 scores.2, a total energy intake of 800–4200 kcal/day, no history of cardiovascular events, and no consumption of diabetes and lipid regulating medications were included.This cross-sectional study used data from the adult population who participated in Shiraz University of Medical Sciences Employees Health Cohort Study (SUMS EHCS) in April 2020. SUMS EHCS is an ongoing cohort which has started in 2017 and investigates health parameters in the employed population of SUMS who were visited at the cohort center in Motahari Clinic, Shiraz, Iran in accordance with the Helsinki Declarations of Ethics. In this study, the participants aged 40–74 years with a BMI of higher than 18.5 kg/mAll participants who joined the study signed a written informed consent and the ethics committee of Shiraz University of Medical Sciences approved our study (Code: IR.SUMS.REC.1399.482). Demographic, anthropometric, and dietary evaluations were performed by experts. Also, at the beginning of the study, participants were asked to record their current smoking status and current status of receiving the blood pressure medication.To measure the height and weight, we used a stadiometer to the nearest 0.1 cm and a standard scale  to the nearest 0.1 kg in participants without shoes and with light clothing. BMI was computed as weight (kg) divided by squared height (meter) . Based oBlood pressure was performed by an experienced expert using a standard sphygmomanometer . Participants were rested in a sitting position for 10 min before blood pressure measurement. Then blood pressure was measured twice on the right and left arm at an interval of 10 min. The average of these multiple blood pressures was reported as the final number.Blood sample was collected by a laboratory technician after 12 h of fasting. Plasma glucose levels, total cholesterol, and high-density lipoprotein cholesterol (HDL-C) were assayed by an enzymatic colorimetric methodology .The FRS and QRISK3 equations for CVDs were used to predict the risk of an event. The FRS was estimated for each participant using the risk score based on age, gender, total cholesterol, HDL-C, systolic blood pressure, smoking, diabetes, and hypertension medication intake . HoweverAll data were collected by trained nutritionists in a face-to-face interview. A semi-quantitative food frequency questionnaire (FFQ) with 125 items was used to assess the participants' food intake on a daily, monthly, and annual basis. The validity and reliability of the questionnaire had been confirmed in previous studies . DietaryHEI-2015 was used for evaluating adherence to the healthy eating guidelines. HEI-2015 contains 13 components including total fruits, whole fruits, total vegetables, greens and beans, whole grains, refined grains, dairy products, total protein foods, seafood and plant proteins, fatty acids ratio, sodium, added sugars, and saturated fatty acids (SFA). Intake of total fruits, whole fruits, total vegetables, greens and beans, total protein foods, seafood, and plant proteins received 5 scores in the highest consumption, and the lowest intake scored 0. High consumption of whole grains, dairy, and fatty acids (polyunsaturated fatty acids (PUFAs) and monounsaturated fatty acids (MUFAs) to SFAs ratio) received 10, and the lowest intake of them was scored 0. Moreover, the intake of high amounts of refined grains, sodium, added sugars, and saturated fats had 0 points, while the lowest intake of them had 10 points. Finally, the scores were summated, and the HEI-2015 was scored from 0 to 100 .P < 0.05 was considered significant.Data were analyzed using SPSS software . Normally distributed data were expressed as mean ± standard deviation (SD) and data not normally distributed were presented as the median and interquartile range (IQR). The qualitative variables results were expressed as percentages. To determine the association between the 10-year risk of CVDs or BMI, with dietary intakes across different quartiles of HEI-2015, we used one-way ANOVA or Kruskal–Wallis test and linear regression. Moreover, the Mann–Whitney test was used to compare the variables between the pair groups. P = 0.08), and the participants were homogeneously distributed. Height and weight values were 171.2 ± 9.2 cm and 73.0 ± 0.13 kg, respectively. Of all participants, 260 (0.34%), 366 (47.9%), and 138 (18.1%) were normal, overweight, and obese, respectively.The general characteristics of the subjects are shown in Table The QRISK3 index demonstrated that 707 (96.7%) people were at low risk and 24 (3.3%) at moderate risk. The FRS showed that 639 (87.7%) participants were at low risk, 86 (11.5%) were at moderate risk, and 6 (0.8%) were at high risk.p < 0.05). Those in higher quartiles of HEI-2015 had higher scores including intake of total fruits, whole fruits, whole vegetables, greens and beans, whole grains, dairy products, total protein foods, seafood, plant proteins (P < 0.001), and, unsaturated to saturated fatty acids ratio (P < 0.05). Intake of refined grains was heterogeneously decremental through the quartiles (P < 0.001). Added sugar and SFA intake increased significantly through the quartiles (P < 0.001); however, added sugar scores showed a decremental trend through the quartiles (P < 0.001).Table P = 0.03). There was also a significant difference between the daily consumption of whole grains in the overweight and obese groups (P < 0.05), so the overweight subjects had a higher intake than the obese subjects.HEI-2015 and its components were compared based on BMI categorization: normal, overweight, and obese. As the results presented in Table P = 0.003), the whole fruit (P = 0.003), added sugar (P = 0.01), and SFA intake (P = 0.008) indicated a statistically significant inverse difference between the low and moderate Framingham risk groups.The total fruit (P = 0.02) among people with low and medium risk, based on the QRISK3 risk score. There was no remarkable difference between the two groups in other variables. Also, a significant reverse association between HEI-2015 and QRISK3 and Framingham risk scores was observed  minerals, and phytochemicals which might have an impact on the body weight, alleviate insulin resistance, and reduction of CVDs risk , 32. In According to the results of the present study, higher intake of fruits was associated with lower FRS and QRISK3 scores. Fruits have anti-inflammatory and antioxidant properties due to fiber content, various types of vitamins , minerals, and bioactive phytochemicals (polyphenols), which have been negatively associated with CVDs risk factors . In addiBased on our findings, higher added sugar and SFAs intake was significantly related to lower FRS, which is contrary to previous findings. As LeungScD et al. indicated a higher intake of sugar-sweetened beverages was associated with poorer diet quality in children . MoreoveOn the other hand, some investigations have revealed a correlation between SFAs and an increased risk of ischemic heart disease. SFAs consumption showed an increasing trend in cholesterol levels, which is an important risk factor for CVDs , 46. HowOne possible limitation of the current study was its cross-sectional design, so no causal association can be obtained from the findings. Second, in case FFQ is used as a retrospective dietary evaluation tool, the risk of recall bias is probable. As to the strengths of our study, it is important to note that we used HEI-2015, which is the latest version of the questionnaire and updated based on new guidelines. Also, we used the latest version of QRISK3 and Framingham online software. The large sample size of the present study was another strength.In conclusion, the results of our study support dietary recommendations to increase fruit and whole grains intake to prevent obesity and risks of CVDs, by achieving a higher quality diet. Also, a significant reverse association between HEI-2015 and QRISK3 and Framingham risk scores was observed. However, results for added sugar and SFAs were controversial. Further studies are needed to confirm these results.